Purpose of Review <p>Traumatic peripheral nerve injuries (PNIs) are high-stakes presentations in the emergency department (ED). Missed deficits and delayed referral can lead to functional loss and chronic neuropathic pain. This review summarizes an ED-centered approach to evaluation, early risk stratification, and management pathways.</p> Recent Findings <p>Contemporary epidemiology suggests PNIs after extremity trauma occur at clinically meaningful rates. High-resolution ultrasound and neuromuscular ultrasound can visualize nerve continuity, focal enlargement, traumatic neuroma, and entrapment, though performance depends on operator skill and nerve depth. Magnetic resonance neurography complements ultrasound for deeper nerves, plexus-level injury, and muscle denervation patterns. Electrodiagnostic testing remains central for localization and prognosis but is usually most informative in the subacute period.</p> Summary <p>ED care should integrate mechanism-based suspicion, nerve-specific examination with repeat post-reduction reassessment, selective imaging when it changes decisions, timely surgical consultation for suspected transection/entrapment/progression, and clear documentation with structured follow-up.</p> Opinion Statement <p>We recommend an emergency department approach to traumatic peripheral nerve injury that prioritizes early recognition, identification of time-sensitive lesions, and a closed-loop follow-up plan when observation is appropriate. Every at-risk extremity trauma should receive a nerve-specific motor and sensory exam documented before and after reduction, splinting, or casting, because evolving deficits can reflect entrapment, hematoma expansion, ischemia, or compartment syndrome. When mechanism and exam raise concern for high-grade injury, particularly sharp lacerations with motor loss, open fractures with neurologic deficit, progressive weakness after immobilization, or deficits out of proportion to pain, urgent surgical consultation is warranted. High-resolution ultrasound adds the most value when it answers a focused question that changes acute decisions, specifically whether the nerve is in continuity, whether there is focal compression by hematoma or displaced fragments, and whether post-reduction positioning is producing dynamic impingement. In stable closed injuries with preserved continuity and no red flags, we favor functional splinting, multimodal analgesia, and early specialty follow-up with a planned timeline for electrodiagnostic testing in the subacute period to localize injury and guide prognosis. For suspected deep nerve or plexus involvement, equivocal ultrasound, or complex regional injury patterns, magnetic resonance neurography can complement ultrasound by defining lesion extent and demonstrating denervation patterns that influence urgency. Overall, ED success depends less on assigning a perfect injury grade at presentation and more on reliably detecting injuries unlikely to recover spontaneously, reassessing after interventions, and ensuring timely definitive nerve evaluation.</p>