Penetrating Extremity Injury

Case:

37 yo male with multiple gsw to right upper extremity.  One to the shoulder and one to the forearm.  The primary survey was intact, GCS was 15, and the secondary survey was significant for three wounds and a palpable missile to the posterior shoulder.  He had an apparent through and through wound crossing the forearm compartments and a wound to the medial bicep leading to the palpated missile.  Also noted was tenderness to palpation of lateral shoulder, as well as, tenderness approximate to wound sites.  There was hematoma to the bicep wound, tense forearm compartments on the right, and diminished pulse at right radial.  Bleeding was controlled.  The patient’s vital signs were stable, and he complained of parasthesias to the distal right upper extremity. 

 

Imaging:

 

 

 

 

 

  

 

Some brief information regarding penetrating extremity injury:

XRs indicated-

●Extremity deformity

●Point tenderness

●Ecchymosis  

●Laceration deep to the muscle fascia

●Laceration in proximity to a joint

●Joint laxity

 

Antibiotics – Start at diagnosis of open fracture. 

 

Tetanus prophylaxis

Hard signs of arterial injury on exam:

·         Active hemorrhage

·         Expanding or pulsatile hematoma

·         Bruit or thrill over wound

·         Absent distal pulses

·         Extremity ischemia (pain, pallor, paralysis, cool to touch)

 

In penetrating extremity trauma, the presence of a hard sign of arterial injury was nearly 100 percent predictive of a vascular injury warranting surgical repair without additional imaging.  

 

Soft Signs of arterial injury:

 

·         Decreased pulse or ABI

·         Proximity to vasculature

·         Hematoma

·         Neurologic deficit

·         History of blood loss

 

A normal ABI (i.e., >0.9) has a high negative predictive value for vascular injury, allowing the patient to be observed or managed without immediate vascular imaging – our patient could not tolerate ABI.

 

Indeterminate signs of vascular trauma warrant additional imaging with CT or conventional digital subtraction angiography (DSA)

 

Hard signs of arterial injury on CT angio

 

●Extravasation of contrast or pseudo aneurysm

●Arteriovenous fistula

●Flow-limiting intimal flap (flow-limiting based upon clinical exam). If the injured extremity index is normal, any observed flap is not considered to be flow-limiting.

●Occlusion of axial extremity arteries

●Distal embolism (may occur even in the presence of a relatively minor proximal injury)

Our patient had no hard signs of vascular injury, but displayed multiple soft signs.  The CTA of the right upper extremity demonstrated right radial artery occlusion and vascular surgery was consulted for possible repair in the OR. 

References:

Frykberg ER. 'Advances in the diagnosis and treatment of extremity vascular trauma.' Surg Clin N Am 1995;75:207-223

EAST Practice Management Guidelines. 'Practice Management Guidelines for Penetrating Trauma to the Lower Extremity.' EAST 2001 http://www.east.org/tpg/lepene.pdf

Karim Brohi, ‘Peripheral Vascular Trauma.’ trauma.org 7:3, March 2002

Franz RW, Shah KJ, Halaharvi D, et al. A 5-year review of management of lower extremity arterial injuries      at an urban level I trauma center. J Vasc Surg 2011; 53:1604.

 

from Dr. Adam Whitsett