Case Study - Lower Limb Peripheral Nerve Injury in Disasters and Conflicts

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Patient Characteristics

Background

Ahmed, 22 years old, presen ts with a gunshot injury to his right lower limb from an exploding

sniper bullet from a distance of about 200m. He has an open wound with a displaced, comminuted,

medial shaft tibia and fibular fracture and there was no information about possible nerve or

vascular injury. Ahmed came to the emergency department with temporary immobilisation and

primary wound care was administered. The initial medical plan was to maintain immobilisation

until surgical wound debridement and application of external fixator is possible.

Rehabilitation assessment

Subjective assessment: Ahmed is married and a father of three children; his wife is currently

seven months pregnant. He arrived at the hospital unaccompanied by any family member or

friends. Ahmed lost his job as a first-aid provider four months ago and has now been given the

opportunity to start a part-time job as a health assistant in two weeks’ time. He lives with his

family and parents-in-law, both older and partially dependent on him. He lives in a fourth-floor

flat of a roughly finished building (shared shower on the ground floor, plastic sheets on the

windows, no stairs, and handrail). Ahmed regularly helps his brother-in-law to cultivate a small

piece of earth, where the family grows vegetables to support their difficult economic situation.

Objective assessment in emergency room: Ahmed is lying in bed with no mobility aid available;

he is conscious and alert and consents to assessment. Noted open wound on the back of the right

leg. Swelling (toes, dorsal aspect and malleolus and skin area surrounding the wound) and pale

skin colour of the toes are also noted. There is a lower temperature of the toes and dorsal part of

the foot, as compared to the other side.

Sensation: loss of light touch sensation on the sole and lateral part of the foot, decreased

sensation on the top part of the foot

Toes active flexion: M0, toes active extension: M2, ankle dorsal flexors and plantar flexors

unable to test due to fracture immobilisation

PROM toes: complete, but with pain. ROM ankle and knee unable to test due to fracture

immobilisation

VAS of injured site: 7/10

Possible vascular compromise, further investigation needed once stabilised

Objective assessment 24 hours later, after surgery with wound debridement and tibial

external fixator application: Ahmed lying in bed, no mobility aid available. Conscious and alert,

consents to assessment. Noted increased oedema throughout right lower leg and pale skin

colour of the toes ( no change after 24 hours)

Sensation: loss of light touch sensation on the sole of the foot, strong sensation of pins

and needles on the lateral part of the foot

Toes active flexion: M0, toes active extension: M2, ankle dorsal flexors: M2, ankle plantar

flexors: M0, foot inversion: M0, foot eversion M2

Pedal pulses and capillary normal bilateral lower limbs.

PROM toes: full range but with pain. PROM ankle and knee: full ROM

VAS of injured site: 5/10

Red flag: vascular injury excluded after surgical evaluation

Clinical impression

22-year-old patient with comminuted right

side tibia/fibula fracture treated with external

fixator. Suspected partial tibial nerve injury

and potential partial peroneal injury, with

more severe involvement of the tibial nerve.

(Complete nerve injury not suspected due

to maintenance of at least some sensation).

Nerve damage resulting in lack of ability to

heel raise/push-off when walking. Lack of

plantar flexion and inversion affecting stability

of the ankle, resulting in risk of further soft-

tissue injury. Ankle movement allowed with

position of external fixator. Wife and caregiver

will help with facilitating treatment and follow-

up/care at home.

Treatment goals

* Do not use electrical stimulation in the presence of an unhealed fracture or metal work

Make the patient aware of implications of the ongoing loss of sensation on the foot

Begin to normalise the hyperesthesia (tingling) on the lateral part of the foot and toes (may

take up to the next eight weeks)

Prevent ROM limitation in ankle and toes, prevent muscle weakness of leg (immediately)

Decrease pain and adequate pain management

Being able to walk with two elbow crutches in and outside with weight bearing (as per

post-op instructions) for at least 300m independently within seven days in order to safely

discharge home

To be able to climb up and down stairs with elbow crutches twice daily in order to safely

discharge home

Long-term goals (within six months)

Regain significant improvement to full power in plantarflexion, inversion and toe flexion,

plus normal sensation

Return to walking independently without aids

Return to work as a health assistant

To be able to care for new baby, help brother with food provision and take care of family duties

Reassessment of injury to determine severity of nerve injury, i.e. neuropraxia or neurotmesis

Treatment approach

Desensitisation and re-sensitisation techniques with different materials

Adapt shoe (padding or foam) to wear on the affected foot

Passive ROM and active ROM exercises, including strengthening glute and core exercises,

e.g. bridging

Transfers training and progressive safe gait training ensuring heel-toe walking pattern and

retraining on different surfaces, e.g. uneven gravel, grass etc., practising stairs

Intrinsic foot exercises, e.g. picking up a tissue with toes

Education

Explanation of recovery timing of a neuropraxia or axonotmesis: good possibilities to

recover but not 100% assured. Re-evaluation of the symptoms after eight weeks will give

a better picture of the final outcome and degree of lesion

Positioning of the foot during lying (no heel contact, use pillow) and sitting position (ankle

90 degrees) with foot on the ground and padded shoe

Importance of foot ground contact while walking, respecting medical prescriptions on

weight bearing

Regularly check the skin of the foot on the top and plantar part, with special attention to the heel

Wash the foot in lukewarm, clean water daily and drying it well. Keep pin sites dry and

clean, monitor for signs of infection (heat, swelling, redness, pain)

Continue three times daily with active and passive ROM and neural mobilisation exercises,

as per instruction received

Outcome

On discharge (after seven hospitalisation

days), Ahmed has good active ankle mobility

in dorsiflexion (M3+) but needs to improve

his active plantar-flexion (M1+), for which

he received a home programme. He is also

following the instruction on daily exercises

for passive ROM to maintain ankle and toes

mobility with the help of his wife, who has been

trained accordingly. Ahmed is independently

mobilising with two crutches, but from time

to time he walks barefoot, which he has been

told is a dangerous habit. He knows that he

has decreased sensation on the sole of his foot

and because of this, he is very susceptible to

injuries, especially when he goes to the field

with his brother-in-law. He has been informed

that improvement/normalisation of sensation

and muscle activity might take a long time and encouraged to continue to adhere to the advices

and the home programme. He is able to climb stairs independently and safely, which allows him

to be independent in reaching the shower and to go out of his house (see pictures)

Examination Findings

References