Injuries to the extremities from gunshots, stab wounds, and other penetrating trauma can cause significant morbidity by damaging bones, nerves, soft tissue, and blood vessels. Early identification and treatment of these injuries is important to prevent permanent disability or loss of limbs.
Ascertain the events surrounding the injury, including the type of weapon and number of shots or stabs. Obtain a thorough history of any prior injuries, deficits, or ischemic events in the affected limb. Perform a detailed vascular and neuromuscular examination.
When examining the patient, early identification of any arterial injury is crucial. Note pulses distal to the injury, capillary refill, and the color and temperature of the limb. Any “hard” signs of arterial injury should prompt immediate surgical consultation and intervention. “Soft” signs of arterial injury should also be noted and require observation and surgical consultation (Table 168-1).
Table 168-1 Clinical Manifestations of Extremity Vascular Trauma |Favorite Table|Download (.pdf)
Table 168-1 Clinical Manifestations of Extremity Vascular Trauma
Absent or diminished distal pulses
Obvious arterial bleeding
Large expanding or pulsatile hematoma
Distal ischemia (pain, pallor, paralysis, paresthesias, coolness)
Small, stable hematoma
Injury to anatomically related nerve
History of hemorrhage
Proximity of injury to major vascular structures
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.
Diagnosing significant injuries to the extremities requires a meticulous exam. Ankle-Brachial indices (ABIs) and imaging may also be indicated. The decision to obtain vascular imaging in the absence of hard signs of injury is controversial and should be made in conjunction with a careful history and examination (Fig. 168-1).
Algorithm for the evaluation of an injured extremity for vascular trauma.
Obtain ABIs on the affected and unaffected limb, though they have variable sensitivity and specificity for arterial injury and do not reliably detect injuries such as intimal flaps or pseudoaneurysms. Perform them in all 4 extremities with the patient supine, using the Doppler and a manual blood pressure cuff. The ankle systolic pressure is then divided by the greatest systolic pressure from the upper extremities. A result of 0.5 to 0.9 indicates injury to a single arterial segment, while a result of <0.5 indicates either severe arterial injury or injury to multiple segments of the artery.