Frykberg E R, Dennis J W, Bishop K, Laneve L, Alexander R H
Department of Surgery, University of Florida Health Science Center, Jacksonville.
J Trauma. 1991 Apr;31(4):502-11. doi: 10.1097/00005373-199104000-00009.
All cases of penetrating extremity trauma (PET) seen at an urban trauma center were prospectively studied to determine the accuracy and safety of physical examination as the sole mode of evaluation for vascular injury. All patients with PET producing obvious or "hard" signs of vascular injury underwent immediate surgery. All asymptomatic proximity wounds were observed in hospital for 24 hours before discharge to outpatient followup. Patients with non-proximity wounds were discharged immediately. Patients with shotgun wounds and thoracic outlet injuries also underwent arteriography. Of 2,674 trauma patients evaluated during the 1-year study period, 310 (11.6%) had 366 penetrating extremity wounds, most (71%) occurring in the lower extremities. Gunshots caused most (82%) of the wounds, followed by stabs or lacerations (14.5%), and shotguns (3%). Clinically occult wounds in proximity to major limb vessels were the most common (78%) category of clinical presentation, followed by asymptomatic non-proximity wounds (16%), and wounds producing hard signs (6%). There were two missed vascular injuries, both in the asymptomatic proximity group (0.7% false negatives). Every patient taken immediately to surgery for hard signs had major arterial injury requiring repair, for a 100% positive predictive value for physical examination. No mortality or morbidity were related to protocol management. These results to date support prior reports of a negligible incidence of significant vascular injury following clinically occult proximity PET, and further suggest that the overall predictive value of physical examination of PET for vascular injury approaches 100%.
对一家城市创伤中心收治的所有穿透性肢体创伤（PET）病例进行了前瞻性研究，以确定体格检查作为评估血管损伤的唯一方式的准确性和安全性。所有出现明显或“硬性”血管损伤体征的PET患者均立即接受手术。所有无症状的临近伤口患者在出院前在医院观察24小时，之后进行门诊随访。非临近伤口患者立即出院。猎枪伤和胸廓出口损伤患者也接受了动脉造影检查。在为期1年的研究期间评估的2674例创伤患者中，310例（11.6%）有366处穿透性肢体伤口，其中大多数（71%）发生在下肢。枪伤导致了大多数（82%）的伤口，其次是刺伤或撕裂伤（14.5%），猎枪伤（3%）。靠近主要肢体血管的临床隐匿性伤口是最常见的（78%）临床表现类型，其次是无症状的非临近伤口（16%）和出现硬性体征的伤口（6%）。有两例血管损伤漏诊，均在无症状临近伤口组（假阴性率0.7%）。每例因硬性体征立即接受手术的患者均有需要修复的主要动脉损伤，体格检查的阳性预测值为100%。未出现与方案管理相关的死亡或并发症。迄今为止，这些结果支持了先前关于临床隐匿性临近PET后严重血管损伤发生率可忽略不计的报道，并进一步表明PET体格检查对血管损伤的总体预测价值接近100%。
