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Gupta R, Herzog I, Phung L, Roth J, Weisberger J, Luthringer M, Lee ES, Ignatiuk A. Treatment of Brachial Plexus Injuries following Gunshot Injuries: A Systematic Review. Adv Orthop 2024; 2024:7708192. [PMID: 39247210 PMCID: PMC11379507 DOI: 10.1155/2024/7708192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 08/20/2024] [Indexed: 09/10/2024] Open
Abstract
Introduction Brachial plexus injuries (BPI) from gunshot injuries are uncommon but usually severe and can cause chronic pain, loss of function, and permanent nerve damage. Multiple surgical techniques including neurolysis, end-to-end suture repair, and graft repair have been described for the treatment of these injuries. However, surgical indication, timing, and technique for these injuries remain controversial. This systematic review aims to investigate the treatment modalities for patients with BPI due to gunshot-related injuries. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology was employed for this review. PubMed, Cochrane Reviews, Embase, and CINAHL databases were included. The following keywords constituted our search criteria: gun-shot-wounds, brachial plexus, traum∗, and management. Results A total of 90 studies were imported for screening, from which 9 papers met our final inclusion/exclusion criteria. The most common studies utilized in this review were retrospective chart reviews followed by case series. In total, there were 628 patients that suffered from gunshot wounds to the brachial plexus. Most patients underwent some form of delayed nerve repair consisting of neurolysis, end-to-end epineural repair, or graft repair with a sural or antebrachial cutaneous nerve graft. Several patients suffered from complications, with neuroma being the most common long-term complication that required reoperation. Conclusion The optimal timing for surgeries involving BPIs should be determined after examining the level of nerve damage, associated injuries, operative risks, and electrophysiological workup for indications of spontaneous regeneration. Early surgical interventions were indicated for patients presenting with associated vascular or thoracic injuries, compressive masses, and nerve transection by sharp instruments in most selected papers.
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Affiliation(s)
- Rohun Gupta
- Division of Plastic and Reconstructive Surgery St. Louis University School of Medicine, St. Louis, MO, USA
| | - Isabel Herzog
- Department of Plastic Surgery Rutgers New Jersey School of Medicine, Newark, NJ, USA
| | - Lauren Phung
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Jacquelyn Roth
- Department of Plastic Surgery Rutgers New Jersey School of Medicine, Newark, NJ, USA
| | - Joseph Weisberger
- Department of Plastic Surgery Rutgers New Jersey School of Medicine, Newark, NJ, USA
| | - Margaret Luthringer
- Department of Plastic Surgery Rutgers New Jersey School of Medicine, Newark, NJ, USA
| | - Edward S Lee
- Department of Plastic Surgery Rutgers New Jersey School of Medicine, Newark, NJ, USA
| | - Ashley Ignatiuk
- Department of Plastic Surgery Rutgers New Jersey School of Medicine, Newark, NJ, USA
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Wu RT, Chuieng-Yi Lu J. Nerve Autograft: Preservation of a Lost Art. Hand Clin 2024; 40:347-356. [PMID: 38972679 DOI: 10.1016/j.hcl.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
Nerve autografts involve the transplantation of a segment of the patient's own nerve to bridge a nerve gap. Autografts provide biological compatibility, support for axonal regeneration, and the ability to provide an anatomic scaffold for regrowth that other modalities may not match. Disadvantages of the autograft include donor site morbidity and the extra operative time needed to harvest the graft. Nevertheless, nerve autografts such as the sural nerve remain the gold standard in reconstructing nerve gaps, but a multitude of factors need to be favorable in order to garner reliable, consistent outcomes.
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Affiliation(s)
- Robin T Wu
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Standford, CA 94305, USA
| | - Johnny Chuieng-Yi Lu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, No. 5, Fuxing Street, Guishan District, Taoyuan City, 333 Taiwan; Chang Gung University, Taoyuan, Taiwan.
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3
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Bateman EA, Pripotnev S, Larocerie-Salgado J, Ross DC, Miller TA. Assessment, management, and rehabilitation of traumatic peripheral nerve injuries for non-surgeons. Muscle Nerve 2024. [PMID: 39030747 DOI: 10.1002/mus.28185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/28/2024] [Accepted: 06/02/2024] [Indexed: 07/22/2024]
Abstract
Electrodiagnostic evaluation is often requested for persons with peripheral nerve injuries and plays an important role in their diagnosis, prognosis, and management. Peripheral nerve injuries are common and can have devastating effects on patients' physical, psychological, and socioeconomic well-being; alongside surgeons, electrodiagnostic medicine specialists serve a central function in ensuring patients receive optimal treatment for these injuries. Surgical intervention-nerve grafting, nerve transfers, and tendon transfers-often plays a critical role in the management of these injuries and the restoration of patients' function. Increasingly, nerve transfers are becoming the standard of care for some types of peripheral nerve injury due to two significant advantages: first, they shorten the time to reinnervation of denervated muscles; and second, they confer greater specificity in directing motor and sensory axons toward their respective targets. As the indications for, and use of, nerve transfers expand, so too does the role of the electrodiagnostic medicine specialist in establishing or confirming the diagnosis, determining the injury's prognosis, recommending treatment, aiding in surgical planning, and supporting rehabilitation. Having a working knowledge of nerve and/or tendon transfer options allows the electrodiagnostic medicine specialist to not only arrive at the diagnosis and prognosticate, but also to clarify which nerves and/or muscles might be suitable donors, such as confirming whether the branch to supinator could be a nerve transfer donor to restore distal posterior interosseous nerve function. Moreover, post-operative testing can determine if nerve transfer reinnervation is occurring and progress patients' rehabilitation and/or direct surgeons to consider tendon transfers.
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Affiliation(s)
- Emma A Bateman
- Parkwood Institute, St Joseph's Health Care London, London, Canada
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Stahs Pripotnev
- Roth|McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care London, London, Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | | | - Douglas C Ross
- Roth|McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care London, London, Canada
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Thomas A Miller
- Parkwood Institute, St Joseph's Health Care London, London, Canada
- Department of Physical Medicine and Rehabilitation, Schulich School of Medicine and Dentistry, Western University, London, Canada
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Tigre JY, Puerto A, Khalafallah AM, Burks SS. Timing of surgical intervention in peripheral nerve injuries from gunshot wounds: Management and review of the literature. Surg Neurol Int 2024; 15:178. [PMID: 38840615 PMCID: PMC11152554 DOI: 10.25259/sni_197_2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 05/01/2024] [Indexed: 06/07/2024] Open
Abstract
Background Gunshot wounds (GSWs) can result in various peripheral nerve injuries (PNIs), ranging from direct nerve transection to neuropraxia caused by the ballistic shockwave mechanism. PNIs from GSWs can be treated with either early or delayed intervention, with the literature supporting both approaches and sparking a debate between early and delayed intervention for PNIs from GSWs. Here, we present a case that underwent delayed exploration of the right common peroneal nerve after GSW and a literature review comparing early versus delayed intervention for PNIs from GSWs. Case Description A 29-year-old male underwent right common peroneal nerve exploration 2 months after he sustained a GSW to the right lower extremity at the level of the fibular head tracking to the lateral malleolus. Initially, after the injury, he was offered supportive care. On evaluation, 1 month later, he reported a right-sided foot drop and paresthesias in the right lower extremity. A partial-thickness injury of the right peroneal nerve was seen on ultrasound, and a bullet fragment in the distal right lower extremity was revealed on computed tomography. The surgical intervention consisted of the right common peroneal nerve decompression proximally to distally and removal of the bullet fragment. Postoperatively, the patient did well with improvements in his right ankle dorsiflexion and plantar flexion seen at his 1.5-month follow-up visit. Conclusion Many factors must be considered when treating PNIs from GSWs. For each case, clinical judgment, injury mechanism, and risk-benefit analysis must be evaluated to determine each patient's optimal treatment strategy.
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Affiliation(s)
- Joseph Yunga Tigre
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, United States
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Mansor S, Ziu N, Almissmary H, Alawami M, Bujazia A, Eltarhoni A. Abdominal versus pelvic gunshot injuries in terms of postoperative outcomes: A cohort representing the experience of 406 cases in seven years. Turk J Surg 2024; 40:36-46. [PMID: 39036010 PMCID: PMC11257720 DOI: 10.47717/turkjsurg.2024.6303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/07/2024] [Indexed: 07/23/2024]
Abstract
Objectives Gunshot injuries have become a significant problem globally. This study aimed to assess the differences between abdominal versus pelvic gunshot injuries in terms of postoperative outcomes to determine which type of injury is more lethal. Material and Methods This was a cohort study carried out to compare patients who had abdominal versus pelvic gunshot injuries, to analyse the differences in the impact of the anatomical site of injury on morbidity, mortality, and disabilities in all patients who had been admitted to the hospital due to torso gunshot injuries from February 2011 to December 2018. Results During the study period, 406 patients suffered from torso gunshot injuries. 391 were males and 15 were females; 343 (84.4%) patients had abdominal gunshot wounds, which were considered the first group, while in the second group, there were 63 (15.6%) patients who had pelvic gunshot wounds In the first group, 328 (95.6%) patients required urgent explorative laparotomy, complications were observed in 83 (24.2%) patients, while re-operations were reported in 51 (14.9%) patients and 11 (3.2%) patients had permanent functional disabilities, and 46 (13.4%) patients passed away. In the second group, all patients were treated with urgent explorative laparotomy, 17 (27%) patients suffered from complications, re-operation occurred in 13 (20.6%) patients, permeant functional disability occurred in 17 (27%) patients, and mortality was seen in 16 (25.4%) patients. Conclusion Our clinical experience has shown that mortality rates and long-term disability occur at a higher rate in pelvic gunshot injuries therefore early senior surgeon input is mandatory for the potential poor outcome to be minimized.
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Affiliation(s)
- Salah Mansor
- Department of General Trauma and Acute Care Surgery, Benghazi University Faculty of Medicine, Al-Jalaa Teaching Hospital, Benghazi, Libya
- Department of Surgery, Libyan International Medical University Faculty of Medicine, Benghazi, Libya
| | - Naman Ziu
- Department of General Trauma and Acute Care Surgery, Benghazi University Faculty of Medicine, Al-Jalaa Teaching Hospital, Benghazi, Libya
| | - Hannibal Almissmary
- Department of General Trauma and Acute Care Surgery, Benghazi University Faculty of Medicine, Al-Jalaa Teaching Hospital, Benghazi, Libya
| | - Mohammed Alawami
- Department of General Trauma and Acute Care Surgery, Benghazi University Faculty of Medicine, Al-Jalaa Teaching Hospital, Benghazi, Libya
| | - Ayoub Bujazia
- Department of Diagnostic Radiology, Benghazi University Faculty of Medicine, Benghazi Medical Center, Benghazi, Libya
| | - Ahmed Eltarhoni
- Department of Family and Community Medicine, Benghazi University Faculty of Medicine, Benghazi, Libya
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Shields LBE, Iyer VG, Zhang YP, Shields CB. Gunshot-related nerve injuries of the upper extremities: clinical, electromyographic, and ultrasound features in 22 patients. Front Neurol 2024; 14:1333763. [PMID: 38274872 PMCID: PMC10808781 DOI: 10.3389/fneur.2023.1333763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024] Open
Abstract
Objectives Gunshot wounds of the upper extremities may cause permanent neurovascular injuries, leading to significant morbidity, chronic pain, functional loss, and disability. While there are many reports on the incidence and intraoperative findings in gunshot-related nerve injuries (GSNI) sustained during wars, there is a paucity of details pertaining to GSNI of the upper extremities in civilians. The goal of this paper is to provide the clinical, electrodiagnostic (EDX), and ultrasound (US) findings in 22 patients with GSNI of the upper extremities. Methods This is a retrospective study of patients referred for EDX studies to evaluate the presence of nerve injury after sustaining GSWs to the upper extremities. All patients underwent EDX studies, and 16 patients had US evaluations. Numerous metrics were documented including presenting symptoms, neurological abnormalities, EDX findings, and US features. Results The forearm was the most frequent location of injury (8 [36%] patients). The ulnar nerve was the most common injured nerve (10 [45%] patients), followed by the brachial plexus (7 [32%] patients). All patients complained of muscle weakness; the most frequently affected muscles were the first dorsal interosseous (FDI) (14 [64%] patients) and abductor pollicis brevis (APB) (11 [50%] patients). Muscle atrophy was noted in 19 (86%) patients, 15 of whom had atrophy of the FDI. Axonotmesis was the type of nerve injury in all patients based on EDX studies. Of the 16 patients who underwent US studies, a neuroma in continuity was noted in 4 (25%) patients and neurotmesis in 1 (6.2%) patient. Eleven (69%) patients had enlarged and/or hypoechoic nerves. Conclusions Axonotmesis of the ulnar nerve was the most common finding among patients sustaining gunshot injuries to the upper extremities. EDX and US studies provide valuable insight into the underlying pathophysiology and guidance for management of patients with GSNI of the upper extremities.
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Affiliation(s)
- Lisa B. E. Shields
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY, United States
| | - Vasudeva G. Iyer
- Neurodiagnostic Center of Louisville, Louisville, KY, United States
| | - Yi Ping Zhang
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY, United States
| | - Christopher B. Shields
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY, United States
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, KY, United States
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Kauta N, Bott A, Majirija ET, Du Plessis JP, Vrettos B, Maqungo S, Roche S. Surgical management of distal humerus gunshot fractures: descriptive case series. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3711-3716. [PMID: 37322263 PMCID: PMC10651556 DOI: 10.1007/s00590-023-03611-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/01/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE The purpose of this study was to report our 5 years surgical experience and the rate of neurovascular injury following gunshot fractures of the distal humerus in a in level-1 Trauma Centre in South Africa. METHODS A retrospective case series of 25 consecutive adult gunshot injuries to the distal humerus. Demographic and injury data were extracted from clinical case notes and electronic operative records. Imaging archives were used to classify fractures according to the AO/OTA classification. RESULTS Twenty-five male patients, with mean age of 32-years-old, sustained gunshot injuries to the distal humerus. Eleven patients had multiple gunshots. Forty-four percent of patients underwent Computed Tomography Angiography (CTA), 20% had confirmed brachial artery injury. Limbs with vascular injury were salvaged with arterial repair and external fixation. Fractures were extra-articular in 20 cases (80%). Nineteen fractures were classified as highly comminuted. Nerve injuries occurred in 52% and were all managed expectantly. Only 32% of patients attended follow-up beyond 3 months. CONCLUSIONS These are rare challenging injuries with high rates of neurovascular damage. This demographic of patients is poorly compliant with follow up highlighting the need for high-quality early care. Brachial artery injury should be excluded with CTA and can be managed with arterial repair and external fixation. All fractures in this series were surgically managed with conventional anatomical plate and screw fixation techniques. For nerve injury, we advocate expectant management. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | | | | | | | - Basil Vrettos
- Vincent Pallotti Private Hospital, Cape Town, South Africa
| | - Sithombo Maqungo
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Stephen Roche
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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8
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Ujvári B, Oláh Z, Molnár S, Háncs T, Várhelyi L, Szabó N, Bózsik A. Multi-stage management of a right hip gunshot injury; Case report. Trauma Case Rep 2023; 47:100881. [PMID: 37587922 PMCID: PMC10425711 DOI: 10.1016/j.tcr.2023.100881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2023] [Indexed: 08/18/2023] Open
Abstract
A 42-year-old hunter with no previous medical history suffered an accidental gunshot injury while hunting. Upon arrival at our Hospital, the following musculosceletal laesions were diagnosed during the primary survey: comminuted right trochanteric and femur neck fracture, femoral and sciatic nerve palsy. The immediate damage control surgery consisted of debridement, jet-lavage, PMMA-chain insertion and extrafocal fixation. Structural neural damage was disclosed. Primarily the skin wound was treated by delayed closure and later the healing was supported by Negative Pressure Wound Therapy. Six weeks after, the extrafocal fixation was removed and antibiotic spacer was inserted. Primary wound healing occurred without any sign of infection. Neurological recovery of the extremity took almost a year. Low grade infection were excluded by serial labs and culture samples. Finally the patient underwent total hip arthroplasty with excellent result.
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Affiliation(s)
- Béla Ujvári
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
| | - Zoltán Oláh
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
| | - Szabolcs Molnár
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
- University of Physical Education, Budapest, Hungary
| | - Tivadar Háncs
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
| | - Levente Várhelyi
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
| | - Noé Szabó
- Medical Student, Semmelweis University Medicine and Health Sciences, Budapest, Hungary
| | - Attila Bózsik
- Department of Traumatology, Medical Centre Hungarian Defence Forces, Budapest, Hungary
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Farrar J, Yeramosu T, Perdue P. Ballistic diaphyseal forearm fractures result in high incidence of neurovascular injury and compartment syndrome but have low rates of early infection: A single level I trauma center experience. Injury 2023:S0020-1383(23)00400-X. [PMID: 37149441 DOI: 10.1016/j.injury.2023.04.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/18/2023] [Accepted: 04/30/2023] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Ballistic injuries to the upper extremity represent a small subset of injuries, and there is little data to provide guidance on management and outcomes. The purpose of this study is to assess the incidence of neurovascular injuries, compartment syndrome, and early postoperative infection, as well as patient and injury factors predictive of neurovascular injury following ballistic fractures of the forearm. PATIENTS AND METHODS A retrospective review of operatively treated ballistic forearm fractures at a single level I trauma center between 2010 and 2022 was performed. Thirty-three patients with 36 forearm fractures were identified. Only diaphyseal injuries in patients greater than 18 years old were included. Medical and radiographic records were reviewed to identify pre-injury patient-specific factors, including age, sex, smoking status, and history of diabetes. Injury characteristics, including the type of firearm used, forearm fracture location, and any associated neurologic or vascular injury, as well as compartment syndrome, were collected and analyzed. Short-term outcomes such as post-operative infection and recovery of neurologic function were also collected and analyzed. RESULTS The median age was 27 years (range: 18-62), with a majority of male patients (78.8%, n = 26). 4 patients (12.1%) sustained high-energy injuries. 4 patients (12.1%) were found to have compartment syndrome pre-operatively or intra-operatively. 11 patients (33.3%) had nerve palsies postoperatively with 8 patients (24.2%) continuing to have nerve palsies at their final follow-up (mean follow-up= 149.9 +/- 187.2 days). The median length of stay was 4 days. There were no patients with infection at follow-up. CONCLUSION Ballistic forearm fractures are complex injuries and can result in severe complications such as neurovascular injury and compartment syndrome. As such, a comprehensive evaluation and appropriate management of ballistic forearm fractures are essential to minimize the risk of severe complications and optimize patient outcomes. In our experience, when treated operatively, these injuries have a low rate of infection.
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Affiliation(s)
- Jacob Farrar
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1200 East Broad Street, PO Box 980153, Richmond, VA 23298, USA.
| | - Teja Yeramosu
- Virginia Commonwealth University School of Medicine, 1201 E Marshall St #4-100, Richmond, VA, USA
| | - Paul Perdue
- Department of Orthopaedic Surgery, Virginia Commonwealth University, 1200 East Broad Street, PO Box 980153, Richmond, VA 23298, USA
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Henriques VM, Torrão FJL, Rosa LAN, Sanches GE, Guedes F. Surgery as an Effective Therapy for Ulnar Nerve Neuropathic Pain Caused by Gunshot Wounds: A Retrospective Case Series. World Neurosurg 2023; 173:e207-e217. [PMID: 36791879 DOI: 10.1016/j.wneu.2023.02.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Peripheral nerve injuries remain a major medical problem worldwide and are associated with multiple causes, including gunshot wounds (GSWs), which are the second most common cause of brachial plexus injuries in peacetime and the main, or only, cause reported in wartime studies. The ulnar nerve (UN) is one of the most affected nerves. Peripheral nerve trauma may cause intense neuropathic pain, which is very difficult to control. Particularly UN gunshot injuries may impact individual daily life, as injuries to this nerve result in both sensory and motor deficits within the hand. We evaluated the improvement of neuropathic pain after surgical treatment in a consecutive series of 20 patients with UN injury due to GSWs. METHODS This single-center, retrospective, consecutive case series included 20 patients with UN injuries due to GSWs, who presented with excruciating neuropathic pain and underwent surgical treatment between 2005 and 2017. RESULTS Of injuries, 13 occurred in the right upper limb (65%); 12 patients had a high UN injury (60%). Regarding associated injuries, 8 patients had bone injuries (40%), and 4 patients had arterial injuries (20%). A neuroma in continuity was detected in 8 cases (40%), and 4 patients (20%) had shrapnel lodged within the UN. All patients had severe neuropathic pain and functional deficit, with a mean visual analog scale score of 8.45 ± 1.4 and a mean reduction of 6.95 points 12 months after surgery; 10 patients (50%) had a British Medical Research Council score ≥M3. CONCLUSIONS Surgery is an effective treatment for neuropathic pain from GSWs. Early isolated external neurolysis is associated with better pain management and functional outcomes postoperatively.
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Affiliation(s)
- Vinícius M Henriques
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG-Unirio/Ebserh), Rio de Janeiro, Brazil.
| | - Francisco J L Torrão
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG-Unirio/Ebserh), Rio de Janeiro, Brazil
| | - Livia A N Rosa
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG-Unirio/Ebserh), Rio de Janeiro, Brazil
| | - Gabriel E Sanches
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG-Unirio/Ebserh), Rio de Janeiro, Brazil
| | - Fernando Guedes
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG-Unirio/Ebserh), Rio de Janeiro, Brazil
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11
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Starr BW, Dembinski DR, Yuan F, Lax EA, Yalamanchili S, Megee DM. Point Blank: A Retrospective Review of Self-inflicted Gunshot Wounds to the Hand. Hand (N Y) 2023; 18:307-313. [PMID: 34109852 PMCID: PMC10035094 DOI: 10.1177/15589447211014603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND A paucity of literature exists specifically examining self-inflicted (SI) gunshot wounds (GSWs) to the hand and wrist, which impart greater energy and have a higher risk of adverse events than non-self-inflicted (NSI) GSWs. METHODS We retrospectively reviewed records of patients who presented to our plastic surgery service after sustaining acute GSWs involving the hand and wrist between 2016 and 2018. RESULTS We identified 60 patients who sustained GSWs involving the hand and wrist; 17 (28%) were SI, and 43 (72%) were NSI. Within the SI group, 100% of patients were Caucasian, with an average age of 54 years. Within the NSI cohort, 77% of patients were Black, 19% were Caucasian, and 4% identified as other. While not statistically significant, we noted a substantial increase in patients requiring operative intervention in the SI cohort (65% SI vs 37% NSI, P = .08). There was a statistically significant increase in patients requiring more than 1 operation in SI patients (24% SI vs 5% NSI, P = .04). Patients who sustained SI injuries were also more likely to present with acute carpal tunnel syndrome requiring urgent surgical release and to develop wound infections (12% vs 0%, P = .08). CONCLUSIONS Self-inflicted GSWs involving the hand and wrist are associated with greater morbidity than their low-energy NSI counterparts. Individuals presenting with SI GSWs are more likely to be older, to require multiple operations, to develop infections, and to present with acute carpal tunnel syndrome requiring urgent surgical decompression.
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Affiliation(s)
| | | | - Frank Yuan
- University of Cincinnati College of Medicine, OH, USA
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12
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Anantavorasakul N, Westenberg RF, Serebrakian AT, Zamri M, Chen NC, Eberlin KR. Gunshot Injuries of the Hand: Incidence, Treatment Characteristics, and Factors Associated With Healthcare Utilization. Hand (N Y) 2023; 18:158-166. [PMID: 33884931 PMCID: PMC9806535 DOI: 10.1177/1558944721998016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The objectives of this study are to: (1) describe the demographics, injury patterns, and treatment characteristics of patients who sustained a gunshot injury (GSI) of the hand; and (2) examine the utilization of healthcare resources in patients with a GSI of the hand. METHODS We retrospectively identified 148 adult patients who were treated for a GSI of the hand between January 2000 to December 2017 using multiple International Classification of Diseases Ninth and Tenth Edition (ICD-9 and ICD-10) codes. We used bivariate and multivariable analysis to identify which factors are associated with unplanned reoperation, length of hospitalization, and number of operations. RESULTS Multivariable logistic regression showed that fracture severity was associated with unplanned reoperation. Multivariable linear regression showed that fracture severity is associated with a higher number of hand operations after a GSI of the hand, and that a retained bullet (fragment) and patients having gunshot injuries in other regions than the hand had a longer length of hospitalization. Seventy (47%) patients had sensory or motor symptoms in the hand after their GSI, of which 22 (15%) patients had a transection of the nerve. CONCLUSIONS Sensory and motor nerve deficits are common after a GSI of the hand. However, only 31% of patients with symptoms had a transection of the nerve. A retained bullet (fragment), having more severe hand fractures, and GSI in other regions than the hand are associated with a higher number of operation and a longer period of hospitalization.
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Affiliation(s)
- Navapong Anantavorasakul
- Massachusetts General Hospital, Boston,
MA, USA
- Institute of Orthopaedics, Lerdsin
Hospital, Bangkok, Thailand
| | | | - Arman T. Serebrakian
- Massachusetts General Hospital, Boston,
MA, USA
- Harvard Medical School, Boston, MA,
USA
| | | | - Neal C. Chen
- Massachusetts General Hospital, Boston,
MA, USA
- Harvard Medical School, Boston, MA,
USA
| | - Kyle R. Eberlin
- Massachusetts General Hospital, Boston,
MA, USA
- Harvard Medical School, Boston, MA,
USA
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13
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Pereira DE, Desai MJ. Nerves in Continuity Following Hand Trauma: A Descriptive Report. Hand (N Y) 2023; 18:126S-132S. [PMID: 34963376 PMCID: PMC9896280 DOI: 10.1177/15589447211064362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Understanding the clinical presentation of nontransected nerve injuries in acute hand trauma/wrist trauma will help in early intervention, which is vital for maximizing return of function in patients. This retrospective study evaluated patients who experienced traumatic hand injuries with nerve in continuity within the zone of injury. METHODS This was a single-center retrospective chart review of 20 patients with hand or wrist trauma resulting in damage to bone, tendon, or soft tissues within Zones II to V. Patients were 18 to 70 years of age and had documented visualization of at least one nerve within the zone of injury at the time of surgery but no documented full or partial nerve transection. The cohort was characterized using descriptive statistics including mechanism of injury, extent of strength and sensation deficits, and outcomes. Resolution of symptoms was defined as full, partial, or none. RESULTS Of the 20 patients included in the study, 15 patients (75%) showed symptoms of impaired nerve function either prior to surgery or at the first post-surgical follow-up visit. Without direct nerve treatment, only 23% (3/13) of patients experienced full recovery based on qualitative sensory assessment. However, patients reporting pain after surgery (57%; 8/14) showed full recovery from pain despite no direct nerve treatment. CONCLUSIONS In our retrospective cohort of patients with hand/wrist trauma that presented with an intact nerve in continuity, we found that a majority showed symptoms of nerve injury. Further, these patients showed slow recovery over time with a minority achieving partial or full recovery or improvement in pain.
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Affiliation(s)
| | - Mihir J. Desai
- Vanderbilt University Medical Center,
Nashville, TN, USA
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14
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Upper extremity firearm injuries: epidemiology and factors predicting hospital admission. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1173-1178. [PMID: 35486233 DOI: 10.1007/s00590-022-03258-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Civilian gun violence is a public health crisis in the USA that will be an economic burden reported to be as high as $17.7 billion with over half coming from US taxpayers dollars through Medicaid-related costs. The purpose of this study is to review the epidemiology of upper extremity firearm injuries in the USA and the associated injury burden. METHODS The Inter-university Consortium for Political and Social Research's Firearm Injury Surveillance Study database, collected from the National Electronic Injury Surveillance System, was queried from 1993 to 2015. The following variables were reviewed: patient demographics, date of injury, diagnosis, injury location, firearm type (if provided), incident classification, and a descriptive narrative of the incident. We performed chi-square testing and complex descriptive statistics, and binomial logistic regression model to predict factors associated with hospital admission. RESULTS From 1993 to 2015, an estimated 314,369 (95% CI: 291,528-337,750; 16,883 unweighted) nonfatal firearm upper extremity injuries with an average incidence rate of 4.76 per 100,000 persons (SD: 0.9; 03.77-7.49) occurred. The demographics most afflicted with nonfatal gunshot wound injuries were black adolescent and young adult males (ages 15-24 years). Young adults aged 25-34 were the second largest estimate of injuries by age group. Hands were the most commonly injured upper extremity, (55,014; 95% CI: 75,973-89,667) followed by the shoulder, forearm, and upper arm. Patients who underwent amputation (OR: 28.65; 95% CI: 24.85-33.03) or with fractures (OR: 26.20; 95% CI: 23.27-29.50) experienced an increased likelihood for hospitalization. Patients with a shoulder injury were 5.5× more likely to be hospitalized than those with a finger injury (OR:5.57; 95% CI:5.35-5.80). The incidence of upper extremity firearm injuries has remained steady over the last decade ranging between 4 and 5 injuries per 100,000 persons. Patients with proximal injuries or injuries involving the bone were more likely to require hospital admission. This study should bring new information to the forefront for policy makers regarding gun violence.
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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. Eur J Trauma Emerg Surg 2022; 48:3529-3539. [PMID: 35262748 DOI: 10.1007/s00068-022-01929-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/20/2022] [Indexed: 01/24/2023]
Abstract
Ballistic injuries to peripheral nerves are devastating injuries frequently encountered in modern conflicts and civilian trauma centers. Such injuries often produce lifelong morbidity, mainly in the form of function loss and chronic pain. However, their surgical management still poses significant challenges concerning indication, timing, and type of repair, particularly when they are part of high-energy multi-tissue injuries. To help trauma surgeons, this article first presents basic ballistic concepts explaining different types of missile nerve lesions, described using the Sunderland classification, as well as their usual associated injuries. Current controversies regarding their surgical management are then described, including nerve exploration timing and neurolysis's relevance as a treatment option. Finally, based on anecdotal evidence and a literature review, a standardized management strategy for ballistic nerve injuries is proposed. This article emphasizes the importance of early nerve exploration and provides a detailed method for making a diagnosis in both acute and sub-acute periods. Direct suturing with joint flexion is strongly recommended for sciatic nerve defects and any nerve defect of limited size. Conversely, large defects require conventional nerve grafting, and proximal injuries may require nerve transfers, especially at the brachial plexus level. Additionally, combined or early secondary tendon transfers are helpful in certain injuries. Finally, ideal timing for nerve repair is proposed, based on the defect length, associated injuries, and risk of infection, which correlate intimately to the projectile velocity.
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Affiliation(s)
- Laurent Mathieu
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France. .,French Military Hand Surgery Center, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France. .,Department of Surgery, French Military Health Service Academy, Ecole du Val-de-Grâce, 1 place Alphonse Laveran, 75005, Paris, France.
| | - Melody Goncalves
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France.,French Military Hand Surgery Center, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - James Charles Murison
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France.,French Military Hand Surgery Center, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Georges Pfister
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France.,French Military Hand Surgery Center, Percy Military Hospital, 101 avenue Henri Barbusse, 92140, Clamart, France
| | - Christophe Oberlin
- Nerve and Brachial Plexus Surgery Unit, Mont-Louis Private Hospital, 8 rue de la Folie-Regnault, 75011, Paris, France
| | - Zoubir Belkheyar
- Nerve and Brachial Plexus Surgery Unit, Mont-Louis Private Hospital, 8 rue de la Folie-Regnault, 75011, Paris, France
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Baker HP, Straszewski AJ, Dahm JS, Dickherber JL, Krishnan P, Dillman DB, Strelzow JA. Gunshot-related lower extremity nerve injuries. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:851-856. [PMID: 35129680 DOI: 10.1007/s00590-022-03220-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 01/24/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the frequency of nerve injury associated with lower extremity ballistic trauma, the associated skeletal and soft tissue injuries, and the rate of neurologic recovery. DESIGN AND SETTING A retrospective review of an institutional trauma database was completed at a single level 1 trauma academic medical center. PATIENTS This was an institutional review board approved retrospective cohort study of patients over 16 years of age presenting with ballistic-related traumatic injury to the lower extremities between May 2018 and May 2019. All patients identified with lower extremity ballistic trauma were included in this study. The rate of nerve palsy, associated skeletal injury, and operative fixation were recorded for each anatomic zone. Rates of associated concomitant vascular injury, fracture, and compartment syndrome were collected through a review of the electronic medical records. Chart review was performed to evaluate outcomes and nerve recovery. RESULTS Twenty-one patients (21 extremities, 21/148, 14%) were diagnosed by attending physicians, fellowship-trained in orthopedic trauma, as having ballistic-related nerve injuries. Seventy-three percent of patients with a documented neurologic injury (11/15) demonstrated complete nerve recovery as measured by the MRC and sensory scale assessment at most recent follow-up, while the rest demonstrated no improvement in their neurologic deficits from presentation. The rate of associated vascular injury in patients with lower extremity nerve palsies was 38% (8/21). While the rate of vascular injury in the absence of neurologic injury was 3% (4/127). CONCLUSIONS This series of lower extremity nerve injuries in a large sample of urban lower extremity ballistic trauma noted a high rate of concomitant nerve injuries. An associated diagnosis of a vascular injury appears to portend a higher risk of neurologic injury. Treating surgeons should have a high index of suspicion for associated vascular injury in patients presenting with a ballistic lower extremity nerve palsy.
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Affiliation(s)
- Hayden P Baker
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA.
| | - Andrew J Straszewski
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA
| | - James S Dahm
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA
| | - Jason L Dickherber
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA
| | - Pranav Krishnan
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA
| | - Daryl B Dillman
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA
| | - Jason A Strelzow
- Department of Orthopaedic Surgery, The University of Chicago, 5758 S. Maryland Avenue, Dept. 4B, Chicago, IL, 60637, USA
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Straszewski AJ, Schultz K, Dickherber JL, Dahm JS, Wolf JM, Strelzow JA. Gunshot-Related Upper Extremity Nerve Injuries at a Level 1 Trauma Center. J Hand Surg Am 2022; 47:88.e1-88.e6. [PMID: 34030933 DOI: 10.1016/j.jhsa.2021.03.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/04/2021] [Accepted: 03/08/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE Gunshot wounds can result in a spectrum of injuries to nerves, with little data to guide definitive treatment. We performed a retrospective evaluation of gunshot-related upper extremity injuries in an urban trauma center to analyze epidemiology, associated injuries, and short-term outcomes. We hypothesized that gunshot-related injuries would involve soft tissue cavitation, inducing axonotmesis and neuropraxia rather than neurotmesis injuries. METHODS All patients over the age of 16 with upper extremity gunshot trauma from May 2018 to May 2019 were identified through the University of Chicago orthopaedic and general surgery trauma databases. Initial nerve injuries were identified by physical examination. Patient demographic data, soft tissue and skeletal injury, treatment modality, and return of function were collected. RESULTS Ballistic injuries in 1302 patients were treated over 12 months. We identified 126 upper extremity gunshot injuries in 117 patients. Thirty-eight upper extremities (38 patients) had a documented nerve deficit (38/126, 30%) with a follow-up rate of 94% (34/36) at a mean of 351 days after injury (median, 202 days; range, 13-929 days). One patient had a subacute transradial amputation, and 1 patient was deceased at final follow-up. The presence of vascular injury and fracture increased the rate of neurologic injury after gunshot injuries. At the most recent follow-up, 68% (23/34) of patients with upper extremity injury had improvement in nerve function as measured by objective clinical assessment, with 24% (8/34) experiencing full recovery at an average of 368 days (median, 261 days; range, 41-929 days). CONCLUSIONS Nerve injury after ballistic trauma to the upper extremity is common. Vascular injury and fractures were associated with a higher risk of nerve injury. Short-term improvement in nerve function was seen in over half the cohort, suggesting a predominance of neuropraxic effects. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Andrew J Straszewski
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL.
| | - Kathryn Schultz
- Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Jason L Dickherber
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
| | - James S Dahm
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
| | - Jennifer Moriatis Wolf
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
| | - Jason A Strelzow
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, Chicago, IL
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STUDY OF GUNSHOT INJURIES FEATURES OF PERIPHERAL NERVES BY MODERN WEAPONS IN THE EXPERIMENT. WORLD OF MEDICINE AND BIOLOGY 2022. [DOI: 10.26724/2079-8334-2022-3-81-242-247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
OBJECTIVES To evaluate a large series of open fractures of the forearm after gunshot wounds (GSWs) to determine complication rates and factors that may lead to infection, nonunion, or compartment syndrome. DESIGN Multicenter retrospective review. SETTING Nine Level 1 Trauma Centers. PATIENTS/PARTICIPANTS One hundred sixty-eight patients had 198 radius and ulna fractures due to firearm injuries. All patients were adults, had a fracture due to a firearm injury, and at least 1-year clinical follow-up or follow-up until union. The average follow-up was 831 days. INTERVENTION Most patients (91%) received antibiotics. Formal irrigation and debridement in the operating room was performed in 75% of cases along with either internal fixation (75%), external fixation (6%), or I&D without fixation (19%). MAIN OUTCOME MEASURES Complications including neurovascular injuries, compartment syndrome, infection, and nonunion. RESULTS Twenty-one percent of patients had arterial injuries, and 40% had nerve injuries. Nine patients (5%) developed compartment syndrome. Seventeen patients (10%) developed infections, all in comminuted or segmental fractures. Antibiotics were not associated with a decreased risk of infection. Infections in the ulna were more common in fractures with retained bullet fragments and bone loss. Twenty patients (12%) developed a nonunion. Nonunions were associated with high velocity firearms and bone defect size. CONCLUSIONS Open fractures of the forearm from GSWs are serious injuries that carry high rates of nonunion and infection. Fractures with significant bone defects are at an increased risk of nonunion and should be treated with stable fixation and proper soft-tissue handling. Ulna fractures are at a particularly high risk for deep infection and septic nonunion and should be treated aggressively. Forearm fractures from GSWs should be followed until union to identify long-term complications. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Rukmana Tri Pratistha I, Gede Bimantara N, Putra IGM, Karna MB, Asmara AAGY, Meregawa PF. Nerves Transfer Procedure in Patients with Left Upper Extremities Weakness Following Gunshot Wounds: A Case Report. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Gunshot wounds (GSWs) to the extremities can result in damage to the neurovascular structure which results in high morbidity and loss of function. According to the Centers for Disease Control report, the incidence of non-fatal GSWs has increased in the past decade. Trauma to the brachial plexus is a type of peripheral nerve trauma that is most difficult to treat due to its complex surgical procedures. Early exploration and reconstruction of peripheral nerve trauma are still being debated to this day. However, most recommend surgical exploration when the suspicion of neurovascular trauma is very high based on clinical findings. Nerve transfer is one of the recommended methods of nerve reconstruction even in pre-ganglionic lesions. We report a case of a patient with weakness of the upper limb after a gunshot wound to his left shoulder. Based on clinical considerations and investigations, nerve transfer procedure is carried out to restore patient’s shoulder function.
CASE REPORT: Male, 32 years old, working as a policeman, complained difficulty on moving his shoulder for 3 months. Patients had a history of GSWs to the left shoulder which also results in a left clavicular fracture. First aid, debridement, and fracture management were performed at Bhayangkara Hospital, Palu. Physical examination revealed winging scapula positive on his left shoulder, shoulder abduction 5/1, and hypoesthesia at left C5 level. Electromyographic examination revealed lesions on the left posterior chord and left brachial plexus. Based on clinical findings and supporting examination, we performed nerve transfers procedure from the accessory nerve to suprascapular notch. In the previous study, 63% of cases GSWs associated with nerve dysfunction. About 75% of patients with nerve palsy are associated with nerve lacerations during surgical exploration. However, many surgeons continue to recommend early exploration after GSWs to the upper extremities, especially in patients who will undergo surgical treatment for other indications. Based on this, we suggest the probable cause of brachial plexus lesions in this case resulted from gunshot wound which injures the brachial plexus or as a complication from previous procedures. Surgery that is too early can interfere with the spontaneous reinnervation process, but late surgical procedures can result in failure of reinnervation. In general, optimal time is set between 3 and 6 months after trauma. Nerve transfer is one method of reconstructing peripheral nerve lesions that can be applied to pre-ganglionic or post-ganglionic lesions.
CONCLUSION: This procedure has several benefits, namely, the proximity of the donor and the recipient nerve anatomy, shorter operating time and does not require grafts. Brachial plexus trauma due to trauma or non-trauma together has an impact on the patient’s quality of life. However, advances in surgical techniques and further understanding of nerve physiology have led clinicians and patients to better outcomes. The current trend of treatment strategies for brachial plexus trauma is surgical reconstruction with the nerve transfer procedure.
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21
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MacKay BJ, Cox CT, Valerio IL, Greenberg JA, Buncke GM, Evans PJ, Mercer DM, McKee DM, Ducic I. Evidence-Based Approach to Timing of Nerve Surgery: A Review. Ann Plast Surg 2021; 87:e1-e21. [PMID: 33833177 PMCID: PMC8560160 DOI: 10.1097/sap.0000000000002767] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 01/08/2023]
Abstract
ABSTRACT Events causing acute stress to the health care system, such as the COVID-19 pandemic, place clinical decisions under increased scrutiny. The priority and timing of surgical procedures are critically evaluated under these conditions, yet the optimal timing of procedures is a key consideration in any clinical setting. There is currently no single article consolidating a large body of current evidence on timing of nerve surgery. MEDLINE and EMBASE databases were systematically reviewed for clinical data on nerve repair and reconstruction to define the current understanding of timing and other factors affecting outcomes. Special attention was given to sensory, mixed/motor, nerve compression syndromes, and nerve pain. The data presented in this review may assist surgeons in making sound, evidence-based clinical decisions regarding timing of nerve surgery.
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Affiliation(s)
- Brendan J. MacKay
- From the Texas Tech University Health Sciences Center
- University Medical Center, Lubbock, TX
| | | | - Ian L. Valerio
- Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA
| | | | | | - Peter J. Evans
- Orthopaedic Surgery, Cleveland Clinic of Florida, Weston, FL
| | - Deana M. Mercer
- Department of Orthopaedics and Rehabilitation, The University of New Mexico, Albuquerque, NM
| | - Desirae M. McKee
- From the Texas Tech University Health Sciences Center
- University Medical Center, Lubbock, TX
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22
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Epidemiology of Upper Extremity Firearm Injuries among Major Trauma Hospitals in the United States. Plast Reconstr Surg 2021; 148:571-579. [PMID: 34432686 DOI: 10.1097/prs.0000000000008220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As many as 34 percent of nonfatal firearm injuries involve the upper extremity. Although not lethal, these injuries cause substantial morbidity. The authors conducted an epidemiologic study characterizing upper extremity firearm-related injuries presenting to U.S. trauma centers over a 10-year period. METHODS The authors used the National Trauma Databank from 2007 to 2017 to identify isolated upper extremity firearm-related injuries. Descriptive statistics were performed to characterize patient demographic data, firearm type, extremity injury patterns, treatments received, hospital length of stay, and regional variation. RESULTS The authors identified 48,254 upper extremity firearm-related injuries. The patients were largely male patients (85 percent), and over half were between the ages of 20 and 39 years. Handguns (34 percent) were the most frequently used firearm. Shoulder and upper arm were the most frequently injured areas (54 percent); however, 18 percent of patients injured two or more areas. Patients were most often treated at university hospitals (59 percent) with Level I or II trauma designation. Seventy percent were admitted and/or taken directly to the operating room. The mean hospital length of stay was 3 days. Payer mix among these patients was variable: Medicaid, 20 percent; private insurance, 20 percent; and self-pay, 29 percent. CONCLUSIONS Upper-extremity firearm injuries are resource intensive, with three-quarters of patients requiring operative intervention and/or hospitalization. Level I and II trauma centers were the site of care for the majority of patients. Targeted gun policy reform and prevention measures directed toward at-risk groups have the potential to limit the unnecessary morbidity and costs associated with these injuries.
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Loewenstein SN, Wulbrecht R, Leonhard V, Sasor S, Cook J, Timsina L, Adkinson J. Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations. Hand (N Y) 2021; 16:432-438. [PMID: 31409134 PMCID: PMC8283110 DOI: 10.1177/1558944719866865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background: Many patients with complete nerve lacerations after upper extremity trauma have a documented normal peripheral nerve examination at the time of initial evaluation. The purpose of this study was to determine whether physician-, patient-, and injury-related factors increase the risk of false-negative nerve examinations. Methods: A statewide health information exchange was used to identify complete upper extremity nerve lacerations subsequently confirmed by surgical exploration at 1 pediatric and 2 adult level I trauma centers in a single city from January 2013 to January 2017. Charts were manually reviewed to build a database that included Glasgow Coma Scale score, urine drug screen results, blood alcohol level, presence of concomitant trauma, type of injury, level of injury, laterality, initial provider examination, and initial specialist examination. Bivariate and multivariable analyses were performed to evaluate risk factors for a false-negative examination. Results: Two hundred eighty-eight patients met inclusion criteria. The overall false-negative examination rate was 32.5% at initial encounter, which was higher among emergency medicine physicians compared with extremity subspecialists (P < .001) and among trauma surgeons compared with surgical subspecialists (P = .002). The false-negative rate decreased to 8% at subsequent encounter (P < .001). Risk factors for a false-negative nerve examination included physician specialty, a gunshot wound mechanism of injury, injury at the elbow, and age greater than 71 years. Conclusion: There is a high false-negative rate among upper extremity neurotmesis injuries. Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes.
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Affiliation(s)
| | - Reed Wulbrecht
- Indiana University School of Medicine, Indianapolis, USA
| | | | | | - Julia Cook
- Indiana University School of Medicine, Indianapolis, USA
| | - Lava Timsina
- Indiana University School of Medicine, Indianapolis, USA
| | - Joshua Adkinson
- Indiana University School of Medicine, Indianapolis, USA,Joshua M. Adkinson, Division of Plastic Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall 232, Indianapolis, IN 46202, USA.
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Sari A, Ozcelik IB, Bayirli D, Ayik O, Mert M, Ercin BS, Baki H, Mersa B. Management of upper extremity war injuries in the subacute period: A review of 62 cases. Injury 2020; 51:2601-2611. [PMID: 32868071 DOI: 10.1016/j.injury.2020.08.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/20/2020] [Accepted: 08/23/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE In this study, we aimed to describe the relationship between the localization of rarely seen upper extremity war injuries and their complications in the subacute period, and define our preferences for surgery and antibiotic use. METHODS Patients with an upper extremity war injury who presented to our institution between 2015 and 2018 were retrospectively evaluated. Data regarding demographics, time between injury and presentation, location of injury, type of damage, complications, treatment methods, infection rates and antibiotic use were recorded. Tissue defects, fracture fixation, neurovascular damage, infection development and treatment approaches were analyzed. RESULTS Sixty-two male patients with isolated upper extremity injuries (mean age: 31.66 ± 8.28 years) were included in the study. The average time between trauma and hospitalization was 14 days. The mean hematocrit (Hct) level at presentation was 36.3 ± 6.8%. Patients had been followed up for an average period of 95.6 ± 32.1 days. Twenty-nine patients (46.8%) had nerve injury, eight (12.9%) had arterial injury that required repair, and 23 had infection (37.1%), of which five developed osteomyelitis. Infection was polymicrobial in nine cases and monobacterial in 14. A positive correlation was found between the presence of fracture and nerve injury (p = 0.013). The frequency of nerve injuries due to gunshot wounds was higher in the mid-section and lower part of the arms and in the proximal forearm when compared to other regions (p = 0.011). The infection rates were significantly higher in patients with fractures (p = 0.033). The mean hematocrit (Hct) level at presentation of the patients with infection (32.1 ± 6.3%) was significantly lower than that of those who did not have infection (38.8 ± 5.9%) (p<0.001). CONCLUSION Upper extremity war injuries require case-specific solutions. Microbiological samples should be taken prior to empirical antibiotic treatment for infection management and rational antibiotic use principles should be applied according to the culture and antibiogram results. The holistic and ambiguous character of nerve injuries often requires early exploration and combined reconstructive interventions. Arterial injuries can be overlooked by physical examination alone and thus routine angiography should be performed. Completion of the bone and soft tissue reconstructions in the same session using a holistic approach minimizes the possible risks.
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Affiliation(s)
- Abdulkadir Sari
- Department of Orthopedics and Traumatology, Faculty of Medicine, Namık Kemal University, Tekirdağ, Turkey.
| | - Ismail Bulent Ozcelik
- Istanbul Hand Surgery and Microsurgery Group, Yeni Yüzyıl University, Hand and Upper Extremity Surgery Unit, Gaziosmanpaşa Private Hospital, Nisantasi University Vocational High School, Istanbul, Turkey
| | - Derya Bayirli
- Infectious Diseases Clinic, Gaziosmanpaşa Private Hospital, Yeni Yüzyıl University, Istanbul, Turkey
| | - Omer Ayik
- Department of Orthopedics and Traumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Murat Mert
- Orthopedics and Traumatology Clinic, Gaziosmanpaşa Private Hospital, Yeni Yüzyıl University, Istanbul, Turkey
| | - Burak Sercan Ercin
- Mikroplast Hand Surgery and Microsurgery Group, Plastic and Reconstructive Surgery Clinic, Gebze Medical Park Hospital, Kocaeli, Turkey
| | - Humam Baki
- Orthopedics and Traumatology Clinic, Gaziosmanpaşa Private Hospital, Yeni Yüzyıl University, Istanbul, Turkey
| | - Berkan Mersa
- Istanbul Hand Surgery and Microsurgery Group, Yeni Yüzyıl University, Hand and Upper Extremity Surgery Unit, Gaziosmanpaşa Private Hospital, Nisantasi University Vocational High School, Istanbul, Turkey
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Weng J, Li DD, Jiang BG, Yin XF. Temporal changes in the spinal cord transcriptome after peripheral nerve injury. Neural Regen Res 2020; 15:1360-1367. [PMID: 31960825 PMCID: PMC7047785 DOI: 10.4103/1673-5374.272618] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Peripheral nerve injury may trigger changes in mRNA levels in the spinal cord. Finding key mRNAs is important for improving repair after nerve injury. This study aimed to investigate changes in mRNAs in the spinal cord following sciatic nerve injury by transcriptomic analysis. The left sciatic nerve denervation model was established in C57BL/6 mice. The left L4-6 spinal cord segment was obtained at 0, 1, 2, 4 and 8 weeks after severing the sciatic nerve. mRNA expression profiles were generated by RNA sequencing. The sequencing results of spinal cord mRNA at 1, 2, 4, and 8 weeks after severing the sciatic nerve were compared with those at 0 weeks by bioinformatic analysis. We identified 1915 differentially expressed mRNAs in the spinal cord, of which 4, 1909, and 2 were differentially expressed at 1, 4, and 8 weeks after sciatic nerve injury, respectively. Sequencing results indicated that the number of differentially expressed mRNAs in the spinal cord was highest at 4 weeks after sciatic nerve injury. These mRNAs were associated with the cellular response to lipid, ATP metabolism, energy coupled proton transmembrane transport, nuclear transcription factor complex, vacuolar proton-transporting V-type ATPase complex, inner mitochondrial membrane protein complex, tau protein binding, NADH dehydrogenase activity and hydrogen ion transmembrane transporter activity. Of these mRNAs, Sgk1, Neurturin and Gpnmb took part in cell growth and development. Pathway analysis showed that these mRNAs were mainly involved in aldosterone-regulated sodium reabsorption, oxidative phosphorylation and collecting duct acid secretion. Functional assessment indicated that these mRNAs were associated with inflammation and cell morphology development. Our findings show that the number and type of spinal cord mRNAs involved in changes at different time points after peripheral nerve injury were different. The number of differentially expressed mRNAs in the spinal cord was highest at 4 weeks after sciatic nerve injury. These results provide reference data for finding new targets for the treatment of peripheral nerve injury, and for further gene therapy studies of peripheral nerve injury and repair. The study procedures were approved by the Ethics Committee of the Peking University People's Hospital (approval No. 2017PHC004) on March 5, 2017.
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Affiliation(s)
- Jian Weng
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing; Department of Bone & Joint Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Dong-Dong Li
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing; Department of Surgery, the 517th Hospital of the People's Liberation Army, Xinzhou, Shanxi Province, China
| | - Bao-Guo Jiang
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
| | - Xiao-Feng Yin
- Department of Orthopedics and Trauma, Peking University People's Hospital, Beijing, China
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Huang AE, Noland SS, Spinner RJ, Bishop AT, Shin AY. Outcomes of Reconstructive Surgery in Traumatic Brachial Plexus Injury with Concomitant Vascular Injury. World Neurosurg 2019; 135:e350-e357. [PMID: 31837496 DOI: 10.1016/j.wneu.2019.11.166] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/27/2019] [Accepted: 11/28/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate functional outcome from reconstructive surgery in adult traumatic brachial plexus injury (AT-BPI) with associated vascular lesions. METHODS A retrospective review was performed of 325 patients with AT-BPI who underwent reconstructive surgery between 2001 and 2012. Patients with (vascular group) and without (control group) vascular injuries were identified by review of medical documentation. Patient presentation, characteristics of nerve and associated lesions, and surgical management were evaluated to identify prognostic variables. Postoperative muscle strength, range of motion, and patient-reported disability scores were analyzed to determine long-term outcome. RESULTS Sixty-eight patients had a concomitant vascular injury. There were no significant differences in age or sex between the control and vascular groups. The vascular group was more likely to have pan-plexus lesions (P < 0.0001), with significantly more associated upper extremity injuries (P < 0.0001). The control group underwent more nerve transfers, whereas the vascular group underwent more nerve grafting (P = 0.003). Complete outcome data were obtained in 139 patients, which included 111 control (43% of all control subjects) and 28 vascular patients (41%). There was no significant difference in patient-reported disability scores between the 2 groups. However, 73% of control subjects had grade 3 or greater postoperative elbow flexion, whereas only 43% of vascular patients achieved this strength (P = 0.003). Control patients demonstrated a greater increase in strength of shoulder abduction as well (P = 0.004). Shoulder external rotation strength was grade 0 in most patients, with no difference between the 2 groups. CONCLUSIONS Concomitant vascular injury leads to worse functional outcome after reconstructive surgery of traumatic brachial plexus injury.
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Affiliation(s)
- Alice E Huang
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Shelley S Noland
- Department of Plastic Surgery, Mayo Clinic, Scottsdale, Arizona, USA
| | - Robert J Spinner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Allen T Bishop
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Abstract
Upper extremity gunshot wounds result in notable morbidity for the orthopaedic trauma patient. Critical neurovascular structures are particularly at risk. The fractures are often comminuted and may be associated with a variable degree of soft-tissue injury. The literature lacks consensus regarding antibiotic selection and duration, and indications for surgical débridement. Bullets and/or bullet fragments should be removed in cases of plumbism, intra-articular location, nerve impingement, location within a vessel, and location in a subcutaneous position within the hand and/or wrist. Gunshot fractures generally do not follow common fracture patterns seen in blunt injuries, and the complexity of certain gunshot fractures can often be a challenge for the treating orthopaedic surgeon. Common plate and screw constructs may not adequately stabilize these injuries, and innovative fixation techniques may be required. The treatment for bone defects varies by location and severity of injury, and typically requires staged treatment. Nerve injuries after gunshot wounds are common, but spontaneous nerve recovery is expected in most cases.
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