VOL. 94-B, No. 4, APRIL 2012523
Nerve injuries sustained during warfare
PART I – EPIDEMIOLOGY
W. G. P. Eardley,
M. P. M. Stewart
R. Birch, MChir, FRCS,
War Nerve Injury Clinic
J. Etherington, OBE, FRCP,
Defence Medicine Rehabilitation
Centre, Headley Court, Epsom,
Surrey KT18 6JW, UK.
M. P . M. Stewart, CBE, QHS,
FRCS(Glas), FRCS (Tr&Orth), Col L/
RAMC, Defence Medical Consultant
Advisor in Trauma and
James Cook Hospital, Marton Road,
Middlesbrough TS4 3BW, UK.
W.G.P . Eardley, MSc, DIPSEM,
MRCSEd, Specialist Registrar in
Trauma and Orthopaedics
A. Ramasamy, MRCS, MFSEM,
DMCC, Specialist Registrar in
Trauma and Orthopaedics
K. Brown, MSc, MRCS, Specialist
Registrar in Trauma and
J. Clasper, DPhil, FRCSEd, Col L/
RAMC, Defence Professor of
Trauma and Orthopaedics
Royal Centre for Defence Medicine,
Academic Department of Military
Surgery and Trauma, Birmingham
Research Park, Vincent Drive,
Birmingham B15 2SQ, UK.
R. Shenoy, MD(Res), MRCS,
Clinical Research Fellow
P . Anand, MA, MD, FRCP,
Professor in Neurology
P . Misra, MD, FRCP, Consultant
Peripheral Neuropathy Unit,
Imperial College London,
Hammersmith Hospital, Du Cane
Road, London W12 0NN, UK.
R. Dunn, MBBS, FRCS (Plas),
Consultant Plastic Reconstructive
and Hand Surgeon
Odstock Centre for Burns, Plastic
and Maxillofacial Surgery,
Salisbury District Hospital,
Salisbury, Wiltshire SP2 0BJ, UK.
Correspondence should be sent to
Professor R. Birch; e-mail:
©2012 British Editorial Society of
Bone and Joint Surgery
J Bone Joint Surg Br
Received 19 October 2011; Accepted
after revision 1 December 2011
We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men
and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6),
the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36
to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The
nerve lesions were predominantly focal prolonged conduction block/neurapraxia in
116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly
distributed between the upper and the lower limbs. Explosions accounted for 164 (63%):
213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were
injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly
injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve
lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was
needed in 18. A total of 36 patients continued in severe neuropathic pain.
This paper outlines the methods used in the assessment of these injuries and provides
information about the depth and distribution of the nerve lesions, their associated injuries
and neuropathic pain syndromes.
Explosive munitions account for 75% of mod-
ern war injuries1: over 70% of these involve
the limbs. Multisystem trauma is common as
are occult nerve and vascular lesions, distant
from the obvious zone of injury.2,3
The essential elements of modern battlefield
orthopaedic surgery include: 1) time-limited
procedures: operations are restricted to the
identification and correction of life and limb-
threatening injury; 2) early vigorous resuscita-
tion with blood products; 3) rapid stabilisation
of fractures; 4) control and repair of major ves-
sels with extensive decompression of muscle
compartments; 5) control of pain with high
doses of opiates and continuous nerve block-
ade; and 6) prompt evacuation to home nation
hospitals for definitive reconstruction.
Surgery of the ballistic wound is a phased
process. All war wounds are considered con-
taminated (Fig. 1). The first operation, which
includes removal of contaminated and devital-
ised tissue, profoundly influences the outcome.
Decompression of muscle compartments is
performed where indicated. Vascular injuries
are repaired or temporarily shunted and frac-
tures are stabilised using external fixation,
skeletal traction or plaster immobilisation.
Divided nerves and tendons are trimmed and
tagged to the adjacent wound bed with a fine
suture to aid their later identification and
repair. Once haemostasis has been obtained,
wounds are dressed using either dry fluffed
gauze or more recently, with topical negative
pressure dressings. On repatriation to the
United Kingdom, patients are routinely taken
to theatre within 24 hours of arrival for wound
inspection and any necessary further debride-
ment. While well-debrided wounds may be left
for up to five days4 this rapid repatriation
often enables their delayed primary closure
within 48 to 72 hours. Although the mortality
of battle casualties has been reduced,3,5 the
morbidity from injury to the extremities and
their peripheral nerves is profound for many
Patients and Methods
Between 2005 and 2010, all United Kingdom
service personnel with peripheral nerve injuries
(PNI) from ballistic trauma were examined in
the War Nerve Injury Clinic at the Defence
Court. The records from the base hospital and
the admitting hospital were scrutinised.
Patients were followed until active treatment
had been completed and recovery of the nerve
was stable. Data were collected about the
wound, and any associated lesions of nerves,
vessels, soft tissues and skeleton, and were
coded on a purpose-designed data collection
524R.BIRCH, W.G.P. EARDLEY, A.RAMASAMY, K.BROWN, R.SHENOY, P.ANAND, J.CLASPER, R.DUNN, J.ETHERINGTON, P.MISRA, M.P.M.STEWART
THE JOURNAL OF BONE AND JOINT SURGERY
form. We excluded lesions of cutaneous nerves (eight), iso-
lated lesions of the cervical sympathetic chain and spinal
accessory nerve (two). Nerves transected in amputations
(26 limbs in 18 patients) and cases of transient ischaemic or
concussive conduction block, where recovery was well-
advanced or complete at six days, were also excluded. The
sciatic trunk was described by its component tibial and
common peroneal portions, the supraclavicular and lum-
bosacral plexuses by the affected spinal nerve and infracla-
vicular lesions by the main terminal branches.
Injury mechanism: wound evaluation. At first operation,
all wounds were classified by the International Committee
of the Red Cross Wound Score (RCWS).4 The components
of the score include: size of the entry (E) and exit (X)
wounds in centimetres; presence or absence of cavitation
(C) allowing entry of two gloved fingers pre-surgery
(C0 = no cavitation, C1 = cavitation); presence or absence
of metallic debris (M; M0 = no debris, M1= debris pre-
sent); involvement of ‘vital structures’ (V; V0 = no involve-
ment of brain, viscera, vessel or nerve, V1= injury to any
of these) and the presence or absence of associated frac-
ture (F; F0 = no fracture, F1 = simple fracture, F2 = com-
minuted fracture). Wounds may then be further graded in
terms of energy transfer according to the components of
the E, X, C and F scores as: Grade 1: E + X < 10, with
scores C0, F0 or F1 (Low energy transfer (LET)); Grade 2:
E+X < 10 with scores C1 or F2 (High energy transfer
(HET)); Grade 3: E+X ≥ 10 with scores C1 or F2 (Massive
energy transfer (MET)).
In addition, the wound may be described according to
the structures involved: Type ST: wounds with F0 and
V0 (soft-tissue); Type F: wounds with F1 or F2 and V0;
Type V: Wounds with F0 and V1; and Type VF: wounds
with F1 or F2 and V1.
Figure 1a – lateral radiograph of the left thigh of a 24-year-old man on the day of injury, which involved fragmentation from a mortar
round causing lesions of the common peroneal and tibial nerves. The Red Cross Wound Score was: E2, X0, C0, F0, V1, M1 Grade 1,
Type V. Figure 1b – intra-operative photograph after removal of the metal fragment from the common peroneal nerve and excision of
devitalised muscle: the tibial nerve can be seen to be displaced but intact. The wound healed with minimal scarring following delayed
primary closure after four days. Both nerves had recovered by four months.
Intra-operative photograph of a 31-year-old man showing degloving of
buttocks and thigh by massive energy transfer following explosive injury.
Both the common peroneal (1) and tibial (2) nerves are exposed. The Red
Cross Wound Score was: E50, X0, C1, F2, V1, M1 Grade 3, Type VF.
NERVE INJURIES SUSTAINED DURING WARFARE525
VOL. 94-B, No. 4, APRIL 2012
The catastrophic wounds caused by improvised explo-
sive devices indicate massive energy transfer (Fig. 2). Frag-
mentation and bullet injuries usually cause less destruction
The resulting skin loss, muscle destruction or fibrosis and
joint contracture was graded as mild, moderate, or severe at
first attendance at the clinic (Table I).
The Injury Severity Score (ISS) provides a numerical
description of the overall severity of the injury,6 and the
New Injury Severity Score (NISS)7 was calculated from the
Abbreviated Injury Scale (AIS) score.8
Assessment and classification of nerve injury. Unless
nerve is completely severed (neurotmesis) there is usually a
mixture of conduction block (neurapraxia), axonotmesis
and neurotmesis.9 The diagnosis for the whole nerve was
based on an estimate of the predominant lesion affecting its
constituent fibres. We recognise different patterns of con-
duction block on clinical criteria and investigations:
1) Transient anoxic block from ischaemia or concussion
in which recovery occurs within six days. These lesions
2) Focal demyelinating block, often prolonged, affecting
the largest myelinated fibres, from traction or compres-
sion.10,11 This clinical diagnosis was made, in some cases
supported by surgical observations and investigations,
when a) clinical recovery was well-advanced or complete
within six months, whereas regenerative nerve recovery
would be expected to take longer, b) the nerve was
inspected at surgery and found to be intact, or a lesion-in-
continuity, and c) nerve conduction studies performed after
a suitable delay (> 3 weeks after injury) showed normal
conduction distal to the lesion, but absent conduction or
slowing on stimulation proximal to the site of injury. Some
of these patients improved rapidly after decompression
and, where necessary, resurfacing using microvascular free
tissue transfer of fasciocutaneous flaps (FTT).
Lastly, 3) slowly evolving ischaemic or anoxic conduc-
tion block, with remarkably rapid recovery over 24 to
48 hours after nerve decompression. The relief of pain indi-
cates the involvement of small sensory fibres.
The location, intensity and any progression of Tinel’s
sign was recorded at each attendance.12,13 Nerve function
was measured by motor, sensory and sympathetic recovery.
Each modality was graded as good, fair or poor at each
attendance.14 The final grading for the whole nerve
reflected the functional significance of that nerve. The tibial
nerve was graded poor if the sole of the foot remained
insensate. Nerves that were associated with persistent pain
were graded poor.
Nearly all patients experienced severe pain either on the
day of injury or when they regained consciousness, but
most were relieved by treatment of the wound and by inten-
sive methods of pain control including continuous periph-
eral nerve blocks started at the field hospital and continued
thereafter.15-17 However, 36 patients presented with signifi-
cant or severe pain which was recorded using the short
form of the McGill Pain Questionnaire,18 a visual analogue
score (VAS) (ranging from 0 to 10, 0 = no pain, 10 = most
severe pain) and the PNI Unit system.18,19 It was classified
as causalgia, neurostenalgia or post-traumatic neuralgia.20
No patient suffered from the central deafferentation pain of
pre-ganglionic injury to a spinal nerve.
Causalgia is the most severe of the neuropathic pain
states. It is usually caused by a high partial injury to the
median, ulnar or tibial nerves or the trunks of origin with
associated arterial injury.20,21 Pain is spontaneous, persis-
tent, often with a burning feeling extending throughout the
limb and is worsened by physical and emotional stimuli.
There is excessive sweating and vasomotor disturbance.
Allodynia and hyperpathia are intense.
Neurostenalgia is caused by persistent tethering, com-
pression, distortion or ischaemia of an intact or repaired
nerve. Pain is confined to the distribution of the nerve: sym-
pathetic overactivity is rare.
In post-traumatic neuralgia, pain is initially confined to
the territory of the nerve without florid overactivity from
the effects of sympathectomy. Dysaesthesiae and lancinat-
ing pain are usual in nerves with a cutaneous component,
whereas pain is deep, boring and poorly localised from
nerves passing to muscle. The subsequent extension of pain
into adjacent areas indicates central sensitisation. A strong,
painful Tinel’s sign is almost always present at the level of
lesion in all three syndromes.
Supplementary investigations. Neurophysiological investi-
gation was undertaken in 45 patients. The peripheral path-
ways and target organs were studied at the National
Table I. Grading of the extent and consequences of soft-tissue destruction
Muscle loss or fibrosisJoint contractureSkin loss
Mild Correctible deformity. Power
MRC* Grade 5.
Loss of ROM† < 25%. Cosmetic. No tethering to bone
and muscle. Full ROM in adjacent
Tethering to bone and muscle
with loss of passive ROM < 25% at
Tethering to bone and muscle,
loss of passive ROM > 25% at
Moderate Range of active movement
> 50% of normal. Power MRC
Grade 3 to 4.
Range of active movement
> 50% of normal. Power MRC
grade 0 to 2.
* MRC, Medical Research Council
† ROM, range of movement
Loss of ROM 25% to 50%.
Loss of ROM > 50%.
526R.BIRCH, W.G.P. EARDLEY, A.RAMASAMY, K.BROWN, R.SHENOY, P.ANAND, J.CLASPER, R.DUNN, J.ETHERINGTON, P.MISRA, M.P.M.STEWART
THE JOURNAL OF BONE AND JOINT SURGERY
Hospital for Neurology, London, by recording conduction
within the peripheral nerves; of the larger afferent fibres by
sensory action potentials; of the somatic efferent fibres by
measuring motor conduction; and of conduction within the
whole nerve by measuring compound nerve action poten-
tials. The innervation of muscles was examined by electro-
A total of17 patients were studied at Hammersmith Hos-
pital, London, United Kingdom, using quantitive sensory
testing, which included the assessment of thermal and mono-
filament perception thresholds as described previ-
ously.18,23,24 Thresholds for touch were measured using
Semmes-Weinstein monofilaments (made by A. Ainsworth,
University College London, United Kingdom). Thermal
thresholds (warmth perception, heat pain, cool perception
and cold pain) were recorded using the TSA-II neurosensory
analyser (TSA thermode 3 cm × 3cm; Medoc Ltd, Ramat
Yishai, Israel). The patients (all men with a mean age at
injury of 25.5 years (18.1 to 41.8), were studied at a mean of
14 months (2 to 42) after injury. The mechanism of injury
resulting in nerve damage included improvised explosive
devices / blast injuries (n = 11) and bullet wounds (n = 6).
Patients had injuries to the common peroneal nerve (n = 9),
tibial nerve (n = 10), ulnar nerve (n = 5), median nerve
(n = 3), radial nerve (n = 1), bilateral lumbosacral plexus
(n = 1), and one patient had an above knee amputation.
Twelve patients had significant pain with a VAS > 4/10.
Indications for re-exploration of the nerve. The two indica-
tions for further operation were persistent pain and failure
to progress. Neurolysis is an extensive operation: the dam-
aged trunk must be exposed along the whole extent of the
zone of injury, working outside the epineurium, and it is lib-
erated from fibrosed muscle or overlying split skin graft, so
that it lies in healthy and unscarred tissue. Resurfacing by
FTT may be required. Repair was not performed if there
was continuity of nerve bundles, if there was conduction
across the lesion or if delay of target tissue damage was
such that no useful recovery could be anticipated.
Data were collected on 100 consecutive patients with
261 PNIs seen between April 2005 and April 2010. The
incidence of combat casualties with a PNI was 8.1%
(100 from 1237), but this figure excludes nerves transected
by limb amputation, lesions of cutaneous nerves and cases
of injury confined to the sympathetic or spinal accessory
nerves. There were 98 men and 2 women. Their mean age
at presentation was 26.5 years (18.1 to 42.6), the median
interval between injury and first review was 4.2 months
(mean 8.4 months (0.36 to 48.49)) and the median follow-
up was 28.4 months (mean 20.5 months (1.3 to 64.2)).
Medians are presented as the data were skewed, with some
patients sent very late for review (an issue in the early days
of the clinic) and over 20 patients progressed so well that
discharge was very early. A total of 36 patients who had
made a good recovery were discharged within a year of
injury: 34 patients were followed up for more than two
years, 15 for more than three years and these remain under
Severity of injury. The mean NISS scores for all UK service
personnel who survived ballistic wounds over the study
period was 11.54 (1 to 75); it was 18.35 (1 to 75) in 89 of
the patients in this study (Table II). The most common site
of the single most significant injury was the lower extremity
(Fig. 3). Massive energy transfer occurred in 48 patients
(Table III). The injury involved amputation of a limb in
18 patients: of a single limb in 11, of two limbs in six and of
three limbs in one. Injury to main vessel, a fracture or both
occurred in 69 patients within the zone of injury to the
Table II. Extent of injury in surviving battle casualties
New Injury Severity Score (NISS) for all combat injured
United Kingdom casualties (2005 to 2010)*
All survivors (n = 1237)
Survivors without peripheral nerve injuries (n = 1148)
Survivors with peripheral nerve injuries (n = 89)
* details from the first 11 patients in the study were not available
Diagram showing the site of single most significant ballistic injury as
recorded by Abbreviated Injury Scale score.8
NERVE INJURIES SUSTAINED DURING WARFARE527
VOL. 94-B, No. 4, APRIL 2012
nerve (Table IV). Significant soft-tissue loss was sustained
by 50 patients (Table V).
The nerve injury. Explosions caused 164 (63%) of the nerve
lesions, the remainder being the result of gunshot or fragment
wounding: 213 nerve lesions (82%) in 90 patients occurred
in open wounds. The nerve lesion was predominantly
prolonged conduction block/ neurapraxia in 116 (45%),
axonotmesis in 92 (35%) and neurotmesis in 53 (20%):
these were almost equally distributed between the upper
(51.3%) and lower (48.7%) limbs. Two or more main
nerves were damaged within the same zone of injury in
70 patients. The ulnar nerve was the most commonly
injured at the elbow, while the tibial and common peroneal
nerves were particularly vulnerable in the buttock and
around the knee.
Pain. A total of 36 patients presented with persistent signif-
icant or severe neuropathic pain.
Nerve operations. Repairs. A total of 35 nerves were
repaired within three weeks of injury either at the field
hospital or at the receiving hospital, 10 by direct suture
and 25 with grafts. Delayed nerve repairs performed at a
mean interval from injury of 101 days (28 to 186)
included seven grafts, three muscular neurotisations, and
one intercostal transfer.
Secondary operations. These included seven revisions of
earlier repairs in which three FTTs were used, and 11 neu-
rolyses, eight of which required FTT. The mean interval
from injury to the delayed repairs was 196 days. Four FTTs
were performed to treat painful scars.
Other operations. Operations of reconstruction were car-
ried out in 22 patients to correct fixed deformity or to
enhance function: three below-knee amputations proved
necessary because of persistent pain, failure of nerve recov-
ery or the poor condition of the foot and ankle.
Most modern war wounds are caused by explosive devices:
they are multiple and complex. Avulsion, laceration, blast
and crush combine to tear and shred tissues of all compart-
ments. Heavy contamination with dirt and debris is usual
and meticulous debridement is the essential first step in
time-limited resuscitative surgery. The field hospital policy
of emergency restoration of arterial flow and extensive
decompression led to a remarkably low incidence of ischae-
mic fibrosis; the sole case occurred in a patient in whom the
brachial artery was ligated.
Massive fibrosis and skin loss are incompatible with
nerve regeneration and function. Damaged target tissues,
notably in the hand and the foot, diminish function. These
factors account for the seven revision repairs and the
requirement for FTT in 15 patients and they forced delayed
below-knee amputation in three patients. The treatment of
ballistic hand injuries described by Eardley and Stewart25 is
driven by the fact that so many of the wounded have suf-
fered severe injuries or even amputations of lower limbs so
that it is important to restore the highest level of function
possible in the upper limbs and hands.
There is associated severe damage at the level of nerve
lesion with fracture in 50%, arterial injury in 32%, moder-
ate or severe muscle loss in 28% and moderate or severe skin
loss in 50%. In 70% of patients two or more nerves were
injured. The two definitive studies of PNI in World War
II26,27 found that 62% were in the upper limb and that a sin-
gle nerve was involved in over 65% of cases. Gousheh28
found arterial injury in 20% of 369 war wounds of the bra-
chial plexus. The studies from Roganović et al29,30 noted
arterial injury in 13.4% of 2239 PNIs from the Balkan wars,
while 702 injuries to the common peroneal nerve were com-
plicated by fracture in 45.9%, injury to a main artery in
24.4% and severe soft-tissue loss in 24.8%.
Current warfare is characterised by the increased survival
of casualties from the battlefield despite their catastrophic,
predominantly explosion-related, limb injuries. This presents
a new challenge in the rehabilitation of the most severely
injured patients who would not have survived in earlier con-
flicts and for whom every small gain in function is important.
This work describes the nature of peripheral nerve injuries in
contemporary war wounds. The severe and compound
nature of limb injury with associated bone, vessel and skin
loss is related to the distribution and severity of the nerve
lesions. It is emphasised that the goal of the war surgeon is to
deal with the war wound in its entirety. The final outcome
depends on the accuracy and quality of wound debridement
Table III. Grading of the Red Cross Wound Energy
Transfer in the 213 open nerve lesions (90
Grade Energy transfer Number of patients
Table IV. The wound type in the 90 patients with
213 open nerve lesions
Number of nerve
Fracture and main artery
Table V. Soft-tissue destruction and functional disability in
the zone of the nerve lesion (100 patients)
Muscle loss or
528R.BIRCH, W.G.P. EARDLEY, A.RAMASAMY, K.BROWN, R.SHENOY, P.ANAND, J.CLASPER, R.DUNN, J.ETHERINGTON, P.MISRA, M.P.M.STEWART Download full-text
THE JOURNAL OF BONE AND JOINT SURGERY
and prompt attention to the wound and vascular injury. This
enables later reconstruction of injured nerves with recovery
of function. This study benefits from complete information
about all service men and women who sustained nerve inju-
ries in the wars in Iraq and Afghanistan who were reviewed
in a dedicated specialist clinic. Overall outcome, the results
of nerve reconstruction and the response of pain to treat-
ment, will be discussed in a further paper.
Two tables detailing the distribution, mechanism and
nature of lesions in i) the upper and ii) the lower
limb, and (iii) a further table recording pain syndromes in
36 patients, are available with the electronic version of this
article on our website www.jbjs.boneandjoint.org.uk
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
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