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 (c)) 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. CONCLUSION: 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.