Ballistic Nerve Injuries of the Extremities: A Systematic Review of Diagnosis, Timing, Treatment, and Outcomes

Ballistic peripheral nerve injuries (PNIs) are a distinct and complex form of nerve trauma caused by high-energy mechanisms and frequently accompanied by soft tissue and skeletal damage. Despite their prevalence in both military and civilian trauma, the literature on diagnosis, timing, treatment, and outcomes remains fragmented. We conducted a systematic review of PubMed, Embase, and Scopus (1975-2025) following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and included 27 studies with more than 2500 patients that reported original data on ballistic PNIs. Diagnostic approaches were inconsistent, with variable use of electrodiagnostics, imaging, and clinical assessment. The timing of diagnosis and surgery ranged from days to more than a year postinjury, and surgical strategies included neurolysis, direct repair, and nerve grafting. Outcome reporting was heterogeneous, with motor recovery often assessed using the Medical Research Council scale, while sensory and functional outcomes were less consistently measured and rarely evaluated with validated instruments. Across studies, many patients achieved partial motor recovery, but the lack of standardized diagnostic protocols and uniform outcome measures limited comparability. Overall, the evaluation and management of ballistic PNIs remain highly variable, underscoring the need for standardized diagnostic pathways and consistent, validated outcome reporting to guide future research and clinical care.