Abstract
PURPOSE: Extremity trauma resulting from firearms can lead to significant nerve injuries. These injuries have traditionally been conceptualized as ‘closed injuries’, wherein nerve transection (neurotmesis) is less likely and the capacity for spontaneous regeneration is higher, and have thus been managed with ‘watchful waiting.’ However, misdiagnosis of neurotmetic injuries as lower grade injuries results in treatment delay and poor functional recovery. The purpose of our study was to identify the rate of neurotmetic injuries in extremity firearm traumas at a level 1 trauma centre, and assess the trends in management and functional outcomes over time. METHOD: The Sunnybrook Health Sciences Centre trauma and emergency databases were used to identify patients who sustained firearm-related nerve injuries to the upper and lower extremities between January 2000 and January 2020. All patients who had a confirmed nerve injury by physical exam or electrodiagnostic studies were included in the study. Digital nerve injuries and other minor sensory nerve injuries were excluded. 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, of which 931 patients sustained injuries to the upper or lower extremities. Eighty-six patients (9%) had a confirmed nerve injury in 87 limbs; 62 in the upper extremity (71%) and 25 in the lower extremity (29%). A total of 120 nerves were affected; median (n=21, 18%), ulnar (n=28, 23%), radial (n=29, 24%), sciatic (n=15, 13%) and brachial plexus (n=9, 8%) nerve injuries were most common. The median [interquartile range] duration of time between injury and diagnosis was 0 [0-1] days. Twenty-seven percent (n=26) of nerve injuries were confirmed to be nerve transections. The majority of nerve transactions had associated vascular injuries (n=20, 77%); nerve transaction was associated with a fracture in 9 cases (35%). Diagnosis of neurotmesis was aided by early surgical exploration and targeted nerve imaging. Median [interquartile range] duration of hospitalization and follow-up was 8 [2-12] days and 202 [86-394] days, respectively. Superior functional outcomes correlated with earlier surgical intervention. CONCLUSION: Extremity trauma resulting from firearms can result in devastating nerve injuries. Early targeted imaging (ultrasound, MRI) can identify the presence of nerve transection, which warrants early surgical management and improves functional outcomes.
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