Contribution of ultrasound in the management of ballistic nerve injury during the 2020 Nagorno-Karabakh war.

Purpose: To evaluate the contribution of ultrasound in the management of ballistic peripheral nerve injuries (BPNI).

Methods: Twenty-five Armenian soldiers who sustained BPNI of 44 different nerves during the Second Nagorno-Karabakh War in 2020 benefited from multidisciplinary team management including ultrasound examination.

Results: The injuries affected the upper limb in 17 cases (including 2 bilateral cases), the lower limb in 7 cases and both upper and lower limb in 1 case. The injuries were due to shrapnel in 14 cases and to high-velocity bullets in 10 cases. One median-radial nerve injury occurred after prolonged haemostatic tourniquet. Thirteen patients had at least 2 nerves injuries. Ultrasound showed 16 nerves with neurapraxia, including 2 blast injuries, 8 axonotmesis with a neuroma-in-continuity and 8 neurotmesis. Twelve soldiers got surgery prior to our missions. The preoperative skin marking of nerve lesions under ultrasound control was very useful for the surgeon during the operation. A good correlation with surgery was observed, in 7 cases, and in 10 cases, a correlation with electroneuromyography (ENMG) was found. The ultrasound exploration was not informative in 2 patients.

Conclusion: Ultrasound is a useful examination for the assessment of BPNI. It allows exploration of the entire nerve without artefact in the presence of projectiles or external fixator, contrary to MRI. It localizes and characterizes the nerve damage with a good correlation with data from the surgery and ENMG.

Clinical relevance statement: Ballistic wounds of peripheral nerves are frequent in war wounded. Ultrasound can localize and characterize nerve injuries with good correlation with surgical and electrophysiological data.