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Validation of Nonoperative Management of Occult Vascular Injuries and Accuracy of Physical Examination Alone in Penetrating Extremity Trauma: 5- to 10-Year Follow-up

Dennis, James W. MD, FACS; Frykberg, Eric R. MD, FACS; Veldenz, Henry C. MD, FACS; Huffman, Susan BA; Menawat, Sunil S. MD

The Journal of Trauma: Injury, Infection, and Critical Care: February 1998 - Volume 44 - Issue 2 - p 243-253

Purpose To establish by long-term follow-up the safety and efficacy of nonoperative management of clinically occult arterial injuries and the use of physical examination (PE) alone in determining treatment of penetrating extremity trauma (PET).

Methods Two groups of patients were studied: (1) all patients with PET, arterial abnormalities on arteriograms, and no hard signs of vascular injury treated nonoperatively from 1986 to 1989; and (2) all patients with PET to the extremities managed by PE alone from 1989 to 1991. Telephone contact, PE, and duplex ultrasonography (US) were attempted in all group 1 patients, and telephone interviews were attempted in all group 2 patients.

Results Group 1 had 43 patients with 44 clinically occult penetrating injuries to extremity arteries. Arteriography identified 21 intimal flaps/irregularities, 19 narrowings, 2 pseudoaneurysms, and 1 arteriovenous fistula. Four patients (9%) had clinical deterioration within 1 month and required surgery, with good results. Twenty-three of the other 39 patients (58%) were able to be contacted, and 17 (43%) with 18 injuries underwent PE and US. All were asymptomatic and had normal PE, and one had mild residual narrowing on US. The other 6 patients (four in prison, two out of state) reported no symptoms of vascular insufficiency and never sought medical attention for vascular problems. Mean follow-up was 9.1 years (range, 8.6-11.1 years). Group 2 had 287 patients (309 injuries) with PET treated by observation based on PE alone. Four patients (1.3%) required delayed surgery within the first week, and 78 with 90 injuries (29%) were able to be contacted. No patient reported any vascular symptoms or ever saw a physician for vascular problems. Mean follow-up was 5.4 years (range, 2.2-6.0 years).

Conclusion This is the first long-term follow-up of nonoperative management of clinically occult arterial injuries of the extremities and the use of PE alone in the initial management of PET. The results show these approaches to be safe, effective, and now a proven standard of care.

From the Department of Surgery, University of Florida Health Science Center, Jacksonville, Florida.

Presented at the 57th Annual Meeting of the American Association for the Surgery of Trauma and the Japanese Association for Acute Medicine, September 24-27, 1997, Waikoloa, Hawaii.

Address for reprints: James W. Dennis, MD, FACS, Associate Professor of Surgery, Chief, Division of Vascular Surgery, University of Florida Health Science Center, Department of Surgery, 653 West Eighth Street, Jacksonville, FL 32209.

© Williams & Wilkins 1998. All Rights Reserved.