1: J Trauma  1998 Feb;44(2):243-52; discussion 242-3 

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 JW, Frykberg ER, Veldenz HC, Huffman S, Menawat SS.

Department of Surgery, University of Florida Health Science Center, Jacksonville
32209, USA.

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.

Publication Types:
    Review
    Review, Multicase

PMID: 9498494 [PubMed - indexed for MEDLINE]