The Importance of Early Exploration in Ballistic Peripheral Nerve Injury
Andrew I Abadeer, M.D. M.Eng.1, Rajiv Parikh, MD2, Kelsey A Rebehn, MD3, Kevin O'Malley, MD3 and Grant M Kleiber, MD4, 1Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, 2MedStar Plastic and Reconstructive Surgery, Washington Hospital Center and Georgetown University School of Medicine, Washington, DC, 3Medstar Washington Hospital Center, Washington, DC, 4Washington Hospital Center, Washington, DC
Background: Gun violence continues to increase year over year.1 While traditional teaching has advocated for a “watch and wait” approach to ballistic nerve injuries, many patients treated with this paradigm fail to recover distal function and subsequently require tendon and nerve transfers.2,3 This study describes our experience with early exploration in ballistic peripheral nerve injuries in an urban trauma center.
Methods: A retrospective review was performed for ballistic peripheral nerve injuries since February 2022. Data collection included demographic data, number of gunshot wounds (GSW’s), concomitant vascular/orthopedic injury, and peripheral nerve outcomes. Early exploration was defined as exploration within the primary hospitalization. Primary outcome was nerve transection at initial exploration.
Results: Seventeen patients met inclusion criteria. All patients were male with an average age of 33±10.7 years with an average number of 3.5±2.6 GSW’s. Of these, 47.1% (N= 8) of patients had a concomitant vascular injury, and 58.8% (n=10) demonstrated a concomitant fracture. Eleven patients (64.7%) underwent early exploration with a mean of 16 days from injury to exploration. Among these, 70% (N=7) demonstrated nerve transection injury requiring reconstruction. Four of these eleven patients had injury to a named vessel, three patients had ballistic tracking through a constrained nerve entrapment point, and two patients demonstrated retained bullet fragments on radiography. Five patients had delayed reconstruction necessitating tendon transfers. Time to exploration in these delayed patients was 270 days with lack of demonstrable neural recovery.
Conclusions: Early exploration of ballistic peripheral nerve injuries allows for early detection of transected nerves and their prompt reconstruction. The “watch and wait” approach can cost these patients critical time in the reinnervation window. Certain criteria are highly suspicious for nerve transection in ballistic trauma. Patients with 1-transection injury to a major vessel in the same neurovascular bundle, 2-projectile tracking through a constrained neural entrapment point, and 3- evidence of sharp fragmentation such as large exit wound or retained fragments have a high probability of neural transection injury requiring reconstruction.
References
1.Gramlich J. What the data says about gun deaths in the US Pew Research Center. February 3, 2022.
2. Mathieu L, Goncalves M, Murison JC, Pfister G, Oberlin C, Belkheyar Z. Ballistic peripheral nerve injuries: basic concepts, controversies, and proposal for a management strategy. European Journal of Trauma and Emergency Surgery. 2022;48(5):3529-39.
3. Hollerman JJ, Fackler M, Coldwell D, Ben-Menachem Y. Gunshot wounds: 1. Bullets, ballistics, and mechanisms of injury. AJR American journal of roentgenology. 1990;155(4):685-90.
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