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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 limb loss.

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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

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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.

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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.

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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.

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Ankle-Brachial Index

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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 ...

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