Operative Evaluation and Treatment of Civilian Ballistic Nerve Injuries: A Case Series.

PURPOSE: Gunshot wounds (GSWs) to the extremities can be debilitating because of their effect on peripheral nerves and the subsequent loss of function experienced by patients. However, intraoperative findings seen upon nerve exploration in ballistic injuries have not been widely reported in the civilian population. In this study, we examine our experience in the operative management of low-velocity civilian GSW injuries to the extremities with concomitant nerve palsies in regard to indications for exploration, intraoperative findings, and methods of reconstruction. METHODS: We performed a retrospective review of patients undergoing surgical intervention for GSW-related nerve injuries from two large academic centers. Included patients had a documented motor nerve or mixed-motor-sensory-nerve injury of either the upper or lower extremity after GSW. The primary outcomes were the intraoperative status of the nerve as well as the method of nerve reconstruction. RESULTS: Forty-nine patients (57 nerves) were included in this study, 85.7% of whom were men with an average age of 28.9 ± 10.5 years. The median time from injury to surgery was 99 days, and most patients (61.2%) underwent exploration because of lack of improvement in function. Upon exploration, 33.3% had a neuroma in continuity (NIC), 21.1% had partial transection, 21.1% had a complete transection, and 24.6% were found to be in continuity. Nerve transfer and neurolysis were the most performed procedures, followed by autologous nerve graft and nerve decompression. Only 1.8% of nerve injuries were amenable to a direct repair. Comparison of patients who underwent early nerve exploration because of concomitant fracture fixation versus those who had delayed exploration because of lack of return of function demonstrated a considerably lower rate of NIC among patients with earlier exploration. CONCLUSIONS: Our study is one of the few to document intraoperative nerve findings in civilian ballistic injury. Our results demonstrate that nerves affected by ballistic trauma are rarely amenable to direct repair and high rates of NIC with delayed exploration; as such, surgeons should be prepared for grafting and other reconstructive options. Early exploration in the carefully selected patients may help surgeons address nerve injuries in a timelier fashion before the development of NIC. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.