Physical Examination plus Chest Radiography in Penetrating Periclavicular Trauma: The Appropriate Trigger for Angiography

Abstract

In patients with periclavicular penetrating trauma, a normal physical examination and chest radiographic excludes vascular injury. Proximity alone does not warrant angiography, although the test may be useful for therapeutic interventions or to plan operative approaches. A prospective study is essential to validate these findings.

Selective management of penetrating neck injuries using “no zone” approach

“…Demetriades et al [10] conducted a prospective trial evaluating the use of physical examination in PNI patients; they demonstrated that the lack of hard signs of vascular and aerodigestive tract injuries could reliably exclude the need for operative repair with the negative predictive value of 100%. Retrospective studies also showed that physical examination, combined with a negative chest X-ray; could be used to rule out significant vascular injuries (negative predictive value 100%) in zone I PNI patients [14,15]. Hence, observation alone in asymptomatic PNI patients, regardless of the zone, seems to be a safe approach.…”

Imaging of Penetrating Chest Trauma

“…Prehospital mortality from transmediastinal penetrating injury may be as high as 86% for cardiac injuries, 92% for thoracic vascular injuries, and 11% for pulmonary injuries [6,7]. Most patients (60%) who have transmediastinal gunshot wounds, who do not require immediate surgery will need imaging studies to diagnose injuries and plan treatment [6][7][8][9][10]34,35]. Occult injuries to mediastinal structures are not uncommon, and any possible transmediastinal trajectory must be assumed to have created life-threatening injuries [Figs.…”

“…1 and 9-14] [9,10,33]. A significant increase in morbidity and mortality is associated with delayed recognition of such injuries [35].…”

Answer

“…One retrospective study of 100 patients with periclavicular trauma found that a normal physical exam coupled with a normal chest x-ray eliminated the need for angiography and would not have missed any vascular injuries. 5 Treatment is surgical in the majority of cases.…”