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 ...