Ultrasound diagnostics in the assessment of traumatic peripheral nerve damage in combat trauma

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Abstract

BACKGROUND: Traumatic peripheral nerve damage is a significant clinical and social problem, which is characterized by a high level of disability in young patients.

AIM: To assess the diagnostic efficiency of ultrasound in the diagnosis of peripheral nerve damage in combat trauma.

METHODS: A total of 163 patients (362 peripheral nerves) were examined. The duration of traumatic nerve damage was 2–273 days. All patients were men aged 20–48 years. Ultrasound was performed with 7–17 MHz linear transducers on an ACUSSON S2000 device using standard technique in B-mode, in longitudinal and transverse scanning planes, with the use of Doppler techniques. Statistical analysis was conducted to assess diagnostic efficiency. Calculation of operational (sensitivity and specificity) and integral (accuracy) characteristics was performed by the qualitative assessment of the reference method (surgical intervention) and the method under study (ultrasound).

RESULTS: Peripheral nerve damage resulted from combat trauma. In 120 (73.6%) cases, injuries of the limbs were accompanied by injuries of the osteoarticular apparatus and vessels. A total of 274 (75.7%) nerves had signs of traumatic damage. Multiple nerve injuries were observed in 95 (58.3%) people. Nerves of the upper extremities were damaged more frequently (185 [67.5%]) compared to nerves of the lower extremities (89 [32.5%]). Contusional structural changes were observed in 181 (66%) nerves. Impairment of anatomical integrity was diagnosed in 46 (16.8%) nerves, while complete impairment was found in 29 (10.6%) cases with the presence of diastasis between the nerve ends. Early after injury, a wound canal and hematomas were visualized near the nerve. In 4 cases, a foreign body of metallic density was visualized in the nerve sheath. After 3 weeks from the moment of injury, terminal neuromas were observed. The neuroma sizes for the proximal and distal ends were 0.5×0.3 to 1.6×0.6 cm and 0.4×0.2 to 1.3×0.6 cm (avascular), respectively. Adjacent sections of the nerve over 3–5 cm were thickened and characterized by echo structure, however, with thickening of all fasciculi and blood flow observed along the periphery of the nerve. Marginal nerve damage was observed in 17 (6.2%) people. In case of marginal neuroma, a significant nerve thickening of 1.4–3.2 times over a short distance (from 0.4 cm to 1.5 cm) with loss of bundle differentiation of the part of the nerve, pronounced decrease in echogenicity, and absence of Doppler signal was detected. Nerve compression in 47 cases (17.1%) was accompanied by 1.2–2.3 times thickening of nerve trunks, indistinct contours, decreased echogenicity, and significant changes in the nerve structure. Compression was due to cicatricial changes, hematomas, foreign bodies, bone fragments, and — in 2 cases — spokes from external fixation devices. A total of 106 patients underwent surgery.

CONCLUSIONS: The ultrasound sensitivity and specificity were 96% and 67%, respectively. The peculiarities of the examination included extensive soft tissue defects and external fixation devices, which significantly complicated the examination. The diagnostic accuracy was 91%. A pronounced cicatricial process (70%) was the main cause of false-positive (6.6%) and false-negative (2.8%) results.

Full Text

BACKGROUND: Traumatic peripheral nerve damage is a significant clinical and social problem, which is characterized by a high level of disability in young patients.

AIM: To assess the diagnostic efficiency of ultrasound in the diagnosis of peripheral nerve damage in combat trauma.

METHODS: A total of 163 patients (362 peripheral nerves) were examined. The duration of traumatic nerve damage was 2–273 days. All patients were men aged 20–48 years. Ultrasound was performed with 7–17 MHz linear transducers on an ACUSSON S2000 device using standard technique in B-mode, in longitudinal and transverse scanning planes, with the use of Doppler techniques. Statistical analysis was conducted to assess diagnostic efficiency. Calculation of operational (sensitivity and specificity) and integral (accuracy) characteristics was performed by the qualitative assessment of the reference method (surgical intervention) and the method under study (ultrasound).

RESULTS: Peripheral nerve damage resulted from combat trauma. In 120 (73.6%) cases, injuries of the limbs were accompanied by injuries of the osteoarticular apparatus and vessels. A total of 274 (75.7%) nerves had signs of traumatic damage. Multiple nerve injuries were observed in 95 (58.3%) people. Nerves of the upper extremities were damaged more frequently (185 [67.5%]) compared to nerves of the lower extremities (89 [32.5%]). Contusional structural changes were observed in 181 (66%) nerves. Impairment of anatomical integrity was diagnosed in 46 (16.8%) nerves, while complete impairment was found in 29 (10.6%) cases with the presence of diastasis between the nerve ends. Early after injury, a wound canal and hematomas were visualized near the nerve. In 4 cases, a foreign body of metallic density was visualized in the nerve sheath. After 3 weeks from the moment of injury, terminal neuromas were observed. The neuroma sizes for the proximal and distal ends were 0.5×0.3 to 1.6×0.6 cm and 0.4×0.2 to 1.3×0.6 cm (avascular), respectively. Adjacent sections of the nerve over 3–5 cm were thickened and characterized by echo structure, however, with thickening of all fasciculi and blood flow observed along the periphery of the nerve. Marginal nerve damage was observed in 17 (6.2%) people. In case of marginal neuroma, a significant nerve thickening of 1.4–3.2 times over a short distance (from 0.4 cm to 1.5 cm) with loss of bundle differentiation of the part of the nerve, pronounced decrease in echogenicity, and absence of Doppler signal was detected. Nerve compression in 47 cases (17.1%) was accompanied by 1.2–2.3 times thickening of nerve trunks, indistinct contours, decreased echogenicity, and significant changes in the nerve structure. Compression was due to cicatricial changes, hematomas, foreign bodies, bone fragments, and — in 2 cases — spokes from external fixation devices. A total of 106 patients underwent surgery.

CONCLUSIONS: The ultrasound sensitivity and specificity were 96% and 67%, respectively. The peculiarities of the examination included extensive soft tissue defects and external fixation devices, which significantly complicated the examination. The diagnostic accuracy was 91%. A pronounced cicatricial process (70%) was the main cause of false-positive (6.6%) and false-negative (2.8%) results.

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About the authors

Alena V. Tatarina

Central Military Clinical Hospital of A.A. Vishnevsky

Author for correspondence.
Email: Tatarina.74@mail.ru
ORCID iD: 0009-0003-4452-6012
Russian Federation, Krasnogorsk

Svetlana N. Dubrovskikh

Central Military Clinical Hospital of A.A. Vishnevsky

Email: dwetlana1975@icloud.com
ORCID iD: 0009-0000-9498-006X
Russian Federation, Krasnogorsk

Elmira A. Gumerova

Central Military Clinical Hospital of A.A. Vishnevsky

Email: Elmiragumerova1992@yandex.ru
ORCID iD: 0009-0003-1277-2614
Russian Federation, Krasnogorsk

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