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INTRODUCTION

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Isolated penetrating trauma to the extremities that is associated with vascular injury has a nearly 10% incidence of mortality or limb loss. Early identification of injuries requiring imaging and/or surgical intervention has reduced the rates of limb loss and disability.

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CLINICAL FEATURES

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As with all traumatic injuries, a thorough primary survey with attention to life-threatening injuries should be accomplished prior to a detailed extremity exam. Direct pressure or a tourniquet should be applied to actively bleeding injuries. Once an extremity injury is identified, a meticulous vascular and neuromuscular exam should then be performed.

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Note pulses distal to the injury, capillary refill, and the color and temperature of the limb. Use a Doppler to detect a signal in the absence of a pulse. Any “hard” signs of arterial injury should prompt immediate surgical consultation and intervention. Soft signs of arterial injury should also be noted and require further evaluation, typically imaging and observation (Table 168-1).

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Table 168-1

Clinical Manifestations of Extremity Vascular Trauma

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Document the size and shape of each wound, as well as any bony deformities or soft tissue defects. Evaluate the surrounding area for pain with palpation or range of motion. Carefully evaluate joints in the proximity of the wound for the possibility of an open joint. Perform detailed strength and sensory exams on the affected limb to check for peripheral nerve injury. Consult the appropriate surgical specialist for signs of injury to an artery, nerve, joint, or bone, or suspicion of compartment syndrome (see Fig. 168-1).

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DIAGNOSIS AND DIFFERENTIAL

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Figure 168-1

Algorithm for penetrating extremity trauma. ABI, ankle-brachial index.

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Obtain ankle-brachial indexes (ABIs) on the affected and unaffected limb using a Doppler and manual blood pressure cuff. Though they have variable sensitivity and specificity for arterial injury and do not reliably detect nonocclusive injuries such as intimal flaps or pseudoaneurysms, a result of <0.9 is concerning for arterial injury. Soft signs of vascular injury or an abnormal ABI requires further imaging.

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At minimum, AP and lateral films of the affected limb are necessary to evaluate for bone or joint injuries. Retained foreign bodies or embolized bullet fragments may also be seen. Image the joint above and below the injury site.

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CT angiography has largely supplanted conventional angiography in the evaluation of vascular injuries as it is widely available, rapid, relatively noninvasive, and provides high-quality images that may also be useful in ...

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