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Penetrating extremity trauma

Ronald Gross Rgross at harthosp.org
Fri Apr 21 15:11:41 BST 2006


>>> docrickfry at aol.com 04/21 10:09 AM >>>
You have misrepresented our paper below--you should read it before
citing it to support what you say.  In fact, the paper clearly asserts
all the reasons and lack of evidence for any benefit whatever in the use
of nonvasives to assess penetrating (or, in fact any) extremity trauma
for vascualr injury.  One whole section of the discussion reviews this
issue.  They have never ever been shown to have any advantage whatever
over and above what you can determine and decide from physical exam
alone.  Also reviews the evidence out there for 15 years showing that
the whole concept of soft signs is obsolete, no evidence whatever that
they predict or mandate anything at all.  Simply whether hard signs are
presnet or absent tells you all you need to know, the evidence
supporting this quite abundnat, the evidence refuting it simply
nonexistent.  Soft signs only equates to no hard signs, may be
discharged home  if no other injuries requiring attention.  Also, many
penetraitng extrtemity w
 ounds in fact have NO risk of vascular injury just based on location,
unless a hard sign present--il.e. lateral thigh stab--D/C home just on
basis of location--in asymptomatic wounds, only those in proximity to a
major vessel are at risk, and only a small minority of them have any
associated injury whteever, and even then, the absence of hard signs
predicts with an accuracy approaching 100% that any injury present,
being asyumptomatic, will not reuire repair--thus almost no need
whatever for any imaging nowadays for any uncomplicated injured
extremity.  Yes all these refs are on the EAST website.  If you do not
have to do anything with any injury found, then of course there is no
reason to find it...18 years of practicing this approach at our
institution has shown it to clearly be valid.
-----Original Message-----
From: Roy Danks <roydanks at hotmail.com>
To: Trauma &amp; Critical Care mailing list <trauma-list at trauma.org>
Sent: Fri, 21 Apr 2006 08:27:01 -0500
Subject: RE: Re: Penetrating extremity trauma

ABI of > 0.8??!!!  That's not standard thinking in vascular surgery,
last I 

ABI of <0.95 is considered abnormal.  This, to me, indicates you must
at least 
image the vessel.  
Doesn't mean you have to do anything, as evidenced by this paper:  

Validation of Nonoperative Management of Occult Vascular Injuries and
of Physical Examination Alone in Penetrating Extremity Trauma: 5- to
Journal of Trauma-Injury Infection & Critical Care. 44(2):243-253,
Dennis, James W. MD, FACS; Frykberg, Eric R. MD, FACS; Veldenz, Henry
C. MD, 
FACS; Huffman, Susan BA; Menawat, Sunil S. MD 

So, Ron, if you feel an ABI of 0.85 is "OK", then why bother trying to
out which nerve is affected"?  You're obviously
not interested in repairing the potential arterial injury and you can't
do much 
with a severed nerve (within limits and reason)...
so, why bother?  Medicolegal?  If that's the case, I suggest you review
vascular literature.  We image those with ABIs <0.95 who have PVD.

Any other thoughts out there?


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