Management of penetrating injuries of the upper extremities.
BACKGROUND
Routine surgical exploration after penetrating upper extremity trauma (PUET) to exclude arterial injury leads to a large number of negative explorations and iatrogenic injuries. Selective non-operative management (SNOM) is gaining in favor for patients with PUET. The present study was undertaken to assess the validity of SNOM in PUET and to present a practical management algorithm.


METHODS
All consecutive patients presenting to a tertiary referral center following PUET were included in this prospective observational cohort study. Patients were managed along Advanced Trauma Life Support (ATLS©) guidelines, and based on clinical manifestations, either underwent emergency surgery or were treated conservatively with or without additional diagnostic investigations. Computed tomography angiography (CTA) was indicated by a preset protocol based on the physical examination.


RESULTS
During the four-month study period, 161 patients with PUET were admitted. Sixteen (9.9%) patients underwent emergency surgery, revealing 14 vascular injuries. Another 8 (5.0%) patients underwent vascular exploration following CTA. The remaining patients (n=137) were managed non-operatively for vascular matters. Eighteen (11.2%) patients required semi-elective surgical intervention for fractures or nerve injuries. During the follow- up, no missed vascular injuries were detected.


CONCLUSIONS
Neither routine exploration nor routine CTA is indicated after PUET. Stable patients should undergo additional investigation based on clinical findings only. SNOM is a feasible and safe strategy after PUET.
Department of Trauma Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands.
Oscar J F
OJ
Van Waes
Pradeep H
PH
Navsaria
Renske C M
RC
Verschuren
Laurens C
LC
Vroon
Esther M M
EM
Van Lieshout
Jens A
JA
Halm
Andrew J
AJ
Nicol
Jefrey
J
Vermeulen
D000293:Adolescent; D000328:Adult; D000368:Aged; D000465:Algorithms; D000792:Angiography; D001134:Arm Injuries / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures; D057772:Vascular System Injuries / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery; D055815:Young Adult