Elsevier

The Journal of Hand Surgery

Volume 47, Issue 1, January 2022, Pages 88.e1-88.e6
The Journal of Hand Surgery

Scientific Article
Gunshot-Related Upper Extremity Nerve Injuries at a Level 1 Trauma Center

https://doi.org/10.1016/j.jhsa.2021.03.020Get rights and content

Purpose

Gunshot wounds can result in a spectrum of injuries to nerves, with little data to guide definitive treatment. We performed a retrospective evaluation of gunshot-related upper extremity injuries in an urban trauma center to analyze epidemiology, associated injuries, and short-term outcomes. We hypothesized that gunshot-related injuries would involve soft tissue cavitation, inducing axonotmesis and neuropraxia rather than neurotmesis injuries.

Methods

All patients over the age of 16 with upper extremity gunshot trauma from May 2018 to May 2019 were identified through the University of Chicago orthopaedic and general surgery trauma databases. Initial nerve injuries were identified by physical examination. Patient demographic data, soft tissue and skeletal injury, treatment modality, and return of function were collected.

Results

Ballistic injuries in 1302 patients were treated over 12 months. We identified 126 upper extremity gunshot injuries in 117 patients. Thirty-eight upper extremities (38 patients) had a documented nerve deficit (38/126, 30%) with a follow-up rate of 94% (34/36) at a mean of 351 days after injury (median, 202 days; range, 13-929 days). One patient had a subacute transradial amputation, and 1 patient was deceased at final follow-up. The presence of vascular injury and fracture increased the rate of neurologic injury after gunshot injuries. At the most recent follow-up, 68% (23/34) of patients with upper extremity injury had improvement in nerve function as measured by objective clinical assessment, with 24% (8/34) experiencing full recovery at an average of 368 days (median, 261 days; range, 41–929 days).

Conclusions

Nerve injury after ballistic trauma to the upper extremity is common. Vascular injury and fractures were associated with a higher risk of nerve injury. Short-term improvement in nerve function was seen in over half the cohort, suggesting a predominance of neuropraxic effects.

Type of Study/Level of Evidence

Prognostic IV.

Section snippets

Materials and Methods

The University of Chicago institutional review board approved study of patients over 16 years of age presenting with gunshot-related traumatic injury to the upper extremities at our level 1 trauma center. Between May 2018 and May 2019, 1,302 patients presented to our institution as trauma level activations. All patients identified as having upper extremity ballistic trauma were included in this study. Reviews of the University of Chicago orthopaedic and general surgery trauma databases were

Results

Our trauma center treated ballistic injuries in 1,302 patients over a 12-month period. Of these, 650 patients were coded with extremity gunshot wounds in an audit of our general surgery trauma database. Upon detailed chart review, 113 patients had superficial gunshot wounds that did not breach the fascia and were excluded. Of all ballistic trauma activations, an additional 135 patients (10%) were initially coded as extremity gunshot injuries by the trauma research staff, in most cases because

Discussion

Gunshot wounds to the extremities can lead to permanent neurovascular injury, chronic pain, and disability.7,13, 14, 15, 16, 17 The mechanism of nerve injury from ballistic missiles has been described as both a direct impact from the projectile traveling through tissue, as well as the shock wave and cavitation that expands the zone of injury, but reports of the frequency of nerve palsy are highly variable.14,18, 19, 20, 21 Nerve injuries after gunshot wounds have been previously reported; a

References (33)

  • A. Byrne et al.

    Necessity breeds invention: a study of outpatient management of low velocity gunshot wounds

    Emerg Med J

    (2006)
  • A. Burg et al.

    Treating civilian gunshot wounds to the extremities in a level 1 trauma center: our experience and recommendations

    Isr Med Assoc J

    (2009)
  • C.T. Pereira et al.

    Outcomes of complex gunshot wounds to the hand and wrist: a 10-year level I urban trauma center experience: reply

    Ann Plast Surg

    (2013)
  • A. Compston

    Aids to the investigation of peripheral nerve injuries. Medical Research Council: Nerve Injuries Research Committee. His Majesty’s Stationery Office: 1942; pp. 48 (iii) and 74 figures and 7 diagrams; with aids to the examination of the peripheral nervous system. By Michael O’Brien for the Guarantors of Brain. Saunders Elsevier: 2010; pp. [8] 64 and 94 Figures

    Brain

    (2010)
  • R.B. Griggs et al.

    Gabapentin alleviates affective pain after traumatic nerve injury

    Neuroreport

    (2015)
  • G.E. Omer

    Injuries to nerves of the upper extremity

    J Bone Joint Surg Am

    (1974)
  • Cited by (6)

    No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

    View full text