VALIDATION OF NONOPERATIVE MANAGEMENT OF OCCULT VASCULAR INJURIES ANDACCURACY OF PHYSICAL-EXAMINATION ALONE IN PENETRATING EXTREMITY TRAUMA - 5-YEAR TO 10-YEAR FOLLOW-UP

Purpose: To establish by long-term follow-up the safety and efficacy o f nonoperative management of clinically occult arterial injuries and t he use of physical examination (PE) alone in determining treatment of penetrating extremity trauma (PET). Methods: Two groups of patients we re studied: (1) all patients with PET, arterial abnormalities on arter iograms, and no hard signs of vascular injury treated nonoperatively f rom 1986 to 1989; and (2) all patients with PET to the extremities man aged by PE alone from 1989 to 1991. Telephone contact, PE, and duplex ultrasonography (US) were attempted in all group I patients, and telep hone interviews were attempted in all group 2 patients. Results: Group 1 had 43 patients with 44 clinically occult penetrating injuries to e xtremity arteries. Arteriography identified 21 intimal flaps/irregular ities, 19 narrowings, 2 pseudoaneurysms, and 1 arteriovenous fistula. Four patients (9%) had clinical deterioration within 1 month and requi red surgery, with good results. Twenty-three of the other 39 patients (58%) were able to be contacted, and 17 (43%) with 18 injuries underwe nt PE and US. All were asymptomatic and had normal PE, and one had mil d residual narrowing on US. The other 6 patients (four in prison, two out of state) reported no symptoms of vascular insufficiency and never sought medical attention for vascular problems. Mean follow-up was 9. 1 years (range, 8.6-11.1 years). Group 2 had 287 patients (309 injurie s) with PET treated by observation based on PE alone. Four patients (1 .3%) required delayed surgery within the first week, and 78 with 90 in juries (29%) were able to be contacted. No patient reported any vascul ar symptoms or ever saw a physician for vascular problems. Mean follow -up was 5.4 years (range, 2.2-6.0 years). Conclusion: This is the firs t long-term follow-up of nonoperative management of clinically occult arterial injuries of the extremities and the use of PE alone in the in itial management of PET. The results show these approaches to be safe, effective, and now a proven standard of care.