1: J Trauma  1991 Apr;31(4):502-11 

The reliability of physical examination in the evaluation of penetrating
extremity trauma for vascular injury: results at one year.

Frykberg ER, Dennis JW, Bishop K, Laneve L, Alexander RH.

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

All cases of penetrating extremity trauma (PET) seen at an urban trauma center
were prospectively studied to determine the accuracy and safety of physical
examination as the sole mode of evaluation for vascular injury. All patients
with PET producing obvious or "hard" signs of vascular injury underwent
immediate surgery. All asymptomatic proximity wounds were observed in hospital
for 24 hours before discharge to outpatient followup. Patients with
non-proximity wounds were discharged immediately. Patients with shotgun wounds
and thoracic outlet injuries also underwent arteriography. Of 2,674 trauma
patients evaluated during the 1-year study period, 310 (11.6%) had 366
penetrating extremity wounds, most (71%) occurring in the lower extremities.
Gunshots caused most (82%) of the wounds, followed by stabs or lacerations
(14.5%), and shotguns (3%). Clinically occult wounds in proximity to major limb
vessels were the most common (78%) category of clinical presentation, followed
by asymptomatic non-proximity wounds (16%), and wounds producing hard signs
(6%). There were two missed vascular injuries, both in the asymptomatic
proximity group (0.7% false negatives). Every patient taken immediately to
surgery for hard signs had major arterial injury requiring repair, for a 100%
positive predictive value for physical examination. No mortality or morbidity
were related to protocol management. These results to date support prior reports
of a negligible incidence of significant vascular injury following clinically
occult proximity PET, and further suggest that the overall predictive value of
physical examination of PET for vascular injury approaches 100%.

PMID: 2020036 [PubMed - indexed for MEDLINE]