Bullet injury

[Amrina]

Hi

Any advice on this will be very much appreciated please. This is all the information I know so sorry about the lack of it.

My friend suffered from a bullet injury in his right elbow and left hand 4 weeks ago and fractured these areas. He was put in a cast for about 2 weeks and now wears arm supports.

The surgeon has left the bullets inside his arms as he said that hopefully the arm will start working itself and will not need to be removed.

The hand specialist doctor said that he may need an operation on his right arm as the nerve around the elbow is causing the right hand not to work.

He has been having physio for the past 6 days.


His symptoms are the following:

- alot of pain in both hands and right forearm, worse on right
- pain is like an electric current more worse on right
- he can move his fingers on his left hand one by one very very slightly. He can feel on this hand
- his right arm has no sensation from elbow down. Today was the first time he was able to move his right arm
- his right hand remains to be in a fist which has opened up very slightly post-accident

My questions:

Our main concern is his right arm as he's not able to feel from elbow down and no movement in his right hand. How long would you expect the sensation to come back after the injury?
Would it be useful to do a nerve conduction test?
Would it be useful to test with a neurothesiometer?
How long will it take for him to move his right hand?
Leaving the bullets in the arm wouldn't cause stiffness or any other probelms?
What exercises / strengthening should he do?

Many thanks for any advice. If you need more info. Please let me know. Il try to get it?

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[gcoe]

Hi anrina

Our main concern is his right arm as he's not able to feel from elbow down and no movement in his right hand. How long would you expect the sensation to come back after the injury? Would it be useful to do a nerve conduction test?

Yes it could be. I take it the specialist primarily responsible is an orthopaedic surgeon? If so there should be a consultation with a neurlogist/neuorosurgeon team to evaluate the neural problem. Although the hand specialist may be right. They would be the best advisors on what neural tests should be undertaken. Definitely should be seen by the neuro team. No sensation and no movement is a very serious matter.

Would it be useful to test with a neurothesiometer? Not really an expert on this but no i don't think so. This test examines vibration sense and is sensitive for diabtic neurpathy in the foot. The neuro specialists should have organised a comprehensive workup- could include MRI, ultrasound, and nerve conduction

How long will it take for him to move his right hand? Couldn't say as i have no idea what was damaged and to what extent. Again this where the neurlogist/ neurosurgeon should be able to inform you and this should have been assessed. In such a significant high impact injury the concern is if the peripheral nerve has been severed ie Potentially no chance of recovery. Hopefully this is not the case. At the other extreme the nerve could be just bruised ( neuropraxia) due to swelling around the area which can recover within a matter of weeks. But this is a serious matter and must be managed by neuro personnel

Leaving the bullets in the arm wouldn't cause stiffness or any other probelms? Again depends on the site. If the fragments are imbedded somewhere away from the joint surfaces where the movement occurs and where soft tisues won't be irritated be better to leave sleepmg dogs lie. There is always risk involved in surgical removal. I think you have to be guided by the surgeon

What exercises / strengthening should he do? This has to be determined by the orthopaefic team - so the surgeon should guide the physio and the physio can then design a talored program. There may be a reason for a period of immobilisation if the bones need to heal Or ny other reconstructive surgery. Otherwise early mobility exercises within what the healing tissues can tolerate is started as early as possible. Strenthening may be appropriate and all this proceeds in a staged an orderly fashion

I thimk the specifics of the physio can't be given over the net even with an extensive questioning and your questions probably needed to be directed at the medical/surgical specialists. Are you concerned you may not be getting the best care?

[Dr Damien]

Dear Anrina

Gcoe has given you the best advice you could get from anyone in all honesty.

I totally agree that nerve conduction studies are very important in this case. I agree that an urgent review by a neurosurgical team is needed in this case. I also feel that ongoing physiotherapy is relevant. In my home country, we used to see a lot of gunshot victims and all these steps are usually done...

There is loss of sensation and active movement...like Gcoe said is this due to compression by swelling/bone fragments on the nerve or breakdown of the nerve either by a resection by bullets piercing or degeneration from previous compression...
Only nerve conduction studies will give you that information...when this is done, the neurosurgical team can then decide whether a nerve graft is needed or not...

the problem with peripheral nerve injuries that involve nerve resection or degeneration is that even though the nerves will eventually grow back after some years, they often grow hapharzardly causing abnormal movements in the part they supply. this may not be functionally beneficial for the sufferer, also by this time several orthopeadic/musculoskeletal problems will have set in....i.e stiffness, clawing, muscle wastage...etc

So if anything at all, demand that this person is reviewed by the neurosurgical team like Gcoe has said...

with regards physiotherapy, i think this is important at this stage...to maintain/improve at least passive range of motion as well as maintain muscle bulk...

You have mentioned that he is able to move his right hand slightly, this may suggest that the nerves are compressed and not actually resected...also the report of painful electrical type currents indicates that probably the nerves are still intact and are just suffering from compression, a total resection may be painless...or could be painful when irritants in the vascular system agitate the endings...my guess is that the nerves are probably still intact...but this is just a guess from your report

My take on physiotherapy would be to consider the use of electrical stimulation, passive movements and a concise regime of elevation...functional splints may be required...
electrical stimulation when used wisely with compression techniques/ the use of a flowtron machine may help reduce swelling/combined with an elevation regime...this may be painful, painkliiers may be needed and an evaluation of radiological investigations may be needed prior to avoid causing excessive movements in unstable bones (if any), or aggravate preexisting compression

you cannot do any strengthening exercises anyway because there are very little active movements, this is a strong indication for FES (functional electrical stimulation)...

Maintaining range within other unaffected areas is an important consideration for physiotherapy

like Gcoe said if there are fragments within a joint, this might add to stiffness...if the orthopedic team have evaluated and feel there is no real danger from passive exercises, this can be done....

Im with Gcoe on this that the specialists need to give guidance with most if not any physiotherapists decision

[Amrina]

Thank you so much for all the advice. This has been very useful. I will take all your advice to the consultant.
The hand specialist told him that he will review his hands in3 days time and if it doesn't start working they will need to consider surgery but there is a 50% success rate.
Thank you once again, very detailed advice

Amrina

[Amrina]

Hi
You mention an elevation regime should be adopted by the physio. Would it be a good idea then to try to keep his arm elevated as much as possible?
After reading both your posts, I am very concerned his not getting the best care. But with your advice hopefully now he will

Thank you

[gcoe]

Hi Amrina

It must be a very worrying time for you and your friend. A common experience is that when dealing with medical and surgical teams it is very easyto feel not in control - which is exactly right as you have to hand over the control to personnel you hardly know and hope for the best that they will do the best for your friend. These people are usually very busy so it is common for inyeractions to be short and lacking time for them to explain what they are doing and why and in a way that can make you feel you can trust their decision making.

This is over and above if they are really doing the best for your friend or not.

As you are an advocate for your friend i would advise you to engage the Drs in getting them to explain what they are doing qnd why and if you query something just be polite but assertive. It is very important that you can trust the team. If they are inpatient sometimes it helps if you just diclose your concerns and ask them if they could take the time to explain things. If you are not happy with the answer you can ask for a second opinion. Drs generally don't get too defensive about this these days

Any advice we give is necessarily general and you really need specific answers now.

BTW elevation of the limb above the heart line at least for a good period of the day is a good idea.

[Amrina]

Hi Gcoe
It is very difficult, especially because he is in Pakistan and got shot there by accident. His only 23 years old and has been shot in both arms and stomach, the gun was in repeat so got 36 gun shot wounds. He had to undergo a colectomy and spent 4 days in coma after the incident. So suddenly dealing with the stoma and his arms it's very difficult. I do trust the doctors there but If his hands doesn't start working he will travel abroad for medical treatment in the hope that he may get a better success rate ( they have given him 50% success rate)

Thank you once again

[gcoe]

Hi Amrima

That is a terrible story - It must be devastating for him to come to terms with. With 36 bullets he is extremely lucky to be alive. He may have a long journey ahead to recuperate and also to deal with the psychological issues. Being oung, of course will give him resilience

As far as the standard of medical care in Pakistan I am not very knowledeable. However I can understand you having concerns about it- i certainly would if you are able to get him to a country with a jnown track record and can afford thid that sounds a really good idea. Ciuntries who have highly developed medical systems AND have a problem with gun control may be a good choice because of their extensive experience.

[Amrina]

Hi
Yes very fortunate to be alive. He had the best surgeons in Pakistan and even they were very shocked he is alive
Tomorrow he has an appointment with the neurosurgeon, so will decide after that if he needs the operation onhis arms.
Thank you

[Amrina]

Hi
What would be the cause of nodule type lesions which are red and feel quote firm on the middle part of his right forearm?
It hurts when touched and when he has physio and he moves the right hand it hurts alot then too?

Thanks

[gcoe]

Not sure. Two possibilities i can think of:

Bone fragments on the soft tissue of the forearm. If it is near the fracture this could possibly be. This can potentially be problematic as as the bone goes through a healing process laying doen more bone where it shouldn't (heterotopic calcification is the technical name).
bullet fragment that is irritAting the tissues
Localisd infection is another possibility.

Any of these need to be investigated

Trigger points - or otherwise known as myofascial pain. This can produce tender knotts and bumps in muscle bellies that are tender to touch and refer pain down the forearm. If it is this then they are relatively benign and will probably resolve as he gets stronger and with more mobility

[Amrina]

Great thanks. His neurosurgeon consultation got cancelled so waiting for another appointment to be arranged. The info you give is very useful.
Thank you

[Amrina]

Hi

Can anyone tell me the best/specialist hospital/consultant in London for mulitiple nerve injury in the forearm following a bullet injury?

Thanks
Amrina