1638 - Proximal Median Nerve Injury of the Right Upper Extremity Following Gunshot Wounds: Clinical and Electrodiagnostic Correlation in a Case of Persistent Hand Pain, Paresthesias, and Thenar Atrophy

Proximal median nerve injury of the right upper extremity following gunshot trauma, presenting with hand pain, paresthesias, and thenar atrophy.

Case Description:

A man in his 30s underwent EMG five months after sustaining gunshot wounds to the volar and dorsal right forearm. He reported persistent dull, crushing pain with paresthesias in the thenar region, thumb, and digits 2–3, plus intermittent “electric” pain radiating from the medial biceps to proximal forearm. Exam showed thenar atrophy, impaired sensation over the lateral biceps, thumb, and thenar eminence, and weakness most severe with thumb IP flexion (1/5) and PIP flexion of digits 2–3 (2/5). Tinel and Phalen were positive. EMG revealed active denervation of the abductor pollicis brevis, early reinnervation in FDP (digits 2–3), chronic reinnervation in flexor carpi radialis, and complete denervation of the flexor pollicis longus without axonal continuity. Findings supported proximal median nerve injury rather than isolated carpal tunnel syndrome.

Discussions:

Gunshot wounds to the upper limb frequently injure peripheral nerves, with the median nerve particularly vulnerable in forearm trauma. Distinguishing proximal neuropathy from entrapment syndromes such as carpal tunnel is crucial for management. Clinical examination supplemented by electrodiagnostic testing—and when indicated, ultrasound—enables accurate localization. While many ballistic nerve injuries are neuropraxic or axonotmetic with potential for recovery, neurotmetic lesions may require early surgical exploration. Timely electrodiagnostic evaluation aids prognosis and guides referral to specialized care.

Conclusions:

This case underscores the importance of thorough clinical and electrodiagnostic assessment in firearm-related upper extremity trauma. Differentiating distal entrapment from proximal median nerve lesions is essential to determine severity, prognosis, and the need for early surgical consultation.