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Examining the Dogma of "Watchful Waiting" in Firearm-related Nerve Injuries: Are nerve Transection Injuries Unrecognized?
Emma Claire Avery, MD, MSc; Harry Lau, BSc; Jana Dengler, MD, MASc
University of Toronto, Toronto, ON, Canada

Introduction: Firearm-related extremity trauma with nerve injury can lead to life-altering impairment and disability. The current management for these blunt injuries is “watchful waiting”. However, nerve transection secondary to firearm trauma requires operative management and failure to identify transection injuries can lead to delayed surgical management and loss of functional recovery. The purpose of our study was to evaluate the occurrence of nerve injury in firearm-related injuries at a Level 1 trauma centre and to identify the rate of nerve transection in firearm-related peripheral nerve injuries. The secondary aim was to evaluate assessments that can aid in early diagnosis.
Materials & Methods: Following Ethics Board approval, the trauma and emergency databases at a Level 1 trauma centre were reviewed to identify patients who sustained firearm-related extremity nerve injuries between January 2000 and January 2020. Retrospective chart review of clinical notes and electrodiagnostic data were used to confirm the nerve injury. Demographic data, injury details, imaging and electrodiagnostic data, treatment plans and functional outcomes were collected.
Results: A total of 1957 patients sustained trauma from firearms between 2000 and 2020 and 9% (n=86) suffered a peripheral nerve injury (95% male, median age 25 [IQR 21-33]. A total of 121 peripheral nerves were affected and the most common nerves were: radial (n=29, 24%); ulnar (n=28, 23%); median (n=21, 18%); and sciatic (n=15, 12%). Surgical exploration (n=19) and/or high definition ultrasound imaging (n=2) confirmed nerve transection (neurotmesis) in 22% of cases (n=21) and in-continuity lesion (axonotmesis) in 20% (n=20). Only thirty-nine percent of nerve injuries (n=38) recovered spontaneously. The remaining 19% (n=19) did not recover function spontaneously; the presence of nerve transection versus in-continuity lesion was unknown due to lack of investigation. There was no significant difference between the severity of nerve injury and the patient’s overall injury severity score (p=0.27). Compared to those injuries which recovered spontaneously within 3 months, neurotmetic injuries had a significant increase in the likelihood of concomitant vascular injury (p=0.002); there was no significant difference compared to axonotmetic injuries (p=0.16). Operative management (n=29, 24%) included: nerve repair n=14, nerve graft n=10, nerve transfer n=2, and tendon transfer n=7.
Conclusions: Our study found nerve transection in 22% of closed firearm-related peripheral nerve injuries. High-definition ultrasound is a promising tool to identify nerve transection and can help to guide early treatment following extremity trauma from firearms. We suggest that the dogma of watchful waiting in firearm-related nerve injuries be re-examined.


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