Peripheral nerve traction injury. Literature review




peripheral nerve injury, traction mechanism of injury, pathogenesis, biomechanics of injury, classification of injury degrees


Traction injury of the peripheral nerve (TIPN) is an injury that occurs as a result of stretching the nerve beyond its normal elastic properties. An analysis of the available literature has revealed the following. TIPN is the most common type of severe nerve injury in the setting of road traffic accidents, catatrauma, gunshot wounds, birth injuries, etc. The dynamics of TIPN during fast and slow stretching is the same and includes three phases: elastic, inelastic and tearing. The limits of elastic stretching of the nerve are determined by the degree of tortuosity of myelinated fibers and the elasticity of the connective tissue framework of the nerve. Stretching of the nerve beyond its elastic limits is characterized by rupture of axons and endoneurial sheaths, including at a considerable distance from the epicenter of pathomorphological changes, which determines the severity of the injury and the impossibility of effective nerve autoregeneration. The force of stretching and the direction of its application to the nerve trunk determine the severity of TIPN. The degree of nerve stretching varies along its length and reaches a maximum in the periarticular areas. A fairly moderate stretching of the nerve can lead to a noticeable change in the conductivity of electrical impulses. Unlike other localized types of nerve injury, the pattern of pathomorphological changes in TIPN includes various forms of damage to structural elements. Understanding the pathophysiology of TIPN is a prerequisite for the development of optimal treatment of this type of injury.


1. Lopes B, Sousa P, Alvites R, Branquinho M, Sousa AC, Mendonça C, Atayde LM, Luís AL, Varejão ASP, Maurício AC. Peripheral Nerve Injury Treatments and Advances: One Health Perspective. Int J Mol Sci. 2022 Jan 14;23(2):918. [CrossRef] [PubMed] [PubMed Central]

2. Stashkevich AT. [Clinic, diagnostics and microsurgical treatment of damaged peripheral nerves with their simultaneous damage at different levels] [dissertation]. Kyiv (Ukraine): Kyiv Institute of Neurosurgery; 1988. Russian.

3. Lovaglio AC, Socolovsky M, Di Masi G, Bonilla G. Treatment of neuropathic pain after peripheral nerve and brachial plexus traumatic injury. Neurol India. 2019 Jan-Feb;67(Supplement):S32-S37. [CrossRef] [PubMed]

4. Tsymbalyuk VI, Yaminskyi YY. [Results of surgical treatment of neuropathic pain syndrome in patients with consequences of traumatic and non-traumatic spinal cord injuries]. Ukrainian Neurosurgical Journal. 2009(3):53a. Ukrainian.

5. Karsy M, Watkins R, Jensen MR, Guan J, Brock AA, Mahan MA. Trends and Cost Analysis of Upper Extremity Nerve Injury Using the National (Nationwide) Inpatient Sample. World Neurosurg. 2019 Mar;123:e488-e500. [CrossRef] [PubMed]

6. Foster CH, Karsy M, Jensen MR, Guan J, Eli I, Mahan MA. Trends and Cost-Analysis of Lower Extremity Nerve Injury Using the National Inpatient Sample. Neurosurgery. 2019 Aug 1;85(2):250-256. [CrossRef] [PubMed]

7. Campbell WW. Evaluation and management of peripheral nerve injury. Clin Neurophysiol. 2008 Sep;119(9):1951-65. [CrossRef] [PubMed]

8. O’Berry P, Brown M, Phillips L, Evans SH. Obstetrical Brachial Plexus Palsy. Curr Probl Pediatr Adolesc Health Care. 2017 Jul;47(7):151-155. [CrossRef] [PubMed]

9. Chang KW, Yang LJ, Driver L, Nelson VS. High prevalence of early language delay exists among toddlers with neonatal brachial plexus palsy. Pediatr Neurol. 2014 Sep;51(3):384-9. [CrossRef] [PubMed] [PubMed Central]

10. Coroneos CJ, Voineskos SH, Christakis MK, Thoma A, Bain JR, Brouwers MC; Canadian OBPI Working Group. Obstetrical brachial plexus injury (OBPI): Canada’s national clinical practice guideline. BMJ Open. 2017 Jan 27;7(1):e014141. [CrossRef] [PubMed] [PubMed Central]

11. Thatte MR, Nayak NS, Hiremath AS. Management of Birth Brachial Plexus Injury Including Use of Distal Nerve Transfers. J Hand Surg Asian Pac Vol. 2020 Sep;25(3):267-275. [CrossRef] [PubMed]

12. Rider Sleutel M, True B, Webb J, Valdez E, Van Thi Tran M. Integrative Review of Lower Extremity Nerve Injury During Vaginal Birth. J Obstet Gynecol Neonatal Nurs. 2020 Nov;49(6):507-524. [CrossRef] [PubMed]

13. Rayner MLD, Brown HL, Wilcox M, Phillips JB, Quick TJ. Quantifying regeneration in patients following peripheral nerve injury. J Plast Reconstr Aesthet Surg. 2020 Feb;73(2):201-208. [CrossRef] [PubMed]

14. Coroneos CJ, Voineskos SH, Coroneos MK, Alolabi N, Goekjian SR, Willoughby LI, Thoma A, Bain JR, Brouwers MC; Canadian OBPI Working Group. Primary Nerve Repair for Obstetrical Brachial Plexus Injury: A Meta-Analysis. Plast Reconstr Surg. 2015 Oct;136(4):765-779. [CrossRef] [PubMed]

15. Modrak M, Talukder MAH, Gurgenashvili K, Noble M, Elfar JC. Peripheral nerve injury and myelination: Potential therapeutic strategies. J Neurosci Res. 2020 May;98(5):780-795. [CrossRef] [PubMed] [PubMed Central]

16. Liu B, Xin W, Tan JR, Zhu RP, Li T, Wang D, Kan SS, Xiong DK, Li HH, Zhang MM, Sun HH, Wagstaff W, Zhou C, Wang ZJ, Zhang YG, He TC. Myelin sheath structure and regeneration in peripheral nerve injury repair. Proc Natl Acad Sci U S A. 2019 Oct 29;116(44):22347-22352. [CrossRef] [PubMed] [PubMed Central]

17. Nocera G, Jacob C. Mechanisms of Schwann cell plasticity involved in peripheral nerve repair after injury. Cell Mol Life Sci. 2020 Oct;77(20):3977-3989. [CrossRef] [PubMed] [PubMed Central]

18. Li R, Li D, Wu C, Ye L, Wu Y, Yuan Y, Yang S, Xie L, Mao Y, Jiang T, Li Y, Wang J, Zhang H, Li X, Xiao J. Nerve growth factor activates autophagy in Schwann cells to enhance myelin debris clearance and to expedite nerve regeneration. Theranostics. 2020 Jan 1;10(4):1649-1677. [CrossRef] [PubMed] [PubMed Central]

19. Guo W, Stoklund Dittlau K, Van Den Bosch L. Axonal transport defects and neurodegeneration: Molecular mechanisms and therapeutic implications. Semin Cell Dev Biol. 2020 Mar;99:133-150. [CrossRef] [PubMed]

20. Martín-Noguerol T, Montesinos P, Hassankhani A, Bencardino DA, Barousse R, Luna A. Technical Update on MR Neurography. Semin Musculoskeletal Radiol. 2022 Apr;26(2):93-104. [CrossRef] [PubMed]

21. Wang ML, Rivlin M, Graham JG, Beredjiklian PK. Peripheral nerve injury, scarring, and recovery. Connect Tissue Res. 2019 Jan;60(1):3-9. [CrossRef] [PubMed]

22. Soubeyrand M, Melhem R, Protais M, Artuso M, Crézé M. Anatomy of the median nerve and its clinical applications. Hand Surg Rehabil. 2020 Feb;39(1):2-18. [CrossRef] [PubMed]

23. Cattin AL, Lloyd AC. The multicellular complexity of peripheral nerve regeneration. Curr Opin Neurobiol. 2016 Aug;39:38-46. [CrossRef] [PubMed]

24. Yeoh S, Warner WS, Merchant SS, Hsu EW, Agoston DV, Mahan MA. Incorporating Blood Flow in Nerve Injury and Regeneration Assessment. Front Surg. 2022 Apr 20;9:862478. [CrossRef] [PubMed] [PubMed Central]

25. Frueh FS, Gousopoulos E, Power DM, Ampofo E, Giovanoli P, Calcagni M, Laschke MW. A potential role of lymphangiogenesis for peripheral nerve injury and regeneration. Med Hypotheses. 2020 Feb;135:109470. [CrossRef] [PubMed]

26. Frank T, Nawroth P, Kuner R. Structure-function relationships in peripheral nerve contributions to diabetic peripheral neuropathy. Pain. 2019 May;160 Suppl 1:S29-S36. [CrossRef] [PubMed]

27. Kong L, Gao X, Qian Y, Sun W, You Z, Fan C. Biomechanical microenvironment in peripheral nerve regeneration: from pathophysiological understanding to tissue engineering development. Theranostics. 2022 Jun 27;12(11):4993-5014. [CrossRef] [PubMed] [PubMed Central]

28. Davis GA. Reflections on the History of Nerve Repair - Sir Sydney Sunderland’s Final Presentation to the Neurosurgical Society of Australasia. Neurosurgery. 2020 Sep 1;87(3):E373-E382. [CrossRef] [PubMed]

29. Beris A, Gkiatas I, Gelalis I, Papadopoulos D, Kostas-Agnantis I. Current concepts in peripheral nerve surgery. Eur J Orthop Surg Traumatol. 2019 Feb;29(2):263-269. [CrossRef] [PubMed]

30. Sencar L, Güven M, Şaker D, Sapmaz T, Tuli A, Polat S. Ultrastructural effects of nerve growth factor and betamethasone on nerve regeneration after experimental nerve injury. Ultrastruct Pathol. 2020 Nov 20;44(4-6):436-449. [CrossRef] [PubMed]

31. Mtui E, Gruener G, Dockery P. Fitzgerald’s Clinical Neuroanatomy and Neuroscience. Elsevier Health Sciences; 2020 Aug 4. eBook ISBN: 9780702079108

32. Leckenby JI, Chacon MA, Grobbelaar AO, Lichtman JW. Imaging Peripheral Nerve Regeneration: A New Technique for 3D Visualization of Axonal Behavior. J Surg Res. 2019 Oct;242:207-213. [CrossRef] [PubMed]

33. Cui J, Wu S, Wang J, Wang Y, Su Y, Xu D, Liu Y, Gao J, Jing X, Bai W. Visualizing the Morphological Characteristics of Neuromuscular Junction in Rat Medial Gastrocnemius Muscle. J Vis Exp. 2022 May 17;(183). [CrossRef] [PubMed]

34. Zochodne DW, Levy D. Nitric oxide in damage, disease and repair of the peripheral nervous system. Cell Mol Biol (Noisy-le-grand). 2005 Sep 5;51(3):255-67. [PubMed]

35. Gordon T. Peripheral Nerve Regeneration and Muscle Reinnervation. Int J Mol Sci. 2020 Nov 17;21(22):8652. [CrossRef] [PubMed] [PubMed Central]

36. Menorca RM, Fussell TS, Elfar JC. Nerve physiology: mechanisms of injury and recovery. Hand Clin. 2013 Aug;29(3):317-30. [CrossRef] [PubMed] [PubMed Central]

37. Elfar JC, Jacobson JA, Puzas JE, Rosier RN, Zuscik MJ. Erythropoietin accelerates functional recovery after peripheral nerve injury. J Bone Joint Surg Am. 2008 Aug;90(8):1644-53. [CrossRef] [PubMed] [PubMed Central]

38. Adidharma W, Khouri AN, Lee JC, Vanderboll K, Kung TA, Cederna PS, Kemp SWP. Sensory nerve regeneration and reinnervation in muscle following peripheral nerve injury. Muscle Nerve. 2022 Oct;66(4):384-396. [CrossRef] [PubMed]

39. Toews AD, Barrett C, Morell P. Monocyte chemoattractant protein 1 is responsible for macrophage recruitment following injury to sciatic nerve. J Neurosci Res. 1998 Jul 15;53(2):260-7. [CrossRef] [PubMed]

40. Napoli I, Noon LA, Ribeiro S, Kerai AP, Parrinello S, Rosenberg LH, Collins MJ, Harrisingh MC, White IJ, Woodhoo A, Lloyd AC. A central role for the ERK-signaling pathway in controlling Schwann cell plasticity and peripheral nerve regeneration in vivo. Neuron. 2012 Feb 23;73(4):729-42. [CrossRef] [PubMed]

41. Geraldo S, Gordon-Weeks PR. Cytoskeletal dynamics in growth-cone steering. J Cell Sci. 2009 Oct 15;122(Pt 20):3595-604. [CrossRef] [PubMed] [PubMed Central]

42. Contreras E, Bolívar S, Navarro X, Udina E. New insights into peripheral nerve regeneration: The role of secretomes. Exp Neurol. 2022 Aug;354:114069. [CrossRef] [PubMed]

43. Mahar M, Cavalli V. Intrinsic mechanisms of neuronal axon regeneration. Nat Rev Neurosci. 2018 Jun;19(6):323-337. [CrossRef] [PubMed] [PubMed Central]

44. Yang X, Liu R, Xu Y, Ma X, Zhou B. The Mechanisms of Peripheral Nerve Preconditioning Injury on Promoting Axonal Regeneration. Neural Plast. 2021 Jan 6;2021:6648004. [CrossRef] [PubMed] [PubMed Central]

45. Panagopoulos GN, Megaloikonomos PD, Mavrogenis AF. The Present and Future for Peripheral Nerve Regeneration. Orthopedics. 2017 Jan 1;40(1):e141-e156. [CrossRef] [PubMed]

46. Cattin AL, Burden JJ, Van Emmenis L, Mackenzie FE, Hoving JJ, Garcia Calavia N, Guo Y, McLaughlin M, Rosenberg LH, Quereda V, Jamecna D, Napoli I, Parrinello S, Enver T, Ruhrberg C, Lloyd AC. Macrophage-Induced Blood Vessels Guide Schwann Cell-Mediated Regeneration of Peripheral Nerves. Cell. 2015 Aug 27;162(5):1127-39. [CrossRef] [PubMed] [PubMed Central]

47. Cattin AL, Lloyd AC. The multicellular complexity of peripheral nerve regeneration. Curr Opin Neurobiol. 2016 Aug;39:38-46. [CrossRef] [PubMed]

48. Lien BV, Brown NJ, Ransom SC, Lehrich BM, Shahrestani S, Tafreshi AR, Ransom RC, Sahyouni R. Enhancing peripheral nerve regeneration with neurotrophic factors and bioengineered scaffolds: A basic science and clinical perspective. J Peripher Nerv Syst. 2020 Dec;25(4):320-334. [CrossRef] [PubMed]

49. Taylor CA, Braza D, Rice JB, Dillingham T. The incidence of peripheral nerve injury in extremity trauma. Am J Phys Med Rehabil. 2008 May;87(5):381-5. [CrossRef] [PubMed]

50. Mathieu L, Goncalves M, Murison JC, Pfister G, Oberlin C, Belkheyar Z. Ballistic peripheral nerve injuries: basic concepts, controversies, and proposal for a management strategy. Eur J Trauma Emerg Surg. 2022 Oct;48(5):3529-3539. [CrossRef] [PubMed]

51. Horteur C, Forli A, Corcella D, Pailhé R, Lateur G, Saragaglia D. Short- and long-term results of common peroneal nerve injuries treated by neurolysis, direct suture or nerve graft. Eur J Orthop Surg Traumatol. 2019 May;29(4):893-898. [CrossRef] [PubMed]

52. Kuffler DP, Foy C. Restoration of Neurological Function Following Peripheral Nerve Trauma. Int J Mol Sci. 2020 Mar 6;21(5):1808. [CrossRef] [PubMed] [PubMed Central]

53. Plastaras CT, Chhatre A, Kotcharian AS. Perioperative lower extremity peripheral nerve traction injuries. Orthop Clin North Am. 2014 Jan;45(1):55-63. [CrossRef] [PubMed]

54. Zimmermann MS, Abzug JM, Chang J, Stern PJ, Osterman AL. Iatrogenic nerve injuries in common upper extremity procedures. Instr Course Lect. 2014;63:105-11. [PubMed]

55. Alharmoodi BY, Arumugam A, Ahbouch A, Moustafa IM. Comparative effects of tensioning and sliding neural mobilization on peripheral and autonomic nervous system function: A randomized controlled trial. Hong Kong Physiother J. 2022 Jun;42(1):41-53. [CrossRef] [PubMed] [PubMed Central]

56. Yan L, Entezari A, Zhang Z, Zhong J, Liang J, Li Q, Qi J. An experimental and numerical study of the microstructural and biomechanical properties of human peripheral nerve endoneurium for the design of tissue scaffolds. Front Bioeng Biotechnol. 2022 Dec 5;10:1029416. [CrossRef] [PubMed] [PubMed Central]

57. Mahan MA, Yeoh S, Monson K, Light A. Rapid Stretch Injury to Peripheral Nerves: Biomechanical Results. Neurosurgery. 2019 Jul 1;85(1):E137-E144. [CrossRef] [PubMed]

58. Warner WS, Yeoh S, Light A, Zhang J, Mahan MA. Rapid-Stretch Injury to Peripheral Nerves: Histologic Results. Neurosurgery. 2020 Mar 1;86(3):437-445. [CrossRef] [PubMed]

59. Mahan MA, Warner WS, Yeoh S, Light A. Rapid-stretch injury to peripheral nerves: implications from an animal model. J Neurosurg. 2019 Oct 4:1-11. [CrossRef] [PubMed]



How to Cite

Tsymbaliuk, V. I., Vorodi, M. V., Petriv, T. I., Tsymbaliuk, I. V., & Nekhlopochyn, O. S. (2023). Peripheral nerve traction injury. Literature review. Ukrainian Neurosurgical Journal, 29(3), 19–25.



Review articles