Nerve Injury to the Upper Extremity after a Gunshot Wound: A Systematic Review
Thomas J Ergen, MD1, Kyros Ipaktchi, MD2, Fraser J Leversedge, MD1 and Alexander Lauder, MD2, (1)University of Colorado School of Medicine, Aurora, CO, (2)Denver Health Medical Center, Denver, CO
Gunshots can cause low energy penetrating trauma. The neurologic impact from the projectile results in a spectrum of injury from neuropraxia to laceration. Historically, these nerve deficits have been observed with a watch and wait approach. We aimed to find out what the incidence of nerve laceration was in patients who suffered nerve deficits from a gunshot wound in the literature.
We identified 111 articles through a pubmed search looking at gunshot wounds AND nerve injury AND upper extremity. Each article had the title and abstract read in full. Articles were removed if they were not in the English language or the abstract did not reference upper extremity nerve injury. Thirty-five articles were then included and read in full. Articles were excluded if they didn't reference upper extremity nerve injury, was a wartime study, or didn't have extractable data. We found 10 articles and included them in our study. We evaluated patients with nerve palsies at the time of injury and whether the exploration showed a lacerated nerve. Early exploration was within 6 weeks of injury, and late exploration was later than 6 weeks.
In the early exploration group, there were 97 explored nerves with 30 nerves lacerated (30.1%). In the late exploration group, there were 102 explored nerves with 40 nerves lacerated (39.2%). A total of 70 nerves were found to be lacerated out of 199 explorations (35.2%). The percent of palsies that recovered was 64.3%.
The incidence of nerve laceration was high enough to point out that the historical dogma that these injuries will recover with the watch and wait approach may not be ideal. Early nerve exploration would be beneficial in some settings. There are several pros to doing an early exploration in the setting of a nerve palsy after a gunshot wound. One can explore a wound that would be devoid of scar which helps identify nerve injury much easier. One can decide to graft/repair or come back in 2-3 weeks for definitive treatment. There would be no delay in treatment as one would have with the watch and wait approach. We believe that a future prospective study should be performed to help confirm the incidence of nerve laceration and determine outcomes for the acute intervention.
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