Outcomes in Ballistic Injuries to the Hand: Fractures and Nerve/Tendon Damage as Predictors of Poor Outcomes
Patrick M Dugom, BS1, Mitchell Jester, BS1, Joshua Scarcella, BS1 and Yifan Guo, MD2, (1)Brody School of Medicine at East Carolina University, Greenville, NC, (2)Brody School of Medicine, Greenville, NC
Introduction: Firearms were responsible for nearly 40,000 deaths in 2017. Case reports and meta-analyses of ballistic injuries primarily focus on cases involving the trunk. However, gunshot wounds to the upper extremity, and more specifically the hand, have not been thoroughly investigated in the literature. This study proposed that ballistic associated fractures of the hand could be used as an indicator of nerve and tendon involvement, and future permanent complications.
Methods: A retrospective chart review of patients with gunshot injuries to the upper extremity at a single, level 1 trauma center in a 2-year period between 2016 and 2017 was conducted. Patient demographics and mechanisms of injuries were reviewed. Only patients sustaining ballistic injuries distal to the elbow were included. Injury patterns, gunshot locations, tendon and neurovascular involvement, and bony involvement were assessed. Surgical interventions and long-term outcomes were reviewed. Patient outcomes were evaluated using the presence of fractures and nerve/tendon involvement as independent variables.
Results: A total of 32 patients met the inclusion criteria for our study. This group was comprised of 15 patients who sustained gunshot injuries to the hand, 10 patients to the fingers, and 7 patients involving both the fingers and hand. Of these, 21 patients (65.6%) had fractures, and 16 patients (50%) had tendon and/or nerve involvement. The presence of metacarpal or phalangeal fractures were associated with a 7.9-fold increase in nerve or tendon injuries (71.4% vs. 9.1%, p = 0.03) (Table 1). Furthermore, 8 patients (25%) had long term disability, including permanent nerve damage, weakness, decreased range of motion, or pain. The presence of tendon and nerve injuries were more likely associated with poor outcomes (p = 0.01) (Table 2). Poor outcomes were also associated with patients who sustained fractures, although this was not statistically significant (p = 0.13) (Table 2).
Conclusion: Although only 25% of the patients in this study had poor outcomes, of these individuals, 87.5% had both fracture and nerve/tendon involvement. Though this sample represents a small percentage of total ballistic-associated hand injuries, the presence of damage to these structures may indicate a higher likelihood of permanent deficits. This study is meant to serve as a foundation for further investigation in to gunshot-related metacarpal or phalangeal fractures in an effort to increase suspicion and workup for tendon and nerve injuries for better prognostic outcomes.
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