Extremity Vascular Trauma Clinical Presentation

Updated: Nov 12, 2019
  • Author: H Scott Bjerke, MD, FACS; Chief Editor: Vincent Lopez Rowe, MD  more...
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Presentation

History and Physical Examination

Worldwide, patients with extremity vascular injuries most frequently present after a penetrating injury to an extremity. In the United States, high-speed motor vehicle accidents, often with fractures or dislocations, result in the next largest group of patients. In patients with large lacerations or open wounds, persisting or increasing hemorrhage with resuscitation is an early indication of vascular injury requiring operative exploration.

Vascular injuries can be classified clinically into hard signs and soft signs of injury on the basis of examination. Classic so-called hard signs of vascular injury include the following:

  • Observed pulsatile bleeding
  • Arterial thrill (ie, vibration) by manual palpation
  • Bruit over or near the artery by auscultation
  • Signs of distal ischemia
  • Visible expanding hematoma

These signs are used to identify patients requiring surgical intervention. A finding of cool, cold, and pulseless extremities may be attributable to a low systemic blood pressure, but isolated pulse abnormalities and significant variation in pulse quality from side to side are strong indicators of underlying proximal vascular injury. Neurologic deficit, delayed capillary refill, and bony abnormalities should increase the suspicion of extremity vascular injury and the need for emergency arteriography or surgical exploration and repair.

Soft signs of vascular injury include the following:

  • Significant hemorrhage found on history
  • Decreased pulse compared to the contralateral extremity
  • Bony injury or proximity penetrating wound
  • Neurologic abnormality

Clinical examination and reexamination remain the mainstays for identifying and treating these wounds. Clinical examination and findings should determine the need for adjunctive studies such as noninvasive Doppler ultrasonography (US) and arteriography.

The physical examination may be augmented by measurement of the ankle-brachial index (ABI), also referred to as the arterial pressure index. Measurement of the ABI is a standard component in the evaluation of atherosclerotic peripheral vascular disease, and its value extends to the identification of penetrating injuries to extremity vessels.

Both hard and soft signs help direct the clinician to the best diagnostic and treatment options for an individual patient.