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War Surgery and Medicine
APPENDIX — INJURIES TO PERIPHERAL NERVES IN SERVICEMEN OF SECOND WORLD WAR
APPENDIX
INJURIES TO PERIPHERAL NERVES IN SERVICEMEN OF SECOND WORLD WAR
Details of Survey of Late Results in 445 Cases involving 510 Nerves (By Dr D. Macdonald Wilson, 1951)
injuries to the brachial plexus
The 21 cases included three due to accidental injury and 18 to gunshot wounds.
| (a) |
Accidental Injuries (3 cases).—Only one case recovered function; this was a contusion of left axilla with temporary loss of function. One case resulted from a fall from a cycle, and the remaining case occurred when lifting a heavy weight. This latter case was operated upon to remove adhesions and the stellate ganglion seven months after injury without improvement. |
| (b) |
Gunshot Wound Injuries (18 cases—9 right and 9 left).—Three cases resulted in complete recovery without operation, 1 was described as a partial lesion, and 1 was associated with torn axillary vessels requiring ligation. Another 3 cases, 1 a partial lesion, resulted in almost complete recovery without operation. Twelve cases of the 18 showed no recovery of nerve function. |
Three cases were operated upon for the nerve lesion.
In 1 case the median nerve trunk was sutured without benefit, while the ulnar and radial nerve trunks were not sutured. The brachial artery and vein also required ligation. Another case was operated upon seven months after injury, when a cable graft was inserted without benefit, and subsequently an arthrodesis of the shoulder was performed to improve the function of the arm. The third case received novocain injections for the relief of pain two months after wounding. One year later a posterior rhizotomy was performed which gave relief to causalgic pain.
the ulnar nerve
This nerve was that most frequently injured, there being 137 cases, all but 16 being due to gunshot wounds. In 71 cases the right ulnar nerve was injured, in 64 cases the left, and in 2 cases both right and left were involved.
In 79 cases the nerve was injured above, and in 60 cases below, the elbow, while in 27 cases the lesion was described as partial division of the nerve.
There were associated nerve injuries as follows: median, 32 cases; radial, 6 cases; median and radial, 3 cases; radial nerve of opposite arm, 1 case; sciatic, 2 cases; external saphenous, 1 case.
Associated bone injuries of the arms were: fractures of humerus, 15 cases; ulna, 9 cases; radius, 4 cases; ulna and radius, 2 cases; humerus, ulna, and radius, 1 case.
Associated injuries of main blood vessels occurred as follows: axillary artery, 1 case; axillary vein, 1 case; brachial artery, 8 cases; radial artery, 1 case; ulnar artery, 3 cases; radial and ulnar arteries, 1 case.
Results of Treatment
| (a) |
Accidental Injuries (16 cases).—In 10 cases there was an incised or lacerated wound, while in 6 cases there was no open wound, the nerve injury being associated with a fracture or bruising about the elbow. In one case only was there complete recovery. This was a case with a history of an injured elbow as a child who gradually without obvious cause developed neuritis with sensory and motor changes in 1943. In 1944 the nerve was transplanted to the front of the elbow with relief of the neuritis and return of normal function. In 4 cases there was return of good function, but not complete recovery. In 3 cases operation with suture was carried out on the day of injury, while the fourth case was one associated with a bruised elbow in which the nerve was transposed some five years later. Of the 3 sutured cases two were forearm and one upper arm injuries. Eleven cases showed no evidence of recovery, although 7 of these cases were incised wounds, in 5 of which operation with suture of nerve and muscle tendons were carried out on the day of injury. In 4 cases there was associated ligature of either the brachial, ulnar, or radial arteries. |
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| (b) |
Gunshot Wounds.—Out of these 121 cases of gunshot wounds 44 were operated upon with the following results:
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In 21 cases suture was attempted at various periods after injury.
Cases operated within six months were 6; within twelve months, 7; within two years, 2; within three years, 2; within four years, 2; within five years, 2.
Two cases of suture subsequently had a neurolysis performed. In 6 cases a neuroma was removed and subsequently sutured. In 7 cases the nerve was transposed to the front of the elbow, either to allow suture or associated with neurolysis to relieve pain in the nerve distribution. In 2 cases neurolysis only was carried out, and in 1 case a tendon transplant only in an attempt to improve the function of the hand.
MEDIAN NERVE
There were 84 cases, including 7 due to accidental injury and 77 to gunshot wounds. Forty-six were above and 38 below the elbow. There were 37 right and 47 left nerve injuries. Twenty-five cases were described as partial division of the nerve.
Associated nerves injured were: brachial plexus, 1; ulnar, 32; ulnar and radial, 5: radial, 7; internal cutaneous, 2.
Associated injuries to bones of upper limb were: fractures of humerus, 9; humerus and ulna, 1; humerus and radius, 1: radius, 8; ulna, 2; radius and ulna, 5; metacarpals, 2.
Associated injuries of main blood vessels were: brachial artery, 9 (with aneurysm in 1 case); brachial vein, 1; axillary artery, 2; radial and ulnar artery, 2.
Results of Treatment
| (a) |
Accidental Injuries (7 cases).—Complete recovery in 2 upper arm cases and no recovery in 5 cases. Of the recovered cases, 1 was an accidental partial laceration of the nerve operated six months after injury for removal of a neuroma and suture. There was full recovery two years after injury. The second case of recovery was merely a contusion with temporary paralysis of the median and radial nerves. |
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| (b) |
Gunshot Wounds:
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injuries to radial nerve
There were 81 cases, 7 due to accidental injuries and 74 to gunshot wounds. Seventy were lesions in the upper arm and 11, including 1 accidental injury, were forearm injuries.
Forty-five were right and 36 left, while 19 were described as partial lesions.
Associated lesions of nerves were: median, 9; ulnar, 5 and 1 opposite arm; median and ulnar, 5; external-internal popliteal, 1.
Associated bone injuries were: fractures of humerus, 34; humerus and ulna, 4; radius, 3; scapula, 1; humerus and radius, 1; radius and ulna, 1.
Associated injuries to main blood vessels: brachial artery, 2; axillary artery and vein, 1.
Results of Treatment
Complete Recovery: Occurred in 32 cases (5 caused by accidental injury and 27 from gunshot wounds):
| (a) |
Of the 5 cases of accidental injury 3 were lesions in the upper arm, 2 in the forearm, and none were operated on. These injuries consisted of contusions or were associated with fracture of the humerus. |
| (b) |
Of the 27 cases of gunshot wounds, 25 were not operated upon, while 2 underwent operations. In 1 case the nerve was sutured in the upper arm on the day of injury, and in the other case freeing and suture of the nerve was carried out eight months after injury, with complete recovery from wrist drop. |
Good but Not Complete Recovery: Occurred in 12 cases, all gunshot wounds. In 5 cases suture of the nerve was carried out after periods of one to eight months from date of injury, while in 7 cases there was no operation on the nerve.
No Recovery: Occurred in 37 cases, including 5 forearm injuries, all of which were partial lesions only of the nerve. Thirteen of these 37 cases were operated upon in an attempt to restore nerve function by suture (3 cases within one year of injury), 2 had neurolysis, and 2 exploration. No improvement following these operations, tendon transplants were carried out at a later date, while operations on the tendons were also carried out on 3 cases without previous exploration of the nerve.
page 191injuries to other nerves of upper extremity
Several of the smaller nerves were injured by gunshot wounds as follows: long thoracic, 1; circumflex, 2; musculo-cutaneous 3; internal cutaneous, 1; and posterior interosseous, 8.
Five of the posterior interosseous nerve cases made a complete recovery, 1 a fair recovery, and 2 of the musculo-cutaneous nerve injuries recovered. There was no recovery in any other case.
injuries to sciatic nerve
There were 69 cases, 32 being injury to the right and 35 to the left sciatic nerve, while in two cases both right and left were injured. All injuries were due to gunshot wounds, and 26 were described as partial lesions. Two cases were associated with wounds of upper limbs involving the ulnar nerve.
Associated bone injuries were fractures of pelvis, 3 cases; femur, tibia and patella, 1; femur, 5; patella, 1; tibia, 1.
Associated injuries to main blood vessels which required ligation were femoral artery, 4 cases, and popliteal vein, 1 case.
Results of Treatment
| (a) |
Full recovery was made in 7 cases, including 3 partial lesions, 1 of which affected both right and left nerve. |
| (b) |
Good results but not complete recovery occurred in 14 cases, including 9 partial lesions. |
| (c) |
No recovery was made in 48 cases. These included all the cases associated with main blood vessel injuries. |
Operations for Sciatic Nerve Injuries
Twenty-four cases underwent operation:
| (a) |
Nerve Suture, 6 cases, without recovery (all operated on from four to fourteen months after injury). |
| (b) |
Exploratory, 6 cases (gap too wide to allow approximation and nothing further done). |
| (c) |
Neurolysis for nerve irritation, 3 cases. |
| (d) |
Procain Block of lumbar ganglionated chain -for causalgia, 1 case. |
| (e) |
Ganglion-ectomy for neuritis, 3 cases. |
| (f) |
Ultimate Amputation, 3 cases: One below-knee amputation, seven years after injury for complete nerve lesion with trophic sores. One below-knee amputation two and half years after injury following burns and skin grafting. One above-knee amputation eight months after injury. |
| (g) |
Arthrodesis of Metatarso-phalangeal Joint big toe, 2 cases. |
Of the 7 recovery cases only 1 was operated upon (ganglionectomy three years after for neuritis). In the 14 cases of good but partial recovery there was only 1 operation (neurolysis for irritation was performed one year after injury).
injuries to popliteal nerve
Twelve cases of gunshot wound injuries affected the following popliteal nerves: external right, 7 cases; external left, 2 cases; internal left, 1 case; external and internal right, 2 cases.
page 192Results of Treatment
There was good recovery in 4 cases, and no recovery in 8 cases.
Associated injuries were: fractured femur, 1; fractured fibula, 4; and popliteal vessels, 1.
Operations performed were: 1 suture day of injury (no recovery); 1 suture eight months after injury (good recovery); 1 suture four months after injury (no recovery); 1 suture one year after injury (without recovery and followed six years later by an arthrodesis of foot).
injuries to peroneal nerve
There were 30 cases of gunshot wounds and 3 accidental injuries, 15 being the right and 18 the left nerve, while 9 cases were described as partial lesions.
Associated bone injuries were: fractures of tibia, 2; fibula, 5; and tibia and fibula, 1.
An associated vascular injury produced an arterio-venous aneurysm of popliteal artery and vein.
Results of Treatment
Fully recovered, 9 cases (2 partial injuries); good recovery, 4 cases (1 partial injury); no recovery, 20 cases (6 partial injuries).
Operations
Two cases were sutured within one year of injury without recovery; 1 case was simply explored; tendon transplants were done in 3 cases; and in 1 case a neurolysis was performed eighteen months after injury, with subsequently lumbar ganglionectomy eighteen months later to relieve neuritis.
injuries to the tibial nerves
There were 36 cases caused by gunshot wounds, and 1 was a pre-war accidental injury. (Thirteen lesions were described as partial). The tibial nerves affected were: posterior right, 10 cases; posterior left, 17 cases; anterior right, 3 cases; anterior left, 4 cases; posterior right and left, 1 case; anterior and posterior, 2 cases.
Associated bone injuries were: fractures of tibia, 2 cases; fibula, 2 cases; tibia and fibula, 2 cases.
Associated injuries to blood vessels were: torn posterior tibial artery, 2 cases; torn posterior tibial vein, 1 case; arterio-venous aneurysm of anterior tibial vessels, 1 case.
Results of Treatment
Fully recovered, 8 cases; good recovery, 2 cases; no recovery, 27 cases.
The fully recovered cases include the pre-war accidental injury case. This man suffered a laceration of tendons and anterior right tibial nerve and made a complete recovery. In 1945 he developed a dropped foot without obvious cause, but made a complete recovery.
Operations undertaken were:
| (a) |
Suture 3 (without recovery, and all carried out from six to twelve months after injury). |
| (b) |
Exploration without any action on nerve, 5. page 193 |
| (c) |
Neurolysis, 2 (one operation carried out fourteen months after injury for the relief of causalgia was followed by a good but not complete recovery). |
| (d) |
Sympathectomy for relief of pain, 1 case (pain was partly relieved). |
| (e) |
Tendon transplant, 1 case. |
injuries to other nerves supplying the lower limb
Lumbar-sacral plexus, 1 (no recovery); anterior crural nerves, 5 (2 right and 3 left, with 1 fair recovery); saphenous nerve, 5 (4 right and 1 left with 2 cases of fair recovery); and external plantar nerve, left, 1 (no recovery).
Only 1 of these cases was operated upon, when a saphenous nerve was dissected out of a scar in an attempt to relieve pain.
injuries to cranial nerves
A few cases of injury to branches of cranial nerves occurred in the 445 cases of nerve injuries. There were 5 cases of facial nerve injury, 1 being accidental and 4 due to gunshot wounds. The accidental injury, caused by a blow on the face, was the only one to recover function. In 1 case nerve exploration was carried out fifteen months after wounding, without benefit.
Other nerves injured were the inferior dental, 1; spinal accessory, 1; and infraorbital, 2, with fractured maxilla. No operations were done, and no recovery occurred in these cases.