Rehabilitation of Peripheral Nerve Injuries in Disasters and Conflicts

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Tarina van der Stockt, Kim Jackson and Jess Bell      

Introduction[edit | edit source]

Peripheral nerves can sustain injury from numerous causes including traumatic thermal, chemical, or mechanical injury, inherited causes, infections, collagen or metabolic diseases (diabetes mellitus being one of the most common), exposure to endogenous or exogenous toxins; malignancies and iatrogenic causes[1], which manifest with neurological deficits distal to the level of the lesion. In disaster and conflict situations there can be a significant increase in the number of traumatic peripheral nerve injuries, but all of these other causes of nerve injury will continue to be seen by patients in these situations. [2] In disaster and conflict situations patients with peripheral nerve injuries tend to present with other injuries, often complex and most frequently associated with limb fractures. In many cases, these associated injuries need to be stabilised prior to the peripheral nerve injury being treated, which can often result in a delay in the identification and treatment of the peripheral nerve injury.

Disasters including earthquakes and storms can lead to large numbers of peripheral nerve injuries, as a result of complex limb trauma and crush injuries, or those which incur deep soft tissue injuries from flying debris, while in conflict situations, peripheral nerve injuries are also associated with complex injuries as a result of explosives devices, gunshot wounds, and penetrating injuries. Primary injury to the nerve is generally a result of the same trauma that injures the bone or joint, but can also occur as a result of moving the patient or stretching, or manipulating of the limb while treating the injury, rather than by the initial force. Infection, scar, callus, or vascular complications including haematoma, arteriovenous fistula, ischemia, or aneurysm can also result in secondary injury to the nerve. [3]

In traumatic nerve injuries, upper limb radial nerve injuries are most the common with 14% associated with humeral shaft fractures, 3% associated with fractures of the middle third of the humerus; 50%, with fractures of the distal third of the humerus; 7%, with supracondylar fracture of the humerus; and 7%, with dislocation of the radial head, while in shoulder dislocations it is the axillary nerve that may be injured as a result of stretch injuries, although this is rare and only occurs in about 5% of shoulder dislocations. Ulnar injuries account for 30% of patients with combined skeletal and neural injuries to the upper limb, and are generally associated with fractures of the medial humeral epicondyle, but often as a result of callus formation around the elbow. While elbow dislocations tend to result in median nerve injury in about 15% of combined skeletal and neural injuries of the upper limb, or after injury to the distal forearm of the wrist. [4] In the lower limb it is the peroneal nerve that is most commonly injured at the fibular neck, as a result of fracture of the tibia and fibula or dislocation of the knee, while the tibial nerve is injured more in distal fractures of the tibia or ankle. Lumbosacral plexus branches are injured in less than 3% of pelvic fractures; and in 10% to 13% of posterior dislocations of the hip. [4]

In conflict situations, nerve injuries are generally distributed evenly between the upper and lower limbs, with explosions (63%) the main cause of peripheral nerve injury with 82% of nerve injuries associated with open injuries, and a portion of patients presenting with injury to two or more nerves. [5] Associated injuries included fractures (31.1%), multiple multiple peripheral nerve injuries (76.8%), vascular injury (30.4%), and traumatic brain injury (34.1%), [6] with the lower extremity the most common site of the single most significant injury.[5] Neurapraxia (45%) is the most common type of injury to the nerve, followed by axonotmesis (35%) and neurotmesis (20%). The ulnar, common peroneal and tibial nerves were most commonly injured, and a large portion of these injuries was associated with a vascular injury, fracture, or both at the level of the nerve lesion, which is a small number of situations that result in amputation secondary to major tissue loss and the level of nerve damage.[7] In conflict situations research suggests that there was no association between Sunderland Classification and time to evaluation, mechanism of injury, or nerve-injured, but the Sunderland Classification was correlated with final motor and final sensory scores highlighting that those with more severe initial injuries having worse final outcomes. [8]

Immediate Emergency Care[edit | edit source]

In disaster and conflict situations peripheral nerve injuries are generally associated with multiple injuries and can be missed when the medical or surgical teams prioritise working to save a limb or life, and rehabilitation professionals are often the first member of the team to identify possible nerve injury during their assessment. As such rehabilitation professionals should always ensure that every patient who has injured a limb or limb-girdle should be evaluated and monitored for any possible peripheral nerve damage, in particular post-surgery, manipulation, casting, and recovery from any limb injury to detect any possible primary or secondary neural injury.[3] While timely referral for most peripheral nerve injuries does not always occur in disaster and conflict situations, research does suggest that a shorter time to presentation does lead to improved sensory recovery. As such rehabilitation professionals involved in early rehabilitation play a key role in both the identification and management of peripheral nerve injuries to ensure optimal recovery. [6]

Peripheral nerve injury is one of the most common injuries that can cause long term disability following disaster and conflict and proper care and knowledge regarding peripheral nerve injury is critical in any emergency response. In particular, moving and handling principles including on-scene immobilization are especially important to prevent further secondary injury to the nerve. Additionally, rapid referral to a multidisciplinary care facility with appropriate rehabilitation services is essential for optimal outcome, particularly in those with axonotmesis and neurotmesis.

Early diagnosis and treatment of peripheral nerve injury can be challenging in the aftermath of disaster and conflicts, particularly in those with complex polytrauma. During the early stages of a peripheral nerve injury, early diagnosis and management are key to minimizing further neurological damage and development of secondary complications.

Observation and conservative treatment (e.g., activity modification, splinting, electrical stimulation) are indicated in most closed injuries, which have a high rate of spontaneous recovery, while open injuries typically require surgical treatment, which is highly specialised and may not be available in conflicts and disasters, or the available, limited surgical resources may be prioritised for life-saving interventions. Surgical interventions where available can include primary repair (end to end), which connects the two ends of a severed nerve and is the ideal surgical option; however, this should be completed within the first few days of injury and without any stretch or tension through the repair site, which requires the injury to be identified early. Nerve grafting (to bridge gaps in nerves) is the other approach that can be used that can occur at a later date than primary repair but must still take place within two years of the initial injury. The grafts can either be an autograft, whereby healthy nerve tissue is transplanted from elsewhere in the patient’s own body or an allograft, where a commercially processed scaffold is used. [3]

Taking into account the challenges in disaster and conflicts, early deployment of specialized emergency medical teams (national and international) to meet the immediate needs is often a key element of the initial emergency response. A range of World Health Organization initiatives helps guide these teams, including the Emergency Response Frameworks (Standards and Guidelines); Coordination Mechanisms, and the Emergency Medical Team Accreditation Process so that only rehabilitation professionals, with appropriate experience and skills, form part of the Emergency Medical Teams. [9]

Emergency Medical Teams[edit | edit source]

Emergency Medical Teams. with specialist capacity for the rehabilitation of peripheral nerve injuries can play a vital role in supporting the care of individuals who have complex peripheral nerve injuries following disasters and conflicts. Generally, teams will be required in the first week of a disaster and stay for an extended period of time, but timeframes for the arrival of these specialised teams may vary significantly within disaster and conflict settings depending on the safety of the environment. Rehabilitation professionals cover a range of professions, including physiotherapy, occupational therapy, orthotics and prosthetics, rehabilitation nursing, physical rehabilitation medicine, and psychology. These professionals ideally work collaboratively in a multidisciplinary team, each contributing their speciality to achieve comprehensive care and management following peripheral nerve injury. Table 1 provides an overview of the rehabilitation input by Emergency Medical Team type, and specific discharge considerations for Peripheral Nerve Injury: [9]

Table 1: Minimum Technical Standards for Emergency Medical Teams for Management of Peripheral Nerve Injuries [9]
Type 1 Type 2 Type 3 Referral and Discharge Considerations
  • Basic Wound Management
  • Refer to Type 2 or 3 EMT or National Facility
  • Basic Splinting;
  • Assistive Device Prescription Fitting and Training;
  • Positioning and Patient Mobilization, including Early Mobilization;
  • Pain Management
  • Range of Movement and Strength
  • Education and Re-training of Patients and Caregivers in Daily Activities;
  • Provision of Psycho-social Support, for example, Psychological First Aid
  • Identify referral pathways for microsurgery for patients for whom this is considered beneficial.
  • Patients with long-term or permanent nerve injury should be considered for the provision of an orthotic device, Orthotic devices can require continuing maintenance or renewal during the patient’s life and in many cases have to be custom-made. Devices should therefore be obtained from a local provider where possible.
  • Rehabilitation Follow-Up

Peripheral Nerve Injury Overview[edit | edit source]

Figure.1 Nerve Anatomy

The peripheral nervous system consists of the nerves that branch out from the brain and spinal cord. These nerves form the communication network between the central nervous system and the body parts. A nerve contains bundles of nerve fibres, either axons or dendrites, surrounded by connective tissue. Sensory nerves contain only afferent fibres, long dendrites of sensory neurons, providing an area of skin with sensation. Motor nerves have only efferent fibres, long axons of motor neurons supplying the muscles. Mixed nerves contain both types of fibres and are involved in both sensory and motor function. [10][11] A connective tissue sheath called the epineurium surrounds each nerve. Each bundle of nerve fibres is called a fasciculus and is surrounded by a layer of connective tissue called the perineurium. Within the fasciculus, each individual nerve fibre, with its myelin and neurilemma, is surrounded by connective tissue called the endoneurium. A nerve may also have blood vessels enclosed in its connective tissue wrappings.[10]

A peripheral nerve injury can result in a minor injury up to a full transection of the nerve. Based on the type and amount of damage, nerve regeneration may or may not be possible. Peripheral nerve injury treatment will depend on the type of injury, amount of nerve injury sustained and symptoms which can include pain (ranging from tingling to intense burning pain), numbness or altered sensations, muscle weakness in the affected body part, loss of function (eg. a hand or leg being difficult to use whilst performing tasks), loss of active movement (eg. wrist drop and foot drop), joint stiffness and emotional stress. [10]

Mechanisms of Injury[edit | edit source]

Nerve injury can occur as a result of traction/stretch, laceration, compression, or ischemia. The nerve dysfunction results primarily from the direct mechanical forces applied to it and secondarily from the vascular compromise that follows, with consequent ischemic nerve damage.

Laceration[edit | edit source]

A nerve can be lacerated or completely transected as a consequence of a traumatic injury. This is more likely to occur as a result of a penetrating injury mechanism (eg, knife wound, gunshot, flying debris), rather than a blunt injury mechanism. Laceration to the nerves may also be accidentally cut during surgery, e.g. a misplaced fixator pin cutting the peroneal nerve.[12]

Traction / Stretch[edit | edit source]

Peripheral nerves allow for a significant degree of tension or stretch before developing internal/external structural damage, in part due to length redundancy that allows the nerve to adapt to stretching during normal movements of the limb (eg, the ulnar nerve at the elbow), allowing for stretching up to 10 percent with minimal traumatic consequences. However, when the peripheral nerve is stretched beyond these limits both internal and external damage to the nerve can occur.[13] Rapid-stretch nerve injuries are among the most devastating lesions to peripheral nerves, often resulting in poor functional outcomes. Specific nerves are more susceptible than others to trauma from stretch due to their location and level of resting tension, including nerves around the brachial plexus, in particular the axillary nerve.[12] Peripheral nerves may be injured by being stretched beyond their limit, e.g. if a person is pulled by their limb through rubble or a narrow space after a building collapse.

Compression[edit | edit source]

External pressure can injure the nerve through compressive forces, which can either be continuously applied for hours at a time, such as occurs with compressive radial neuropathy ("Saturday Night Palsy") or following a crush injury, or repeatedly applied with cumulative effect, such as in habitual leaning on the elbow. More commonly, the nerves can be chronically compressed by abnormal neighbouring structures, or while passing through fibro-osseous spaces such as with carpal tunnel syndrome or in situations with swelling such as compartment syndrome. [12][14] Compression injury may occur to the nerve when a person or a limb is crushed, e.g. trapped under debris in a collapsed building, or in compartment syndrome (see Fractures chapter), e.g. compression of the radial nerve with crushed/swollen arm.[14] It is worth noting that sensory information is transported in the outer layer of the nerve tissue, and so in compression injuries, sensation is often more impacted than power or motor function.[3]

Combined Mechanisms[edit | edit source]

In disaster and conflict situations in many cases, peripheral nerve injuries are a result of a combination of the above mechanisms. Vehicle-related injuries are predominantly stretch/traction injuries, although both contusion and laceration may also occur, missile-related injuries (eg, gunshot wounds) more commonly cause nerve contusions or transection, while laceration injuries occur most commonly as a result of sharp objects (eg, knife wound, gunshot, flying debris). Compression injuries often occur following building collapse or tend to relate to body positioning during anaesthesia or surgeries; which are usually a result of a combination of contusion, compression and ischemia. Any injury with significant soft tissue damage that can also cause swelling may also cause subsequent compression.[12]

Classification of Peripheral Nerve Injuries[edit | edit source]

Figure.2 Seddon Classification

Classification systems provide a common language for medical and rehabilitation professionals to effectively discuss nerve pathophysiology based upon the severity and extent of injury to the structural components of the peripheral nerve. Classification systems also play an important role in prognosis prediction and treatment strategy determination. [10]

There are two commonly used classification systems in use for peripheral nerve injury; the Seddon Classification developed in 1942 and the Sunderland Classification first proposed in 1990. [2][12][15] Seddon was the first to classify nerve injuries into three categories; neurapraxia, axonotmesis, and neurotmesis, based on the presence of demyelination and the extent of damage to the axons and the connective tissues of the nerve. Sunderland later expanded on this initial classification to distinguish the extent of damage in the connective tissues. McKennon and Dellon introduced a further classification to denote combinations of Grade III-V injuries along the route of the damaged nerve, although it is not as widely accepted in use.[12][16][17]

Table.1 Peripheral Nerve Injury Classification Systems [2][12][17]
Seddon Classification Sunderland Classification Mechanism of Injury Level of Injury Potential for Recovery & Timeline
Neuropraxia Grade I Usually caused by a mild injury
  • Local myelin damage is usually secondary to compression.
  • The whole nerve remains structurally intact.
  • High likelihood for full recovery
  • Recovery generally within 2 - 3 months of onset once compression is removed but may often recover earlier within days or weeks.
Axonotmesis Grade II Typically occurs as a result of crush injuries, nerve stretch injuries (eg, motor vehicle accidents, falls), or percussion injuries (eg, gunshot wounds).
  • Axon severed
  • Endoneurium intact
Good likelihood of full recovery.
  • Time course is significantly protracted as compared with neurapraxia.
  • 0.5mm to 2mm per day
  • Recovery proximal to distal from the site of injury
  • Recovery up to a maximum of two years
Grade III
  • Axon discontinuity, endoneurial tube discontinuity.
  • Perineurium and fascicular arrangement preserved
Potential for partial recovery, with less than 100% recovery Surgery often required.
Grade IV
  • Loss of continuity of axons, endoneurial tubes,
  • Perineurium and fasciculi; epineurium intact
Potential for partial recovery, with less than 100% recovery. Surgery required.
Neurotmesis Grade V Most often occurs in association with severe lesions, such as sharp injuries, traction injuries, percussion, or exposure to neurotoxic substances.
  • Complete Nerve Transection
  • Total physiologic disruption of the entire nerve trunk
  • No significant regeneration or recovery occurs with such a lesion unless surgical reanastomosis is performed.
  • 0.5mm to 2mm per day after surgery
  • Recovery proximal to distal from the site of injury.
  • Recovery up to a maximum of two years.

In disaster and conflict situations with traumatic peripheral nerve injuries, most lesions are mixed and a single traumatic event can cause a combination of neurapraxia, axonotmesis, and neurotmesis in various degrees. As such the final prognosis and functional outcome depends on the ratio between the individual components of the injury, which may be difficult to assess clinically.[12]

Assessment of Peripheral Nerve Injury[edit | edit source]

In disasters and conflicts, the diagnosis of a traumatic peripheral nerve injury is generally clinical and is based upon the presence of neurologic symptoms and signs consistent with a nerve injury along with a history of or suspicion for acute or repetitive trauma as the probable cause. A thorough clinical history and physical examination should be completed and should follow the same format as a standard rehabilitation assessment, with a focus on neural to determine whether a muscle or area of skin is neurally intact. For some patients, symptoms and signs may reveal overt sensorimotor loss corresponding to a specific nerve, while in some, the clinical findings may be more subtle. You can review assessment considerations for disasters and conflict here.

Specific considerations during assessment for patients with known or suspected peripheral nerve injury should include the following during the subjective questioning around function, sleep and sensation and objective testing focused on motor, sensory and vascular assessment. [3]

Subjective[edit | edit source]

Questioning around function, sleep and sensation;

  • Function:
    • Determine what function is affected, e.g. dressing, washing, working and caring for dependents. Hand dominance is important in hand and arm injuries and will influence the impact of an upper limb injury
  • Sleep:
    • Determine if sleep is affected by pain or their ability to get into a comfortable position at night. If sleep is impacted, finding a comfortable sleeping position should be an early treatment goal.
  • Sensation:
    • Determine the presence of pins and needles, numbness and reduced sensation/feeling. [3]

Objective[edit | edit source]

  • Sensory Testing:
    • A sensory test can serve as a quick check for nerve damage, in a setting where a full examination is difficult, e.g. in the presence of multiple fractures, or external fixation. See Table.3 & 4 for Sensory Testing.
  • Motor Testing:
    • Major peripheral nerve injuries usually lead to severe muscle weakness and consequential atrophy, which can start 72 hours after injury. The neuromuscular junction undergoes significant changes after nerve injury and is the most critical point for functional recovery, even after proper nerve regeneration. Besides the manual muscle testing examination, there are motor nerve function tests that can detect muscle weakness of upper and lower limb peripheral nerve injuries. Pick one muscle for each peripheral nerve to check for nerve function and record strength. Choose at least one functional movement for the affected area. See Table.3 & 4 for Motor Testing.
    • Neural mobility, i.e. how much the peripheral nerve moves within the tissues, can be assessed by considering the path of the nerve and what limb movement will put it under stretch, remembering that the nerve glides both backwards and forwards during a limb movement, and ensuring tension points which can cause pain or restricted recovery, which typically would occur at a joint or when the nerve passes through soft tissue. Be careful to avoid over-stretching or tensioning the nerve (pins and needles will appear).[3]
  • Peripheral Pulses
    • Peripheral pulses can be used as a valuable clinical tool for a suspected peripheral nerve injury.

Red Flags[edit | edit source]

The following red flags are specific to peripheral nerve injury only. You should always be aware of non- condition-specific red flags in your patient, such as infection. With all of the following signs and symptoms, you should stop treatment immediately and alert the surgical or medical team (Table.2). [3]

Table.2 Red Flags
Signs or Symptoms Possible Underlying Condition
Red, hot swollen limb, the patient complains of severe pain which is worsened with passive movement Compartment Syndrome
Red, hot, swollen limb with lack of pulses. The patient complains of pain and shortness of breath at rest Deep Venous Thrombosis or Pulmonary Embolism
Patient complains of severe pain; you may notice malalignment at the joint or abnormal bony movement or shape Unstable fracture which has not been diagnosed, or immobilised
Bilateral pins and needles

and numbness, weakness bilaterally in hands/feet, headaches and numbness around the head, severely reduced neck ROM. Fatigue inability to maintain head posture. Multisegmental weakness and multisegmental sensory changes

Unstable Cervical Spine

Peripheral nerve injuries are common conditions with broad-ranging symptoms depending on the severity of the nerve injury and what nerves are involved. Thus injury to peripheral nerves can have various secondary complications, which can be significant and have long term effects depending upon the classification of nerve injury. Read more about the secondary complications of nerve injury here.

Common Peripheral Nerve Injuries[edit | edit source]

Upper Limb[edit | edit source]

  • Proximal nerve lesions, are more likely to cause hand distortions (e.g. hand of benediction), which are only visible when the patient tries to flex the fingers or make a fist.
  • Distal nerve lesions are more likely to cause claw deformities (e.g. ulnar claw or median claw) as a result in a loss of function with intact extrinsic flexors [18]

Table.3 Common Upper Limb Nerve Injuries
Nerve Related Injuries Muscle Affected Motor Function Sensation Test
Spinal Accessory Nerve
  • Fractured Atlas or Hyoid
  • Neck Trauma
  • Elevates Pectoral Girdle
  • Retracts Scapula
  • Depresses Shoulder
  • Ipsilateral side flexion of neck


  • Hand behind back and lift hand away from the back
Long Thoracic Nerve

C5 - C7 Nerve Root

  • Stab Wounds
  • Sudden Scapular Depression
  • Axillary Crutch Use
  • Impaired Scapula Protraction
  • Impaired Upward Scapular Rotation
  • Impaired shoulder abduction > 90
Axillary Nerve

C5-C6 Nerve Root

  • Most common peripheral nerve injury to affect the shoulder.
  • Impaired Abduction > 15°
  • Impaired External Rotation
  • Atrophy Deltoid - Flat Shoulder
  • Regimental Patch
  • Unable to Abduct Arm to 90 degrees
  • Unable to maintain resisted abduction at 90 degrees
Suprascapular Nerve

C4 - C6 Nerve Root

  • Impaired Initial 15° Abduction
  • Impaired External Rotation
  • Shoulder Instability
  • Atrophy Supraspinatus and/or Infraspinatus
Musculocutaneous Nerve

C5 - C7 Nerve Root

  • Isolated injury to the Musculocutaneous Nerve is rare
  • Knife wound to Axilla
  • Compression
  • Impaired Elbow Flexion
  • Impaired Supination
  • Weak or Absent Biceps Tendon Reflex
  • Atrophy Anterior Compartment Arm
  • Lateral and Volar Aspect of  the Forearm from Elbow to Base of Thumb
  • Unable to Flex Elbow
Ulnar Nerve

C8 - T1 Nerve Root

  • At risk of Injury at Medial Epicondyle, in Cubital Tunnel, or at the Wrist;
  • Fracture Elbow
  • Dislocation Elbow
  • Laceration at Wrist
Forearm: High Lesion - Ulnar Paradox;
  • Hyperextension 4th & 5th Finger at MCP Joint
  • Paralysis 4th & 5th Finger at IP Joint; Straighter Fingers
  • Impaired Ulnar Deviation
  • Loss of FCU Tendon on Ulna Flexion
  • Impaired Interossei Function
  • Loss of Thumb Adduction
  • Wasting Hypothenar Eminence
  • Wasting Interossei
  • Palmar Surface of 5th & ½ 4th Digit
  • Dorsal Surface of 5th & ½ 4th Digit
  • Wartenburg Sign - Slightly greater abduction of the fifth digit,
  • Froment Sign - Weakened ability to pinch normally between the first and second digits
  • Inability to cross second and third finger
  • Poor Grasp and Release

Hypothenar Eminence;

Thenar Eminence;

Short Muscles;

Low Lesion - Partial Claw / Ulnar Claw;
  • Hyperextension 4th & 5th Finger at MCP Joint
  • Flexion 4th & 5th Finger at IP Joint
  • Loss Interossei Function
  • Loss Thumb Adduction
  • Wasting Hypothenar Eminence
  • Wasting Interossei
  • Inability to cross second and third finger
  • Poor Grasp and Release
  • Partial Claw Hand
Radial Nerve

C5 - T1 Nerve Root

  • Axilla Compression
  • Fracture Midshaft Humerous
  • Elbow Fractures
  • Elbow Laceration
  • Fracture Radius
Arm High Lesion;
  • Loss Elbow Extension
  • Loss Wrist Extension
  • Loss Hand Extension
  • Loss Radial Deviation
  • Atrophy Forearm
  • No Sensory Involvement if Posterior Interosseous Branch is Damaged Alone
  • 1st Webspace;
  • Dorsum Aspect Hand from 1st to ½ 4th Digit
  • Wrist Drop Present
  • Decreased Grip Strength
Forearm; Middle & Low Lesion;
  • Impaired Wrist Extension
  • Impaired Hand Extension
  • Impaired Radial Deviation
  • Impaired Thumb Extension
  • Atrophy Forearm
Median Nerve

C5 - T1 Nerve Root

Forearm; High Lesion;
  • Impaired Wrist Flexion
  • Impaired Thumb and Index Flexion
  • Impaired Opposition
  • Loss of Ulnar Deviation
  • Wasting Thenar Eminence
  • Hand of Benediction
  • Palmar Aspect 1st - ½ 4th Ring Finger
  • Ok Test
  • Pinch Test
Low Lesion;
  • Long Flexors Unaffected
  • Impaired Opposition
  • Wasting Thenar Eminence
  • Median Claw
Hand; LOAF Carpal Tunnel;
  • Wasting Thenar Eminence;
  • Weakness Abductor Pollicis Brevis
  • Loss Opposition
  • Ape Hand

Lower Limb[edit | edit source]

Table.4 Common Lower Limb Nerve Injuries
Nerve Related Injuries Muscle Affected Motor Function Sensation Test
Gluteal Nerve
  • Hip Dislocation
  • Impaired Hip Abduction
Femoral Nerve

L2 - L4 Nerve Root

  • Fracture Pelvis
  • Fracture Hip
  • Acetabular Fracture
  • Stab Wounds
  • Gunshot Wounds
  • Prolonged Pressure on the nerve
  • Impaired Flexion Hip
  • Impaired Extension Knee
  • Decreased Patellar Tendon Reflex
  • Anterior Thigh
  • Medial Thigh
  • Medial Leg to Hallux (Great Toe)
  • Difficulty straightening knee
Tibial Nerve

L4 - S3 Nerve Root

  • Dislocation Knee
  • Fracture Tibia
  • Fracture Fibula
  • Laceration Injury
  • Impaired Plantarflexion
  • Impaired Inversion
  • Unable to Curl Toes
  • Bottom of the foot and toes,
  • Unable to walk on toes
Peroneal Nerve

L4 - S2 Nerve Root

  • Dislocation Knee
  • Fracture Fibular Head
  • Impaired Dorsiflexion
  • Impaired Eversion
  • Footdrop
  • Steppage Gait
  • Lateral surface of the lower leg,
  • Dorsum of the feet and toes, except for the space between the first and second toe
  • Unable to walk on heels

Plexus Nerve Injuries[edit | edit source]

A nerve plexus is a branching network of intersecting nerves, composed of afferent and efferent fibres that arise from the merging of the anterior rami of spinal nerves and blood vessels. Four major plexuses include the cervical, brachial, lumbar, and sacral plexuses. Nerve plexus injuries can often occur in disaster and conflict situations. You can further review the following nerve plexus injuries.

  • Brachial Plexus Injury, which can be caused by penetrating injury and blunt mechanisms as in crush injury
  • Sacral Plexus, which can be caused by pelvic fractures, hip surgery, and use of traction.

Rehabilitation[edit | edit source]

Rehabilitation should begin as soon as the patient is medically stable. With peripheral nerve injury in disaster and conflict settings rehabilitation has two main aims: Restoring as much independent function as possible and educating the patients and their caregivers about realistic expectations and management strategies, which is particularly important in disaster and conflict situations as long-term rehabilitation may not be possible in conflicts and disasters and the patient will need to independently continue their rehabilitation, after discharge. [3]

Early rehabilitation for peripheral nerve injury should focus on:

  1. Oedema Management
  2. Pain Management
  3. Range of Movement
  4. Positioning and Splinting
  5. Graded Exercise
  6. Weight-bearing
  7. Psychological Considerations
  8. Patient and Caregiver Education

Oedema Management[edit | edit source]

Oedema is a normal response to injury and an important step in wound healing. However, excessive oedema can negatively affect wound and fracture healing, increase the risk for complications like compartment syndrome with ongoing compression on the nerve, and result in stiffness, decreased range of movement, increased pain and long term impairment or deformity. The 'Peace and Love Principle' includes the full range of soft tissue injury management from immediate care to subsequent management and highlights the importance of patient education and addressing the psychosocial factors involved that will aid recovery. Given that sensation is often impaired in peripheral nerve injuries heat and ice should never be used.

Acute Oedema Management includes:

  • Appropriate extremity positioning
  • Use of muscle pump action through the active range of motion
  • Facial oedema requires a patient to sit up to at least 45 degrees 24 hours/day
  • Expect dressings used for oedema management to be firm but allowing for AROM of all joints

Pain Management[edit | edit source]

Significant pain occurs with root avulsions, causing neuropathic pain. Severe pain will also exhaust the client and if not treated appropriately will hinder physiotherapy rehabilitation. Pain modulation the process of alterations in the pain signals along the transmission pathway of pain, it explains why individuals respond to the same stimulus differently, explains the mechanism of action when using clinical analgesia. Pain control and modulation is a complex chore that is often the primary reason patients seek the services of rehabilitation professionals.  Modulation of pain begins with an understanding of the various levels of pain modulation and extends to clinical interventions and protocols designed to reduce pain. For example, opiates are capable of increasing and decreasing pain experience.

Pain level assessment is key and needs controlling as much as possible to make treatment more comfortable and meaningful. Pharmacological treatment will depend on the type of pain, but neuropathic pain responds to gabapentin, amitryptiline, and pregabalin.

Range of Motion[edit | edit source]

Range of motion, including passive, active-assisted and active, of affected and surrounding soft tissues and joints is beneficial for healing and recovery and should be completed throughout the day at least 4 - 6 times daily. It helps to maintain existing joint and soft tissue mobility, minimises the effects of contracture formation, reduces the risk of pressure ulcers, assists neuromuscular reeducation, and enhances synovial movement Avoid this if there are injury-related contraindications, e.g. recent reconstructive surgery or unstabilised fracture and remember that nerves are mobile tissue but should not be stretched to the point of inducing paresthesia during the range of motion exercises.

Note: Neural Mobilisation; Avoid movements that could overstretch and place traction on the affected nerve and ensure adequate pain relief. When mobilising the limb or doing neural mobilisation, you should think about gliding the nerve in a smooth movement.

Positioning and Splinting[edit | edit source]

Positioning and splinting will form a key aspect of treatment for peripheral nerve injury to maintain optimum position and joint alignment, avoid further damage and reduce pain. It is imperative that a patient with peripheral nerve injury should be positioned and splinted as soon as the injury occurs to minimise compensatory and abnormal movements but allow for the best functional outcomes, to find a comfortable position for rest and sleep. Avoid movements or positions that overstretch and put traction on the affected nerve

The objectives of splinting include protection of injured tissues, improving healing and minimising oedema, prevention or minimisation of contracture formation, compensation for lost motor function and facilitation and enhancement of functional daily activities. Therefore, positioning and splinting should:

  • Minimize oedema formation
  • Prevent movements or positions that could overstretch and traction the affected nerve
  • Maintain nerve in the best position to facilitate recovery
  • Adopt anti-contracture position
  • Optimise and facilitate function
Image showing arm splint
Picture. 2 Arm Splint

A splint is a rigid support made from metal, plaster, or plastic. It's used to protect, support, or immobilize an injured or inflamed part of the body to support healing and to prevent further damage[19]. Using splinting to treat a peripheral nerve injury is important, but often challenging. All injuries to peripheral nerves result in possible motor loss and subsequent muscle imbalance creating the potential for further loss of function as surrounding tissues contract. Splinting may be required in both phases of recovery, acute repair and protection, for contracture prevention and aiding function.[20] There are different types of splinting designs for median nerve palsy, ulnar nerve palsy and radial nerve palsy. While dynamic splinting techniques are frequently employed to allow early prehension activities, in disaster and conflict settings these are often not available to use and require more specialist training to provide.

Splinting is a specialised skill for many nerve injuries, particularly in the upper limb and the prescription, fabrication, and fitting of a custom orthosis requires.[3]

  1. A strong understanding of the basic mechanical principles of splinting
  2. Knowledge of the mechanical properties of splinting materials
  3. Knowledge of deep and surface anatomy
  4. Knowledge of the impact of compressive, tensile, and shear forces on the tissues
  5. A thorough understanding of the pathophysiology, diagnostics, and treatment of peripheral nerve injury.

You can read more about splinting here including the different types of splints, indications and contraindications for splinting, advantages and disadvantages of splinting and possible complications.

In disaster and conflict situations the following materials can be used to support positioning, but the process is often time-consuming, and the results may be poor. Where available patients should be referred on to physical rehabilitation centres, which manufacture dynamic and static splints.

Nerve Related Injuries
Plaster of Paris Prevent Wrist Drop for Radial Nerve Palsy
Arm Sling Prevent Subluxation in Brachial Plexus Injury
Modified Aluminium Finger Splint Prevent Clawing of Fingers in Ulnar Nerve Lesions
Adhesive Tape Maintain Thumb in Apposition at Night for Median Nerve Lesions
Night Splints Maintain Ankle at 90degrees in Sciatic and Lateral Peroneal Nerve lesions to prevent foot drop.

Splint Care

Splint care is vital and educating the patient on the following three principles is a key part of their management

  • Check:
    • When removing a splint, check for any red marks. If the marks fade within half an hour this is fine, but if they persist, the splint will need adjusting. If the joints are stiff after removing the splint, exercise each joint for a few minutes.
  • Wash:
    • If the splint is made of heat-sensitive materials, don’t put it in hot water or leave it near heat sources, such as a radiator or on a sunny windowsill, because it will change shape. It is important to clean the splint using cold or lukewarm water with washing-up liquid or gentle soap.
  • Adjust:
    • If there are any problems with a splint you did not make yourself, then do not try to alter or adjust it. Contact the therapist or centre that delivered the splint. For children and teenagers, the orthosis needs to be adapted to their growth and patients should be followed up every three months. [3]

Graded Progressive Exercise[edit | edit source]

When muscle strengthening exercises can commence it is important not to damage the healing nervous tissue: if pins and needles, numbness or increased pain occur the exercise is too hard and can have a negative effect on healing.

Individualised progressive graded exercise should be utilised according to each patient's needs to improve strength, moving from isometric to anti-gravity to resisted-range exercises. Remember that in the acute phase for some peripheral nerve injuries with other complex injuries, isometric exercises may be the only exercise allowed. Muscle strengthening exercises are employed as appropriate, eg isometric, graded weight progression, open-close chain, and Use of support slings may be employed to assist the movement and take the weight of the limb. The goal is to increase the strength of both the involved and uninjured extremities, increase independence with a graded exercise programme and minimise deconditioning. Progressions can be achieved by: increasing sets and/or repetitions of sit to stand practice, sitting out of bed duration, and mobility practice with pacing (which is vital to minimise fatigue). Sitting out of bed for meals/dressing changes should also be encouraged to support this.

Weight-Bearing[edit | edit source]

Weight bearing refers to how much weight a person puts through an injured body part. The medical or surgical team are responsible for prescribing an appropriate weight bearing status and adherence to these restrictions is vital for optimal recovery, as premature weight bearing can delay healing. Once any fractures and / or nerve injuries are stable, fixed or immobilised, weight bearing should be started as soon as possible for both arm and leg, to stimulate motor control and neural pathways. You can follow the links to read more about weight bearing  and safe transfers and mobility.

Psychological Considerations[edit | edit source]

Muscle weakness, contractures, deformity and pain can impact on mental health following peripheral nerve injury. Chronic neuropathic pain has a life-debilitating effect causing emotional stress and reduced quality of life, and increased risk of post traumatic stress disorder, depression, or anxiety. The ultimate goal is not simply to reduce pain but to achieve an improved quality of life, which can only be achieved if depression, anxiety, and sleep disorders are also addressed.

Patient and Family Education[edit | edit source]

Due to the long healing and rehabilitation timeframe following a peripheral nerve injury and limited rehabilitation follow up in disaster and conflict situations, patient and caregiver education is of vital importance for successful management and rehabilitation. Teach patients or caregivers to take over some elements of treatment if they can safely repeat it without your supervision (always check first). Patients should repeat treatment multiple times per day, in order to be effective, and be able to continue post-discharge

Patient and Caregiver Advice

  • Minimise Risk of Further Injury to the Nerve
    • Stimulate and support the affected limb or area, but take care to avoid doing too much, as stretching and overuse can cause pain and further damage. Do not pull/drag on an affected limb, the traction can further damage a nerve.
    • Take particular care of areas with swelling, and ensure they recognise signs and symptoms that might indicate there may be further damage to the nerve and when they need to seek further medical review.
  • Monitor Skin
    • Be aware that potential sensory loss can increase the risk for burns and pressure sores, which can appear within hours after the initial injury. Ensure they understand how to check the skin and how often it should be done.
    • When washing, avoid water that is too hot and dry the skin area thoroughly afterwards, paying extra attention to skin folds between the fingers and toes
    • Temperature and skincare in general: the person should always wear a shoe, avoid heat/ cold (e.g. ice packs) in insensate/decreased sensation areas
    • Be careful of small scratches which may not be felt or noticed, e.g. scratches from pets/ thorns, which can develop into bigger wounds/infections if not noticed and quickly cleaned and protected
  • Prevention of Contracture
    • Maintain passive ROM to avoid joint contractures and/or tissue shortening. Always be aware of positioning both for comfort to minimise pain but also to minimise the risk of developing contracture. It is very important to find a comfortable resting position for the limb for sleep.
    • For shoulder nerve injuries, always support the arm proximally, i.e. close to the body
    • When using splinting, ensure they are safe and competent with donning, doffing and skincare [3]

Resources[edit | edit source]

Early Rehabilitation in Conflict and Disasters, Humanity and Inclusion

Rehabilitation in Sudden Onset Disasters, Humanity and Inclusion

References [edit | edit source]

  1. Mayo Clinic. Peripheral Neuropathy. Available from: (Last Accessed 24/03/2019)
  2. 2.0 2.1 2.2 Campbell WW. Evaluation and Management of Peripheral Nerve Injury. Clinical Neurophysiology. 2008 Sep 30;119(9):1951-65.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 Lathia C, Skelton P, Clift Z. Early Rehabilitation in Conflicts and Disasters. Handicap International: London, UK. 2020.
  4. 4.0 4.1 Azar FM, Canale ST, Beaty JH. Campbell's Operative Orthopaedics, E-Book. Elsevier Health Sciences; 2020 Dec 23.
  5. 5.0 5.1 Birch R, Misra P, Stewart MP, Eardley WG, Ramasamy A, Brown K, Shenoy R, Anand P, Clasper J, Dunn R, Etherington J. Nerve injuries sustained during warfare: part I–epidemiology. The Journal of Bone and Joint Surgery. British volume. 2012 Apr;94(4):523-8.
  6. 6.0 6.1 Dunn JC, Eckhoff MD, Nicholson TC, Campbell W, Kenney K, Smith J, Landau M, Miller M, Souza J, Nesti LJ. Combat-sustained peripheral nerve injuries in the United States Military. The Journal of hand surgery. 2021 Feb 1;46(2):148-e1.
  7. Birch R, Misra P, Stewart MP, Eardley WG, Ramasamy A, Brown K, Shenoy R, Anand P, Clasper J, Dunn R, Etherington J. Nerve injuries sustained during warfare: part II: Outcomes. The Journal of Bone and Joint Surgery. British volume. 2012 Apr;94(4):529-35.
  8. Eckhoff MD, Craft MR, Nicholson TC, Nesti LJ, Dunn JC. Lower extremity combat sustained peripheral nerve injury in US military personnel. Plastic and Reconstructive Surgery Global Open. 2021 Mar;9(3).
  9. 9.0 9.1 9.2 World Health Organization (WHO). Minimum Technical Standards and Recommendations for Rehabilitation–Emergency Medical Teams. 2016
  10. 10.0 10.1 10.2 10.3 Reza Salman Roghani and Seyed Mansoor Rayegani (2012). Basics of Peripheral Nerve Injury Rehabilitation, Basic Principles of Peripheral Nerve Disorders, Dr. Seyed Mansoor Rayegani (Ed.), ISBN: 978-953-51-0407-0, InTech, Available from: (Last Accessed 24 April 2022)
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  12. 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 Simionescu L, Elkwood AL, and Kaufman MR. Traumatic Peripheral Neuropathies. Mar 2022 [Accessed 24 April 2022]. Available from;
  13. Sunderland S. The Anatomy and Physiology of Nerve Injury. Muscle Nerve 1990; 13:771.
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  16. Cruz AJ, De Jesus O. Neurotmesis. InStatPearls [Internet] 2021 Feb 7. StatPearls Publishing.
  17. 17.0 17.1 Menorca RM, Fussell TS, Elfar JC. Peripheral Nerve Trauma: Mechanisms of Injury and Recovery. Hand Clinics. 2013 Aug;29(3):317.
  18. AMBOSS. Peripheral Nerve Injuries. Available from [Access on 24 April 2022
  19. VanBlarcom CW, editor. The glossary of prosthodontic terms. Mosby; 1999.
  20. Rrecaj S, Hysenaj H, Martinaj M, Murtezani A, Ibrahimi-Kacuri D, Haxhiu B, Buja Z. Outcome of Physical Therapy and Splinting in hand burns injury. Our last four years experience. Materio socio-media. 2015 Dec; 27(6): 380-382.