Gunshot-related lower extremity nerve injuries.

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.

Diabetic Kidney Disease Is Associated With Increased Complications Following Operative Management of Ankle Fractures.

Background: Diabetes mellitus and peripheral neuropathy are established risk factors for complications in operatively treated ankle fractures. Generally, the presence of peripheral neuropathy and diabetic nephropathy have been used as independent variables in studies of diabetic ankle fracture cohorts but are typically treated as binary risk factors. Our purpose was to quantify the effects of risk factors on complication rate specific to diabetic patients undergoing ankle fracture fixation. Methods: We identified 617 rotational ankle fractures treated operatively at a single academic medical center from 2010 to 2019, of which 160 were identified as diabetic. Of these, 91 ankle fractures in 90 diabetic patients met criteria for retrospective review of clinical and radiographic data. Criteria included perioperative laboratory studies, including glycated hemoglobin (HbA1c) and estimated glomerular filtration rate (eGFR), as well as follow-up radiographs in the electronic record. We defined complications in this surgical cohort as deep surgical site infection, unplanned return to the operating room, and failure of fixation. Logistic regression was performed and odds ratios (ORs) calculated. Results: The overall complication rate was 28.6% (26/91) in this cohort. Median follow-up was 29 weeks (range: 5-520 weeks). Mean perioperative HbA1c in patients who experienced postoperative complications was 7.6% (range: 5.1%-14.2%) compared with 7.8% (range: 5.6%-13.5%) who did not (P = .69). Diabetic patients with chronic kidney disease (eGFR <60 mL/min per body surface area) (OR 5.29, P = .006) and peripheral neuropathy (OR 4.61, P = .003) were at significantly higher risk of all complications compared with diabetic patients without these comorbidities. Of note, we did not find an association between perioperative HbA1c or body mass index and complication rate. Conclusion: Patients with diabetes complicated by chronic kidney disease are at significantly higher risk of complications following operative management of ankle fractures. Our study also corroborated previous reports that within this high-risk cohort, the presence of peripheral neuropathy is a significant risk factor for complications. These sequalae of diabetic disease are manifestations of microvascular disease, glycosylation of soft tissues, and impaired metabolic pathways. Identifying these risk factors in diabetic patients allows for patient-specific risk stratification, education, and management decisions of ankle fractures. Level of Evidence: Level III, retrospective cohort study.

Gunshot-Related Upper Extremity Nerve Injuries at a Level 1 Trauma Center.

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.

Are American Surgical Residents Prepared for Humanitarian Deployment?: A Comparative Analysis of Resident and Humanitarian Case Logs.

BACKGROUND: Effective humanitarian surgeons require skills in general surgery, OB/GYN, orthopedics, and urology. With increasing specialization, it is unclear whether US general surgery residents are receiving exposure to these disparate fields. We sought to assess the preparedness of graduating American surgical residents for humanitarian deployment. METHODS: We retrospectively analyzed cases performed by American College of Graduate Medical Education general surgery graduates from 2009 to 2015 and cases performed at select Médecins Sans Frontières (MSF) facilities from 2008 to 2012. Cases were categorized by specialty (general surgery, orthopedics, OB/GYN, urology) and compared with Chi-squared testing. Non-operative care including basic wound and drain care was excluded from both data sets. RESULTS: US general surgery residents performed 41.3% MSF relevant general surgery cases, 1.9% orthopedic cases, 0.1% OB/GYN cases, and 0.3% urology cases; the remaining 56.4% of cases exceeded the standard MSF scope of care. In comparison, MSF cases were 30.1% general surgery, 21.2% orthopedics, 46.8% OB/GYN, and 1.9% urology. US residents performed fewer OB/GYN cases (p < 0.01) and fewer orthopedic cases (p < 0.01). Differences in general surgery and urology caseloads were not statistically significant. Key procedures in which residents lacked experience included cesarean sections, hysterectomies, and external bony fixation. CONCLUSION: Current US surgical training is poorly aligned with typical MSF surgical caseloads, particularly in OB/GYN and orthopedics. New mechanisms for obtaining relevant surgical skills should be developed to better prepare American surgical trainees interested in humanitarian work.