JHS - 2026-08-07 - Journal Article
Operative Evaluation and Treatment of Civilian Ballistic Nerve Injuries: A Case Series.
Ghosh K, Aggarwal S, Blum E, Brogan DM, Dy CJ, Stepan JG
Topics
Key Takeaway
In 57 ballistic nerve injuries explored operatively, only 1.8% were amenable to direct repair, with neuroma-in-continuity found in 33.3% of cases—rising substantially with delayed exploration beyond 99 days.
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Summary
This retrospective two-center series examined intraoperative findings and reconstruction strategies in civilian low-velocity GSW nerve injuries requiring operative intervention. Of 57 nerves explored (median 99 days post-injury), 33.3% had neuroma-in-continuity, 21.1% partial transection, 21.1% complete transection, and 24.6% were in continuity; nerve transfer and neurolysis were the most common procedures. Early exploration concurrent with fracture fixation yielded a considerably lower rate of neuroma-in-continuity compared to delayed exploration driven by failure to recover function.
Key Limitation
Absence of postoperative functional outcome data (motor grading, sensory recovery, validated PROs) prevents any conclusion about whether the reconstruction method chosen actually improved patient outcomes.
Original Abstract
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.