Acta Neurochir (Wien) (2004) 146: 11851192

DOI 10.1007/s00701-004-0361-x

Clinical Article
Missile severances of the radial nerve. Results of 131 repairs
Z. Roganovic1 and S. Petkovic2
1
2

Neurosurgical Department of Military Medical Academy, Belgrade, Serbia and Montenegro

Department for Neurophysiology of Military Medical Academy, Belgrade, Serbia and Montenegro

Received November 27, 2003; accepted July 13, 2004; published online September 30, 2004
# Springer-Verlag 2004

Summary

Introduction

Background. Reports on missile-caused radial nerve injuries are

relatively rare in current literature. We present the outcome after repair of such injuries as well as the factors influencing the result of
treatment.
Methods. Prospective study included 131 complete missile-caused
radial nerve severances repaired with nerve graft or direct suture. Final
outcome was defined 4 years postoperatively at least, on the basis of
motor recovery (M), EMNG recovery (E) and patients judgement on the
quality of outcome (P). Recovery was estimated with 05 points and
final outcome was defined according to the total sum (015 points) as:
poor, insufficient, good or excellent. Both the good and the excellent
outcomes were considered as successful, and both the poor and the
insufficient outcome as unsuccessful.
Results. Excellent outcome was noted in 38.2% and good outcome
in 47.3% of all patients. Average point score was 9.9
3.3 points for
the whole series (domain of good outcome) and 6.6
3.0, 10.1
3.2
and 10.9
2.2 points for high, intermediate and low repairs, respectively (p< 0.01). Useful motor recovery (M3), good EMNG recovery (E3) and affirmative patients judgement on the outcome (P3)
had similar frequencies for intermediate (83.289.7%) and low
repairs (85.792.8%), but for high repairs, good EMNG recovery
was more frequent (70%) than were useful motor recovery and
affirmative patients judgement (40%). Successful outcome was noted
in 89.3% of direct sutures and in 82.7% of nerve grafts (p > 0.05).
Patients with a successful outcome had a significantly shorter nerve
defect (p< 0.001), shorter preoperative interval (p < 0.001) and
younger age (p < 0.05) than patients with an unsuccessful outcome.
Significant deterioration of results began with defects longer than
8 cm, preoperative interval longer than 6 months and age above 40
years.
Conclusions. The outcome is significantly worse after high radial
nerve repairs than after intermediate and low repairs. The length of
nerve defect, duration of preoperative interval and age of the patient
also influence the repair outcome. Correlation of motor recovery with
EMNG recovery and with patients judgement on the outcome is relatively good, but depends on the level of the repair.

Radial nerve paralysis may be the consequence of

direct nerve trauma, complex fractures, compressive
neuropathy, neuritis or, rarely, malignant tumour [15].
Although missile injuries are relatively frequent in civil
practice as well [4], papers about missile radial nerve
injuries are sporadic [29]. Frequently the authors
describe such injuries together with radial nerve injuries
of miscellaneous etiology [13, 26].
In war circumstances, injuries of peripheral nerves
participate in all injuries with 10% and in injuries of
extremities with 30% [21]. Frequent associated extensive injuries of soft tissues, blood vessels and bones
complicate the treatment and prognosis additionally.
During the war in former Yugoslavia, about 2.600
patients with peripheral nerve injuries were operated on in
our hospital and about 90% of such injuries were missilecaused [21]. We present the outcome after repair of missilecaused complete severances of the radial nerve.

Keywords: Nerve injuries; peripheral nerves; radial nerve; wounds;

gunshot; treatment; outcome; prognosis.

Methods
Of 241 missile radial nerve injuries during war activities in former
Yugoslavia (19911994), 110 had partial rupture, epineural scarring
and=or intraneural neuroma. This paper deals with 131 patients with
complete radial nerve severance due to missile injury.
Level of the lesion was defined as high, intermediate or low. The
border between high and intermediate lesions was the middle of the
brachium, while the nerve bifurcation was considered as the border
between intermediate and low lesions (posterior interosseous nerve).
Surgical procedure was performed 4 weeks after injury at least, under
general or block anesthesia, without tourniquet and using standard
surgical approaches, except if external bone fixation, severe contracture

1186

Z. Roganovic and S. Petkovic

Table 1. Grading of EMNG recovery and patients judgement on the quality of outcome
EMNG recovery
E0
E1
E2
E3
E4
E5

SDA 3; no MCV and AMP

SDA 23; no MCV; AMP sparse, prolonged,
nonpolyphasic, with low amplitude
SDA 2; MCV < 25 m=s; AMP with reinnervation
signs; IS 3
SDA 12; MCV 2537 m=s; AMP initially
polyphasic; IS 2
SDA 1; MCV > 37 m=s; AMP obviously polyphasic;
IS 1
SDA 0; normal MCV, AMP and IS

Patients judgement
P0
P1

no improvement or worsening
minimal improvement

P2

obviously improved, but failed in some

usual activities
satisfied with recovery

P3
P4
P5

very satisfied with recovery (activities of fine

coordination)
no difference in relation to intact limb

SDA Spontaneous denervation activity; MCV motor conduction velocity; AMP action muscle potentials; IS innervation sample.

or skin transplant in the region of the repair demanded some modifications. All operations were performed using microsurgical technique, and
the nerve gap was overcome by direct suture or nerve graft. In high
repairs, anterior nerve transposition was sometimes performed to shorten
the defect. Donor nerves for grafts were n.suralis, n.cutaneus brachii
medialis, n.cutaneus antebrachii medialis or r.superficialis n.radialis.
Postoperative immobilization was applied during 23 weeks after direct
suture and after nerve graft which could be impaired by extreme active
or passive movements.
Final results were assessed after 4 years at least, on the basis of motor
recovery, EMNG recovery and patients judgement on the quality of
outcome. Recovery of each of the mentioned categories was scored
using a scale of 0 to 5 points, so three scores were obtained: motor
(M-score), EMNG (E-score) and score of patients judgement on the
outcome (P-score).
Motor recovery was assessed as recommended by the British Medical
Research Council. In an assessment of EMNG recovery the following
factors were analyzed (Table 1): spontaneous denervation activity (03),
appearance of muscle action potentials, innervation sample (13) and
motor conduction velocity.
For closer interpretation of the recovery, we used the following terms:
useful motor recovery (M3), clinically noticeable motor recovery
(M2), good EMNG recovery (E3) and affirmative patients judgement (P3).
On the basis of the total points score, after adding the M-, E- and Pscores, the final outcome was defined as: poor (03 points), insufficient
(47 points), good (811 points) or excellent (1215 points). Both the
good and the excellent outcomes were considered as successful, and both
the poor and the insufficient outcomes were considered as unsuccessful.
All outcomes, except the poor were considered as clinical improvement.
Motor recovery was correlated with EMNG recovery and patients
judgement. The influences of repair level, length of nerve defect, duration of preoperative interval, age of the patient and the way of treatment
on the motor recovery and on total outcome were also tested.
In statistical processing we used two parametric and two nonparametric methods: 1. multivariate analysis and interpretation of obtained Fvalues using Scheffeas procedure; 2. Students t-test; 3. Pearsons (
2)
test; 4. Kruskal Wallis rank correlation test.

Results
Characteristics of the series
All patients were males, aged from 11 to 58 years,
with an average of 30.1
9.3 years. Fourteen patients

had associated severe craniocerebral injury, penetrant

thoraco-abdominal injury or spinal injury with neurological symptoms and signs. In repair region, bone fracture
existed in 67 patients (51.1%), large defect of soft
tissues requiring skin graft in 12 and injury to a major
artery in 10 patients.
The nerve lesion was high in 10 patients, intermediate
in 107 (81.8%) and low in 14 patients. In addition to
radial nerve severance, 17 patients (13%) in addition
sustained severance of the ulnar, median and=or musculocutaneal nerve. Multiple nerve injuries were more frequent in high lesions (4=10), than in intermediate
(11=107) and low lesions (2=14).
The nerve defect was made good by direct suture in
56 and with nerve grafts in 75 cases (57.2%). The length
of the graft ranged from 2.5 to 15 cm, with an average of
5.5
2.5 cm. Operation was performed 1.513 months
after injury, with an average of 4.7
2.6 months.

Postoperative recovery
Maximal obtained values of M-score and P-score
were M3=P3 for high repairs and M5=P5 for intermediate and low repairs. Maximal E-score for all three levels
of repair was E4 (Table 2).
Useful motor recovery (M3), clinically noticeable
motor recovery (M2), good EMNG recovery (E3) and
affirmative judgement of the patient about the outcome
(P3) had similar frequencies for the whole series
(80.290.8%), as well as for intermediate (83.291.6%)
and low repairs (85.7100%) (Fig. 1). Correlation was not
only good for high repairs, because good EMNG recovery
was more frequent (70%), but also for useful motor recovery and affirmative judgement of the patient (40%) (Fig. 1).
Average point-scores (M-, E-, P-) were the greatest
for low repairs, smaller to some extent for intermediate

1187

Missile severances of the radial nerve

Table 2. Recovery after radial nerve repair (%)
High

Intermed.

Low

Total

4.7
3.7
1.9
16.8
58.9
14.0

7.1
14.3
57.1
21.4

4.6
4.6
4.6
18.3
54.2
13.7

7.5
3.7
5.6
42.1
34.6
6.5

14.3
42.9
35.7
7.1

8.4
3.1
8.4
42.0
32.1
6.1

2.8
4.7
3.7
32.7
56.1

7.1
21.4
71.4

2.3
4.6
5.3
32.8
55.0

Motor recovery
M0
M1
M2
M3
M4
M5

10.0
20.0
30.0
40.0

Patients judgement
P0
P1
P2
P3
P4
P5

30.0

30.0
40.0

Fig. 1. Useful motor recovery (M3), clinically noticeable motor recovery (M2), good EMNG recovery (E3) and affirmative patients
judgement (P3) for different levels of radial nerve repair (%)

EMNG recovery
E0
E1
E2
E3
E4
E5

10.0
20.0
50.0
20.0

repairs and the smallest for high repairs (Table 3). Statistical significance was proved only for M- and P-scores
(p < 0.01): both scores were significantly smaller after
high repairs, than after intermediate and low repairs
(p < 0.01), while scores after intermediate and low
repairs were similar (p > 0.05) (Table 3).
The smallest was P-score and M-score was the greatest, except for high repairs, where E-score was greater
than M-score (Table 3). For high and low repairs mutual
differences between the scores were not significant statistically (p > 0.05), but were so for the whole series and
for intermediate level of repair (p < 0.01). Scheffeas test
located statistical significance on the relationship

between M-score and P-score: patients were significantly less satisfied with recovery, than one would
expected on the basis of motor recovery (p < 0.01)
(Table 3). EMNG recovery correlated well with motor
recovery and patients judgement (p > 0.05) (Table 3).

Total outcome
Total point-score was 014 points (Table 4), 9.9
3.3
in average (domain of good outcome). Level of the
repair changed both the maximal value (10 for high
and 14 for intermediate and low repairs) and average
value of point-scores: 6.6
3.0, 10.1
3.2 and 10.9
2.2
respectively. It means that average outcome for
high repairs was insufficient, good for intermediate
repairs and between good and excellent for low
repairs.
Differences between total average point-scores were significant statistically (F 6.54; p < 0.01), and Scheffeas

Table 3. Average point-scores for different levels of repair (multivariate analysis)

Level

M-score

E-score

P-score

Total

F

High
Inter.
Low
Total

2.0
1.0
3.6
1.1
3.9
0.9
3.5
1.2

2.8
0.9
3.3
1.0
3.6
0.6
3.3
1.0

1.8
1.2
3.1
1.2
3.4
0.8
3.0
1.2

6.6
3.0
10.1
3.2
10.9
2.2
9.9
3.3

2.29;
5.48;
1.88;
5.15;

F
FHI
FHL
FIL

10.41;
19.31;
17.14;
0.84;

2.4; p > 0.05

6.12;
11.22;
9.94;
0.48;

p < 0.01
p < 0.01
p < 0.01
p > 0.05

p < 0.01
p < 0.01
p < 0.01
p > 0.05

FMP
p > 0.05
p < 0.01
p > 0.05
p < 0.01

10.68; p < 0.01

12.69; p < 0.01

6.54; p < 0.01

11.41; p < 0.01
10.98; p < 0.01
0.8; p > 0.05

F values mutual comparison of average point-scores for different levels of repair (degrees of freedom: 128 and 2). F values mutual comparison
of average M-, E- and P-scores (degrees of freedom: 27 and 2 for high, 318 and 2 for intermediate, 39 and 2 for low, 390 and 2 for whole series). FHI
FHL FIL FMP Interpretation of F-value by Scheffeas procedure: significance of differences between average scores for high (H), intermediate (I)
and low repairs (L) as well as between average M- and P-scores (border value is 9.21 for p 0.01).

1188

Z. Roganovic and S. Petkovic

Table 4. Point-scores after radial nerve repair

Score

No cases

Total

Interm.
repairs
(107)

5
5
4
4
4
3
3
3
2
1
1
0
0

4
4
4
4
3
3
3
2
2
2
1
1
0

5
4
4
3
3
3
2
1
1
1
0
0
0

14
13
12
11
10
9
8
6
5
4
2
1
0

7
8
29
16
18
11
6
1
2
1
3
2
3

Low
repairs
(14)

5
5
4
4
4
3
3
2

4
4
4
4
3
3
3
2

5
4
4
3
3
3
2
2

14
13
12
11
10
9
8
6

1
2
3
4
1
1
1
1

3
3
2
1
0

4
3
3
2
1

3
3
2
0
0

10
9
7
3
1

2
2
3
2
1

High
repairs
(10)

procedure revealed the relation of high repairs average

point-score to intermediate repairs point-score (F
11.41; p< 0.01) and to low repairs point-score (F
10.98; p< 0.01) as the reason for significance (Table 4).
Total average point-scores of intermediate and low repairs were similar (p > 0.05).
If results were presented using descriptive categories,
than an excellent outcome existed in 38.2% and a good
outcome in 47.3% of all patients (Table 5). Even after
high repairs, good outcome was noted in 40% of
patients, while after intermediate and low repairs excellent outcome was obtained in 41.1% and 42.9% of cases,
respectively. Frequencies of improvement were 70% for
high repairs, 92.5% for intermediate and 100% for low
repairs, while frequencies of successful outcome were
only slightly less (Fig. 2).
Factors influencing the outcome

Table 5. Total outcome after radial nerve repair (%)

Outcome

High

Interm.

Low

Total

Poor
Insufficient
Good
Excellent

30.0
30.0
40.0

7.5
3.7
47.7
41.1

7.1
50.0
42.9

8.4
6.1
47.3
38.2

Successful outcome was noted in 50 of 56 direct

sutures (89.3%) and in 62 of 75 nerve grafts (82.7%)
(
2 1.127; p > 0.05).
Average length of nerve defect and average duration of preoperative interval were significantly shorter
for patients with successful outcome, than for those
with unsuccessful outcome (Students test; p< 0.001).
Length of defect and preoperative interval influenced
the final outcome significantly (Kruskal-Wallis test;
p < 0.01 and p< 0.001) and significant worsening of
the results began with the defect longer than 8 cm (
2
test; p < 0.001, great coefficient of contigency) and with
the interval longer than 6 months (
2 test; p< 0.001)
(Table 6).

Fig. 2. Successful outcome and clinical improvement after different levels of radial nerve repair (%).

Clinical improvement;

successful outcome

1189

Missile severances of the radial nerve

Table 6. Influence of nerve defect, preoperative interval and patients age on final outcome
Tested factor

Successful
outcome

Unsucc.
outcome

Statistical Analysis
Students test

Kruskal-Wallis test

Pearsons test

Defect (cm)

5.0
2.1

8.0
2.8

t 3.47; DF 73
p < 0.001

H 9.50; DF 1
p < 0.01

2 21.45; DF 1; p < 0.001;

C 0.47

Interval (months)

4.2
2.2

7.4
2.6

t 4.94; DF 129
p < 0.001

H 18.55; DF 1
p < 0.001

2 26.35; DF 1; p < 0.001;

C 0.41

29.1
9.0

35.8
11.4

t 2.35; DF 129
p < 0.05

H 6.14; DF 1
p < 0.05

2 11.50; DF 1; p < 0.001;

C 0.28

Age (years)

Patients with successful outcome were significantly

younger on average than those with unsuccessful outcome (Students test; p < 0.05) and age of the patient
influenced significantly on final outcome (KruskalWallis test; p < 0.05) (Table 6). Worsening of final
results began with the age over 30 years (
2 3.9511;
p  0.05; C 0.17), but statistical significance was the
most prominent if the age over 40 years was accepted as
the border line (
2 11.498; p< 0.001, small coefficient
of contigency) (Table 6).
Discussion
The projectile damages the nerve directly or blast
effect lead to considerable contusion of axons, fibrous
network and blood vessels. Low-speed (<2000 feet=sec)
projectiles damage tissue moderately, while high-speed
(>2000 feet=sec) projectiles result in extensive tissue
destruction and in dubious outcome of treatment [30].
But, more than on projectile speed, tissue destruction
depends on energy transfer, influenced by projectile characteristics and biological characteristics of tissue [4].
In our series, injuries were extensive: nerve graft was
frequently necessary to overcome the long defects, proximal (high or intermediate) repairs were needed in
89.3% of all cases and severe associated thoraco-abdominal and craniocerebral injuries were frequent, as well as
severe local tissue damage (fractures, large defects of
soft tissues, lesion of major blood vessels).
According to experiences from World War II, radial
nerve missile severances have a good prognosis, because
some recovery happened after 89% of repairs [24, 31].
Some current authors have similar opinions [29]. Good
outcome is very frequent (70.692% of cases) as well
after repair of non-missile neurotmeses of radial nerve
[2, 3, 5, 9, 13, 16]. Series with poor results, predominantly
consisting of high repairs are considerably rarer [12].
In our series excellent or good outcomes were
achieved in 85.5% of patients, while average point-score

was in the domain of good outcome (9.9 points). After

intermediate level of repair, which was the most frequent, good wrist extension and some finger extension
was noted in over 89% of patients.
Motor recovery M3 or better was achieved in 86.5%
of patients and this is in accordance with the results of
some other authors [13, 16]. EMNG recovery was
slightly better than motor recovery in high repairs and
slightly worse after intermediate and low repairs. However, EMNG recovery correlated well with motor recovery and patients judgement about the outcome at all
levels of repair. Regenerating fibers are of smaller diameter, its internodal distance is shorter and myelinization
is more sparse. Therefore, conduction velocity of regenerating fibers is never above the range of 5880% of
normal values and EMNG recovery in our series have
never achieved E5 grade, in contrast to motor recovery
[11, 14, 17, 28].
Patients were always, but especially after intermediate
repairs, more pessimistic about the outcome, than one
would expected on the basis of motor recovery. There
are several possible reasons for such discontent, including financial and psychological reasons [18].
One of the causes of good outcome after radial nerve
repairs is the fact that complete return of the strength of
denervated muscle is not necessary for good functional
recovery: finger extension with only 20% of maximal
strength results in minimal functional disability [7].
The explanation of good radial nerve recovery with a
small sensory component, causing a great number of
regenerating motor axons to find their path to distal
tubes [22] is dubious to some extent, because the peroneal nerve, comparable with the radial nerve anatomically and functionally, has considerably worse recovery
potential.
Radial nerve lesions are the most frequent in the
region where the nerve pierces the lateral intermuscular
septum, thus around the middle of the humeral bone [6].
Distal injuries (n.interosseous posterior) are somewhat

1190

rarer, while the rarest are high lesions, far above the
middle of the brachium or at brachial plexus level [1, 12].
In contrast to some other nerves, after high radial
nerve repairs regenerating axons grow in to distal effectors in time to prevent irreversible muscle fibrosis (in
thumb extensors in 1618 months) [22]. Because of that,
good functional results are possible also after high radial
nerve repairs, if the preoperative period is not too long.
After high repairs in our series, motor recovery did
not exceed M3 grade, but such recovery, obtained in
40% of cases, was of considerable functional importance, because of establishing wrist extension. For that
reason the usefulness of high repairs is not under question, although in some cases natural recovery should be
supplemented with tendon transposition or other corrective procedures.
After intermediate and low repairs, motor recovery
could be excellent (M5 in 1421% of cases) and similar
results were obtained by other authors also [5, 8, 19, 26].
After low repairs, additional tendon transfer is needed
only in uncommon circumstances: if a large defect of the
antebrachial muscles exists, if the patient is old and if
more than 12 months have passed after injury [5].
Good results are possible as well if nerve defects are
long [9], though numerous series, including our series,
point to worsening of results with increased length of the
graft. According to some authors, 510 cm is considered
as the critical length of defect for a good outcome [2, 7,
10, 16, 26]. The critical length of 8 cm, obtained in our
series, is relatively reliable, taking into consideration the
high coefficient of contingency of Chi-square test.
The timing of repair of transected nerve has been the
subject of much debate. The current standard is primary
repair whenever possible, especially if the nerve is
cleanly transected. However, if nerve edges are sheared
and contused, as after missile injury, delayed neurorrhaphy, 34 weeks after injury, seems to be a better choice
for several reasons. Delay allows the longitudinal extent
of the contusional nerve injury to become more evident.
If contused fascicles are co-apted, the primary repair
will fail, as we noticed in all of 18 our patients operated
on at the begining of the war using primary suture.
Furthermore, most war injuries cannot be treated in the
first few weeks after injury because of wound contamination or massive soft-tissue destruction. Finally, the
first few weeks after injury is the period when the nerve
cell body is at an optimal metabolic potential.
In our series, we did not have patients with clean
nerve transection who would be ideal candidates for
primary nerve suture. All lesions were the consequence

Z. Roganovic and S. Petkovic

of missile wounds and associated with extensive and

widespread nerve contusions. Soon after injury and prior
to nerve repair, all casualties underwent to some kind of
surgical treatment of the missile wound (resection of
devitalized soft tissue, treatment of residual skin defects,
reconstruction of damaged main blood vessels, and
treatment of missile bone fractures). Nerve rupture was
verified in some patients during such procedures, but the
only acute intervention on transected nerves was to mark
the proximal and distal ends of the nerve with 12 nylon
sutures or to tack the accessible stump down to the surrounding tissue, which made it easier to locate the nerve
stumps at re-exploration. Re-exploration was performed
4 weeks after injury at least if local conditions in region
of the repair were favorable (healed wound, no signs of
infection). Nerve repair had to be postponed relatively
often in those patients, because of prolonged treatment
of associated craniocerebral and thoraco-abdominal
injuries or because of complications in nerve injury
region (retarded wound healing, bone fracture complications). Of course, if the radial nerve condition was
unknown immediately after the injury, clinical and neurophysiological assessment during at least 34 months
were necessary, to exclude those injuries where the primary mechanism has been neuropraxic or axonotmetic.
Such patients were the most frequent in our series.
According to some literature data, operation may be
delayed safely for 36 months, but further delay may
endanger successful outcome, because distal endoneural
tubes have been closed progressively and disproportion in size appears between proximal and distal stump
[19, 26, 27]. Delay of operation for more than a year
almost makes a good outcome impossible [19, 26]. This
especially applies to high repairs, where such delay
leads to critical denervation period of 1824 months.
In our results significant worsening of outcome with
an interval longer than 6 months must be noted.
Several authors reported better results of repair in
younger patients [16, 23, 25]. Perhaps the explanation
lies in the shorter distance regenerating axons have to
pass through in children, though experimental work
points out also the longer latent period between the
injury and the beginning of the re-innervation in older
patients, as well as faster and more intensive increase of
muscle protein substance after re-innervation in younger
people.
There were no extremely young and extremely old
patients in our series, but still the age influenced the
outcome significantly. Although statistical processing
of our results point out that worsening of the outcome

1191

Missile severances of the radial nerve

begins with the age above 30 years and is the most

prominent with the age above 40 years; one has to
accept such conclusion with serious reserves, taking into
consideration the small coefficient of contigency for
Pearsons test (C 0.28).
Authors who claim that direct radial nerve suture is
significantly better than nerve grafting are small in number [23]. The majority of authors consider that results
after direct suture and nerve graft are similar in outcome
but after direct suture is slightly better [2, 5, 13, 16, 20].
Our results bear this out as well, because successful
outcome was noted in 89.3% of patients treated by direct
suture and in 82.7% of patients treated with nerve graft.
Although pain syndromes are not frequent after complete radial nerve severances, due to missiles in relation to
such injuries involving some other nerves (tibial, median,
and ulnar), some comments upon this subject are necessary. We did not find true causalgia (complex regional
pain syndrome type II) in our series. Eight patients suffered neuropathic permanent pulsatile pain of variable
intensity in the distribution of the radial nerve that started
in the first ten days after injury and ceased postoperatively
in a specific manner: in the first three days the pain immediately ceased to 50% of its preoperative intensity, but
after that it ceased slowly and gradually in the following
6 months. Four patients had painful neuromas, either on
the stump of the severed nerve or at the point of previously performed nerve suture. Clinical presentation
was in the form of severe local pain during palpation,
associated frequently with distal paresthesias. After nerve
suture or interfascicular neurolysis at the site of the previous repair pain was cured in all cases.
Conclusions
On the basis of the results obtained we may conclude
as follows:
The level of radial nerve severance caused by missile
injury significantly influences the outcome of repair:
motor recovery and total outcome are significantly
worse after high repairs, than after intermediate and
low repairs. However, good outcome is possible after
high repairs as well, making such repairs useful.
The outcome is also influenced significantly by the
length of nerve defect, duration of preoperative interval and patients age, but not by the manner of the
repair (direct suture vs. nerve graft).
After intermediate level of repair, the patients are
significantly less satisfied with recovery, than one
can expect on the basis of motor recovery, while after

high and low repairs good correlation exists between

motor recovery, EMNG recovery and patients judgement of the outcome.

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Comments
The Authors describe the outcome of repairs of the severance of the
radial nerve in a war situation. This is a meticulous study in a large
number of patients and conditions have been assessed regarding the
outcome. The classical factors that influence the outcome of nerve injury
and repair are confirmed such as the length of the nerve defect and the
duration of pre-operative interval and age of the patient.
Of interest also was of course that the outcome was worse after a high
radial nerve injury and repair then after intermediate or lower repairs.
Thomas Carlstedt
Stanmore, UK
This paper discusses a large number of patients with Radial Nerve
Repairs due to missile injuries. As emphasised by the author, missile
injuries are not that common in the literature.
Veer Singh Mehta
New Delhi
Correspondence: Dr. Zoran Roganovic, Pedje Milosavljevica 16=26,
Novi Beograd 11077, Serbia and Montenegro. e-mail: roganovic@
yubc.net