Original communication| Volume 48, ISSUE 5, P946-951, November 1960

Timing of nerve suture after a gunshot wound

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      Differences of opinion exist regarding the desirability of early nerve suture at the time of débridement after a relatively clean incised wound. While many British surgeons disagree, the majority of Americans recommend this course and their statistics appear to justify the resultant saving of time. When a nerve is severed by a high velocity projectile, however, all neurosurgeons trained in the recent wars agree that suture should be deferred to a second stage to be performed at least 1 month after the primary débridement. This delay is mandatory, for a well-executed nerve repair immediately after injury by gunshot is not possible. The softened epineurium cannot be counted on to hold sutures, and there is no way of telling how much to trim off the injured stumps. Adequate proximal and distal neurolysis to insure a suture free of tension is not justified, because it exposes healthy tissue planes to the risk of spreading infection. The suture is therefore threatened by the risk of separation and, if it holds, by an endoneural barrier of scar tissue.
      A typical gunshot injury is described which illustrates the cause of failure of early nerve repair. The only result of suturing the blast-softened, seminecrotic ends of the divided median nerve was the development of neuroma-incontinuity. No regenerating axons could have penetrated the 3 cm. barrier of scar, which had to be excised and resutured after 3 months had been wasted. Attempts at primary suture under such conditions can delay recovery many months before failure of regeneration becomes a certainty and forces the surgeon to resect the neuroma and resuture the nerve.
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