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

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Title

Open, Displaced, Comminuted, Medial Shaft Tibia and Fibular Fracture following Exploding Sniper Bullet from a 200m Distance

Abstract

Ahmed is a 22-year-old male who presents with a right open, displaced, comminuted, medial shaft tibia and fibular fracture following being shot with an exploding Sniper bullet from a 200m Distance. Ahmed undegoes surgery with wound debridement and tibial external fixator placement with suspected partial tibial nerve injury, partial peroneal injury, with more severe involvement of the tibial nerve.

Key Words 

Gunshot, Exploding Sniper Buller, Open Fracture, Peripheral Nerve Injury, Tibial Nerve, Peroneal Nerve

Patient Characteristics

Background

Ahmed, 22 years old, presents 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.

Social History

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.

Examination Findings

Objective Assessment 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

Pain: VAS of injured Site 7/10

Vascular: Possible vascular compromise, further investigation needed once stabilised

Objective Assessment 24 Hours Later

Post Surgery with wound debridement and tibial external fixator application Ahmed is 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

Vascular: Pedal pulses and capillary normal bilateral lower limbs.

PROM Toes: Full range but with pain.

PROM Ankle and Knee: Full ROM

Pain: VAS of Injured Site 5/10

Red Flags: 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

Short Term 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 thi s, 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)

References