The Scope and Distribution of Upper Extremity Nerve Injuries Associated With Combat-Related Extremity Limb Salvage

Colin J Harrington; Marissa E Dearden; Patrick McGlone; Benjamin K Potter; Scott M Tintle; Jason M Souza

doi:10.1016/j.jhsa.2023.09.008

The Scope and Distribution of Upper Extremity Nerve Injuries Associated With Combat-Related Extremity Limb Salvage

J Hand Surg Am. 2024 Jan 12:S0363-5023(23)00500-2. doi: 10.1016/j.jhsa.2023.09.008. Online ahead of print.

Authors

Colin J Harrington¹, Marissa E Dearden², Patrick McGlone², Benjamin K Potter², Scott M Tintle², Jason M Souza³

Affiliations

¹ Division of Orthopaedics, Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD. Electronic address: colinharrington1414@gmail.com.
² Division of Orthopaedics, Department of Surgery, Uniformed Services University-Walter Reed National Military Medical Center, Bethesda, MD.
³ Department of Plastic and Reconstructive Surgery & Orthopaedic Surgery, Ohio State University, Columbus, OH.

PMID: 38219089
DOI: 10.1016/j.jhsa.2023.09.008

Abstract

Purpose: Chronic pain and functional limitations secondary to nerve injuries are a major barrier to optimal recovery for patients following high-energy extremity trauma. Given the associated skeletal and soft tissue management challenges in the polytraumatized patient, concomitant nerve injuries may be overlooked or managed in delayed fashion. Whereas previous literature has reported rates of peripheral nerve injuries at <10% in the setting of high-energy extremity trauma, in our experience, the incidence of these injuries has been much higher. Thus, we sought to define the incidence, pain sequelae, and functional outcomes following upper extremity peripheral nerve injuries in the combat-related limb salvage population.

Methods: We performed a retrospective review of all patients who underwent limb salvage procedures to include flap coverage for combat-related upper extremity trauma at a single institution between January 2011 and January 2020. We collected data on patient demographics; perioperative complications; location of nerve injuries; surgical interventions; chronic pain; and subjective, patient-reported functional limitations.

Results: A total of 45 patients underwent flap procedures on 49 upper extremities following combat-related trauma. All patients were male with a median age of 27 years, and 96% (n = 47) of injuries were sustained from a blast mechanism. Thirty-three of the 49 extremities (67%) sustained associated nerve injuries. The most commonly injured nerve was the ulnar (51%), followed by median (30%) and radial/posterior interosseous (19%). Of the 33 extremities with nerve injuries, 18 (55%) underwent surgical intervention. Nerve repair/reconstruction was the most common procedure (67%), followed by targeted muscle reinnervation (TMR, 17%). Chronic pain and functional limitation were common following nerve injury.

Conclusions: Upper extremity peripheral nerve injury is common following high-energy combat-related trauma with high rates of chronic pain and functional limitations. Surgeons performing limb salvage procedures to include flap coverage should anticipate associated peripheral nerve injuries and be prepared to repair or reconstruct the injured nerves, when feasible.

Type of study/level of evidence: Therapeutic IV.

Keywords: Blast injuries; Flap reconstruction; Limb salvage; Peripheral nerve; War trauma.