Comparative Surgical Outcomes in Ballistic Peripheral Nerve Injuries: A Single-Surgeon Experience and Mechanism-Based Classification of Gunshot versus Shrapnel Trauma

Ballistic peripheral nerve injuries are increasingly encountered in both military and civilian practice. Injuries caused by high-velocity bullets and by shrapnel differ significantly in mechanism, pathological characteristics, and clinical behavior. To compare bullet-related and shrapnel-related peripheral nerve injuries with respect to injury mechanisms, intraneural foreign bodies, neuropathic pain, motor deficit severity, surgical strategy, timing of intervention, and outcomes, and to define optimal microsurgical management principles. A structured review was conducted on 107 patients, including cases previously published by Rochkind et al. (2000, 2002, 2007, 2014) and additional recent clinical experience. Analysis focused on injury morphology, indications for neurolysis versus nerve grafting, timing of surgery, and prognostic factors. Only limb peripheral nerve injuries were included; brachial plexus injuries were excluded. Shrapnel injuries demonstrated higher rates of intraneural foreign bodies (≈55%) and severe neuropathic pain (≈95%) than bullet injuries (≈4–5% and ≈73%). Severe motor deficits (MRC <3) were more common in bullet injuries (≈90%) than in shrapnel injuries (≈62%). Pain improvement was greater after bullet injuries, whereas nerve grafting provided superior pain relief in shrapnel injuries. Early surgery (<3 months) significantly improved pain outcomes in shrapnel injuries. Bullet injuries are typically focal and static, whereas shrapnel injuries are diffuse and progressive. Early microsurgical exploration with foreign-body removal and selective nerve grafting is recommended for shrapnel injuries, while bullet injuries benefit from continuity-based reconstruction strategies. • Gunshot and shrapnel peripheral nerve injuries represent distinct biological entities • Shrapnel injuries are progressive and frequently associated with intraneural foreign bodies • Neuropathic pain is more severe and more refractory in shrapnel-related nerve injuries • Early microsurgical intervention (<3 months) improves pain outcomes in shrapnel trauma • Nerve grafting is more effective than neurolysis alone for pain control in shrapnel injuries