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American Association for Hand Surgery

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Early Operative Intervention for Neurologic Deficits After Upper Extremity Gunshot Wounds
Ryan A Hoffman, MD, John Ibrahim, MD, Stephen Silva, MD and Katharine T Woozley, MD, Einstein Healthcare Network, Philadelphia, PA

INTRODUCTION:
Reported rates of nerve injury after upper extremity (UE) gun shot wound (GSW) are 15-45%. Since some nerve palsies can resolve without operative intervention, many surgeons prefer initial observation; however, this may delay diagnosis of neurotmesis and surgical treatment. We aimed to determine the incidence and predictors of UE nerve transection in adults by GSW mechanism who received surgical treatment.

METHODS:
This was a retrospective chart review approved by the institutional review board. Operative records of five Orthopedic surgeons between 2014-2019 were filtered for ICD-10 and CPT codes cross-referenced to include both UE GSW assault and nerve injuries. Inclusion criteria consisted of age greater than 18 at time of injury, neurologic deficit on presentation, and surgical exploration of nerve. Records were reviewed for degree of nerve injury, procedure performed and complications. Post-operative outcomes included nerve recovery, complications, and reoperation rate.

RESULTS:
There was a total of 17 enrolled patients. The incidence of complete nerve transection was 64.7%. The most common location of GSW was the hand (70.5%).
Average time from presentation to surgery was 26.1 days. There were 14 identifiable nerve injuries—complete transection in 11, partial transection in 1, and contusion in 2 patients. Of patients with nerve transection, 72.7% sustained a fracture. There were 19 fractures in 17 patients and the ulna was the most common fracture. 57% of patients with hand fractures had a degree of nerve laceration.
Post-operative complications included stiffness, chronic pain, and wound infection. Re-operation rate was 29.4%. Average post-operative follow-up was 4.4 months. There was longer follow-up among nerve transection patients (5.3 months) compared to neuropraxia patients (2.68 months).

DISCUSSION/CONCLUSION:
This study demonstrates a higher incidence of nerve transection due to GSW mechansim than reported in the literature. Predictors of nerve transection are GSW to the hand and associated fracture. Our data support earlier operative intervention for patients presenting with UE GSW nerve palsies.


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