Emergency management of penetrating extremity injuries and advances in
surgical technique enable arterial repair with an extremely low
rate of postoperative thrombosis, making the recognition and rapid
treatment of arterial injury important. Associated injury to soft
tissue, nerve, and bone is now the primary determinant of limb salvage.
Emergency physicians play a crucial role in the management of penetrating
extremity injuries by identifying injuries early and promptly initiating
care crucial to limb rescue. Unnecessary delays (>6 to 12 hours)
in treatment can lead to irreversible limb ischemia and subsequent
Greater than 50% of penetrating trauma injuries involve
the extremities. Penetrating trauma accounts for up to 82% of
all vascular injuries to the extremities. Gunshot and shotgun wounds
account for nearly 65% of penetrating vascular extremity
injuries, and stab wounds account for approximately 15%.
In 1950, a patient with a penetrating extremity injury with vascular
involvement had a 50% chance of leaving the hospital with an
amputated limb. With recent advances in emergency care, vascular surgery,
invasive radiology, and the science of thrombosis, penetrating extremity
injury results in amputation in <5% of cases.1 Despite
this improved diagnosis, there is still significant long-term morbidity
due to other complications, such as nerve damage, fractures, wound
infections, open joint injuries, and compartment syndromes.2
Gunshot and stab wounds account for the largest percentage of
penetrating extremity injuries. Diagnosis, treatment, and outcome
differ with the type and severity of the injury. Although the damage
from a stab wound can be relatively predictable with a good knowledge
of clinical anatomy, the tissue damage inflicted by a missile or
blast depends on a variety of factors.
After the initial trauma resuscitation and primary and secondary
surveys are complete, determine preexisting vascular and neuromuscular
deficits, and the events surrounding the injury, such as the type
of gun and number of shots. Perform a careful and thorough physical
examination to identify significant injuries rapidly to determine
whether immediate surgical intervention is necessary and which diagnostic
studies are indicated.
Prompt recognition of arterial injury is one of the fundamental
goals of management. Note the presence and strength of the distal
pulses in the affected extremity and compare with the unaffected
limb. The color, temperature, and capillary refill time are important
clinical indicators of more subtle injury to underlying vessels.
Look for signs of compartment syndrome. Capillary refill alone is
an unpredictable marker of vascular injury but may be useful in
conjunction with other modalities.
Calculate ankle-brachial indices (ABIs) on the affected and unaffected limbs.
Diagnostic accuracy for vascular injury can be as high as 95%,
but sensitivity and specificity vary depending on whether the classification
of abnormal is set at a ratio of 1.0 or 0.9.3,4 The
ABI does not reliably detect nonocclusive arterial disease, such
as intimal flaps and pseudoaneurysms. It can augment the
clinical examination by objectively confirming the subjective impression
of a diminished pulse in a patient under observation. To perform
an accurate ABI, place the patient supine and measure the systolic
blood pressure in all four extremities. To measure an ankle systolic
pressure, place a standard adult blood pressure cuff snugly around
the ankle just above the malleoli. While using the Doppler flowmeter
to monitor the signal from the posterior of the anterior tibial artery,
distal to the cuff, inflate the cuff to a pressure approximately
30 mm Hg above the systolic pressure to occlude flow temporarily.
As the cuff is slowly deflated (2 to 5 mm Hg/s), note the
pressure at which the Doppler flow signal is first heard and recorded
(this is the ankle systolic pressure). To assure accuracy, measure
the upper extremity systolic blood pressure with a Doppler flowmeter
as well. An ABI is then calculated by dividing the ankle systolic
blood pressure by the greater of the two systolic upper extremity
systolic blood pressures. An ABI of >1.0 is normal. An ABI
of 0.5 to 0.9 is indicative of injury to a single arterial segment.
An ABI of <0.5 is indicative of severe arterial injury or injury
to multiple arterial segments. A difference of >20 mm Hg
between the upper extremity blood pressures is indicative of upper
extremity arterial injury. Underlying conditions, such as
preexisting peripheral vascular disease or severe hypothermia, can
also affect the ABI.
Only a small minority of patients (<6%) will present
with classic “hard” signs of arterial injury (Table 263-1). These patients require expeditious operative
management or, under certain circumstances, angiography (Figure 263-1). A surgeon should be involved
in management as soon as possible. Patients with “soft” signs
(Table 263-1) of arterial vascular trauma
can usually be managed without surgical intervention on an inpatient
Table 263-1 Clinical Manifestations
of Extremity Vascular Trauma
| Save Table
Table 263-1 Clinical Manifestations
of Extremity Vascular Trauma
|Absent or diminished distal pulses|
|Obvious arterial bleeding|
|Large expanding or pulsatile hematoma|
|Distal ischemia (pain, pallor, paralysis, paresthesias,
|Small, stable hematoma|
|Injury to anatomically related nerve|
|History of hemorrhage|
|Proximity of injury to major vascular structures|
Algorithm for the evaluation of an injured extremity for
and Compartment Syndrome
Even though arterial injury is the most dramatic result of penetrating
extremity injury and represents the most immediate life threat,
injuries to major nerves are the most likely to lead to long-term
disability. Fortunately, 70% of peripheral nerve injuries
noted during the initial examination recover completely within 6
months of the initial injury. A neuromuscular examination of the
extremities should indicate both muscular and sensory function (Table 263-2 and see Figure 158.1-1), and check for evidence of compartment syndrome. Patients
with suspected nerve, orthopedic, vascular injury, or compartment
syndrome should be immediately evaluated by surgical subspecialists.
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