Selective non-operative management for penetrating extremity trauma: A paradigm shift in management?

Khajuria, Ankur; Geoghegan, Luke; Solberg, Yasmin; Reissis, Dimitris; Jain, Abhilash; Ives, Matthew; Simmons, Jonathan; Lawton, Graham; Hettiaratchy, Shehan

doi:10.1016/j.bjps.2018.05.030

Cited by 7 publications

(5 citation statements)

References 18 publications

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“…Conversely, Miranda et al 10 reported 100% concordance with hand specialist examination and operative findings. Khajuria et al 16 found no difference in the hand examination accuracy of plastic surgery specialists and emergency medicine physicians, although our study found differently. Our data corroborate the findings of Nassab et al, 11 who demonstrated that hand surgeons diagnosed nerve injuries more accurately than emergency medicine physicians (78.8% vs 54.5% vs P < .005).…”

Section: Discussioncontrasting

confidence: 87%

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Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations

Loewenstein

Wulbrecht

Leonhard

et al. 2019

Hand (New York, N,Y.)

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Background: Many patients with complete nerve lacerations after upper extremity trauma have a documented normal peripheral nerve examination at the time of initial evaluation. The purpose of this study was to determine whether physician-, patient-, and injury-related factors increase the risk of false-negative nerve examinations. Methods: A statewide health information exchange was used to identify complete upper extremity nerve lacerations subsequently confirmed by surgical exploration at 1 pediatric and 2 adult level I trauma centers in a single city from January 2013 to January 2017. Charts were manually reviewed to build a database that included Glasgow Coma Scale score, urine drug screen results, blood alcohol level, presence of concomitant trauma, type of injury, level of injury, laterality, initial provider examination, and initial specialist examination. Bivariate and multivariable analyses were performed to evaluate risk factors for a false-negative examination. Results: Two hundred eighty-eight patients met inclusion criteria. The overall false-negative examination rate was 32.5% at initial encounter, which was higher among emergency medicine physicians compared with extremity subspecialists ( P < .001) and among trauma surgeons compared with surgical subspecialists ( P = .002). The false-negative rate decreased to 8% at subsequent encounter ( P < .001). Risk factors for a false-negative nerve examination included physician specialty, a gunshot wound mechanism of injury, injury at the elbow, and age greater than 71 years. Conclusion: There is a high false-negative rate among upper extremity neurotmesis injuries. Patients with an injury pattern that may lead to nerve injury warrant prompt referral to an upper extremity specialist in an effort to optimize outcomes.

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Section: Discussioncontrasting

confidence: 87%

“…Conversely, Miranda et al 10 reported 100% concordance with hand specialist examination and operative findings. Khajuria et al 16 found no difference in the hand examination accuracy of plastic surgery specialists Note. Emergency = emergency medicine; Trauma = trauma surgery; Specialist = extremity subspecialist; Any = any initial provider.…”

Section: Discussionmentioning

confidence: 93%

Risk Factors for a False-Negative Examination in Complete Upper Extremity Nerve Lacerations

Loewenstein

Wulbrecht

Leonhard

et al. 2019

Hand (New York, N,Y.)

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“…Identifying Peripheral Vascular Injuries Detection of peripheral vascular injury in traumatized extremity is sometimes challenging for orthopedic surgeons. 8,9 Extremity color and temperature, capillary refill time, and pulsation of the distal artery are often used to determine whether the injured limb is complicated by vascular injury. However, its accuracy has been doubted.…”

Section: Discussionmentioning

confidence: 99%

Management of Suspected Peripheral Vascular Injuries in Orthopedic Trauma

Li,

Tian,

Fei

et al. 2024

Orthopaedic Surgery

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ObjectiveIn orthopedic trauma, identification of extremity trauma combined with vascular injury is challenging. Missed diagnosis may result in amputation or even death. The purpose of this study was to investigate whether physical examination combined with handheld vascular ultrasound Doppler examination could be an effective method of screening for peripheral vascular injury and to explore the characteristics of vascular injuries in orthopedic trauma patients.MethodsRetrospective analysis of patients in the emergency department of orthopedic trauma in our hospital from January 2022 to October 2023. Physical examination combined with handheld vascular ultrasound Doppler examination was used as a screening method for suspected vascular injuries. Patients with suspected vascular injury would undergo further angiography and receive multidisciplinary treatment. Angiography was used as the gold standard for diagnosing vascular injuries. Patient demographics, mechanism of injury, location and type of injury, angiographic results, surgical notes, and early treatment outcome data were recorded.ResultsA total of 55 cases (58 limb injuries) with suspected vascular injury were ultimately included. Angiography revealed that 53 cases (55 limbs, positive rate 94.8%) were considered to have confirmed vascular injuries. Forty‐three were male (81.1%) and 10 were female (18.9%), with mean age 44.1 ± 16.6 years. The main mechanism of injury was traffic accident (30, 56.7%). Most common site of vascular injuries was knee joint (30/55, 54.5%), and popliteal artery (23, 47.9%) was the most commonly injured blood vessel. After multidisciplinary collaborative treatment, overall patient mortality was 3.8% (2/53), and limb survival rate among surviving patients was 81.1% (43/53) in our study.ConclusionIn orthopedic trauma, “Hard signs” and “soft signs” combined with handheld vascular ultrasound Doppler examination were effective ways to screen for suspected vascular injuries. Most limbs had associated fractures or dislocations at the site of vascular injury. Collaboration of vascular surgery, microsurgery and orthopedic trauma may help improve patients' prognosis.

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“…These risks make rapid diagnosis essential; however, identification can be challenging 9 . Evidence-based examination options for diagnosis include capillary refill and identifying hard signs of vascular injury (lack of distal palpable pulses, expanding haematoma, and continued blood loss) [10][11][12] .…”

Section: Introductionmentioning

confidence: 99%