This study assessed the efficacy of physical examination as a screening modality for the diagnosis of surgically significant arterial injury in proximity penetrating extremity
trauma (
PPET). All cases of
PPET were assessed and admitted per established protocol over a 30-month period from January 1, 1993, to June 30, 1995. No patients were excluded if other body regions were also injured. Landmarks defining upper extremity
injuries were the deltopectoral groove to the wrist and for lower extremities from the inguinal ligament to the ankle. Patients admitted with
PPET fell into one of three categories: 1) no hard signs of
vascular injury present-admitted for 24-hour observation; 2) presence of at least one hard sign of
vascular injury-taken immediately to the operating room; 3) positive sign of arterial injury that requires angiography (i.e., diminished but appreciable pulse by physical examination or doppler, large nonexpanding
hematoma, bilateral pulse deficit, no appreciable pulse with unreconstructable trajectory). Four hundred six patients with 489 injured extremities secondary to
PPET were admitted over a 30-month period. Sixty-two extremities suffered
multiple injuries. Of the extremities injured, 83 per cent were secondary to
gunshot wounds, 12 per cent were attributed to stabs/
lacerations, and 5 per cent were due to shotgun
injuries. Four hundred twenty-one extremities with
PPET fell into Group 1. There were four missed
injuries (specificity, 99%) in this group (one ulnar artery, one radial artery, one posterior tibial artery, and one anterior tibial artery). Two of these
injuries were considered surgically significant. None of the patients suffered limb or functional loss as a consequence of their missed arterial injury. Thirty-nine extremities were entered into Group 2, with two patients found to have no arterial injury. Twenty-nine extremities were placed into Group 3 with 10 (35%) found to have surgically significant injury on angiogram. The overall sensitivity and specificity for physical examination was 92 per cent and 95 per cent, respectively, for surgically significant injury. Physical examination is a highly sensitive and specific screening modality for the identification of surgically significant arterial injury in
PPET. Patients who present with diminished, but appreciable, pulses by physical examination or doppler, large nonexpanding
hematomas as the only sign, bilateral pulse deficits and nonappreciable pulses with unreconstructable trajectory benefit from further investigation with angiography.