Examining the Dogma of “Watchful Waiting” in Firearm-Related Nerve Injuries: Are We Under Treating?

Abstract

Introduction: Firearm-related extremity trauma can lead to significant, life-altering, nerve injuries. The current dogma for treating these injuries is “watchful waiting.” However, nerve transection secondary to firearm trauma does occur, and these injuries require operative management. Failure to recognize higher grade injuries can lead to delayed surgical management and loss of functional recovery. The purpose of our study was to identify the rate of nerve transection in firearm-related peripheral nerve injuries at a level 1 trauma centre, and to evaluate useful diagnostic tools that can aid in early diagnosis. Materials and Methods: The Sunnybrook Health Sciences Centre trauma and emergency databases were used to identify patients who sustained firearm-related extremity nerve injuries between January 2000 and January 2020. Retrospective chart review of clinical notes and electrodiagnostic data was used to confirm the presence of nerve injury. Demographic data, injury details, imaging and electrodiagnostic data, treatment plans and functional outcomes were collected. Results: A total of 1957 patients sustained trauma from firearms between 2000 and 2020 of which 9% (n = 86) suffered a peripheral nerve injury, with a total of 121 peripheral nerves affected. Surgical exploration and/or high definition ultrasound imaging confirmed nerve transection (neurotmesis) in 22% of cases (n = 21) and high-grade axonotmesis in 20% of cases (n = 20). Only 39% of nerve injuries (n = 38) represented a neuropraxic injury which resolved spontaneously. Of those with higher grade injuries, management included nerve repair (n = 14), nerve grafting (n = 6), nerve transfers (n = 2) and tendon transfers (n = 3). No significant difference was found between the severity of nerve injury and the patient’s overall injury severity score (p > 0.05). Nerve transections had a higher likelihood of concomitant vascular injury. Conclusion: Our study found a 22% rate of nerve transection in closed firearm-related peripheral nerve injuries. High-definition ultrasound is a useful adjunct in diagnosing nerve transections, and can help guide early treatment following extremity trauma from firearms.