Brachial Gunshot Wounds: Injury Patterns and Considerations for Managing the Abnormal Neurological Exam
David Chi, MD, PhD1, Damini Tandon, MD2, Adam G Evans, M.D.3, Danielle Jere Brown, BS, MS, MD2, Rachael Marie Payne, MD2, Amelia C Van Handel, M.D.4, Kevin G Shim, MD, PhD2, Susan E Mackinnon, MD, FRCS(C), FACS5 and Mitchell A Pet, M.D.6, 1Washington University in St. Louis, Division of Plastic and Reconstructive Surgery, St. Louis, MO, 2Washington University in St. Louis, Saint Louis, MO, 3Vanderbilt University Medical Center, Nashville, TN, 4The Curtis National Hand Center at Union Memorial Hospital, Baltimore, MD, 5Washington University School of Medicine, St. Louis, MO, 6Washington University School of Medicine, Saint Louis, MO
Introduction:
Nerve injuries from gunshot wounds to the upper arm can cause significant morbidity and loss of function. However, indications for surgical exploration and nerve reconstruction remain unclear as both low- and high-grade injuries can present with an abnormal neurological exam. If these injuries are not appropriately diagnosed and treated, patients can result in avoidable compromise to function and persistent disability
Materials and Methods:
Adult patients presenting with a history of isolated gunshot wound to the upper arm between 2010-2019 at a single urban level 1 trauma center were screened for inclusion in this retrospective study. Patient demographics, neurological exam findings, concurrent injuries, and intra-operative findings were gathered. Bivariate analysis was performed to characterize factors associated with nerve injuries.
Results:
There were 797 adult patients with gunshot wounds to the upper extremity. After the appropriate exclusion criteria were applied, there were 139 adult patients with isolated brachial gunshot wounds in the study cohort, and 49 patients (35%) presented with an abnormal neurological exam. Concurrent injuries that were significantly associated with an abnormal neurological exam were humerus fractures (39% vs 21%, p=0.026) and brachial artery injuries (31% vs 2%, p<0.001). Thirty of these 49 patients were operatively explored. Fifteen patients were found to have observed nerve injuries during operative exploration including 8 patients with nerve transections. The radial nerve was the most commonly transected nerve (6), and among the 16 contused nerves, the median (8) was most common.
Conclusion:
Nerve injury from upper arm gunshot wounds is relatively common with directly traumatized nerves in at least 39% and nerve transection in at least 16% of patients with an abnormal neurological exam. The accepted expectation of neurapraxic injury and impending functional recovery after gunshot wounds has led to a bias towards passive watchful waiting. In a challenging patient population, there is a substantial chance that nerve recovery may not be forthcoming. Timely referral to a hand and/or peripheral nerve surgeon for close clinical follow-up and functional reconstruction with nerve grafts, tendon transfers, and nerve transfers is recommended.
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