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Gunshot-Related Upper Extremity Nerve Injury: A Systematic Review and Meta-Analysis
Helene Retrouvey, MD PhD1, Cecile Harmange, MD2, Moaath Saggaf, MD3, Fraser J Leversedge, MD1 and Alexander Lauder, MD4, (1)University of Colorado, Aurora, CO, (2)University of Colorado School of Medicine, Aurora, CO, (3)University of Toronto, Toronto, ON, Canada, (4)Denver Health Medical Center, Denver, CO

Purpose: Optimal management of upper extremity nerve palsy caused by ballistic gunshot injury remains controversial. The aim of this systematic review was to summarize the available evidence on the management of nerve injuries following ballistic trauma.
Methods: A literature search was completed for the keywords: “Upper extremity�, “Nerve Injury� and “Ballistic�. Two independent reviewers performed a systematic screening of all articles and collected data from relevant publications. The data were summarized and pooled using a random-effect model.
Results: Fourteen studies met inclusion criteria. Cohorts of between 6 to 168 patients with upper extremity gunshot injuries were reported. Neurologic deficits were present in 45% (95%CI: 38-52%) of patients at the time of injury evaluation. Acute nerve exploration was performed in 19% (95%CI: 9-32%) of patients with gunshot injuries and in 50% (95%CI: 27-73%) of patients with clinical nerve deficits. Surgical findings included nerve continuity (49%; 95%CI: 14-84%), nerve contusion (30%; 95%CI: 12-50%), or nerve transection (31%; 95%CI: 14-50%). Nerve transection rates found at the time of exploration ranged from 0% to 71%. Outcomes were good in 62% (95%CI: 41-81%); however, outcomes analyses were limited by subjective outcomes reporting of the included studies.
Conclusions: Contrary to traditional teaching that gunshot injuries predominantly cause neuropraxia, our review highlights that up to 71% of nerve injuries resulting from ballistic trauma produce neurotmesis or axonotmesis injuries. Current data advocate for a higher prioritization of early nerve exploration when neurologic deficit persists in the setting of ballistic injury.

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