Selective non-operative management for penetrating extremity trauma: A paradigm shift in management?
BACKGROUND
Selective non-operative management (SNOM) has been proposed as a safe and adequate strategy for penetrating extremity trauma (PET) management. This may reduce unwarranted surgical exploration and enhance cost-effectiveness. Our experience at a UK major trauma centre advocates SNOM-PET as a viable and safe strategy for selected patients. A PET management algorithm is proposed.


METHODS
A retrospective review was undertaken for isolated PET from October 2015 to October 2016. Examination findings were recorded as positive if neurovascular or tendon deficits were elicited. Surgical exploration was recorded as positive if neurovascular or tendon injuries were found. Diagnostic statistics were employed for upper limb (UL) and lower limb (LL) examinations.


RESULTS
One hundred sixty patients [112 UL and 48 LL PET injuries] were included. Fifty-six out of 112 (50%) patients with UL PET had no examination findings. Twenty-three out of 56 (41%) patients had negative surgical explorations and 33 of 56 (59%) patients had positive surgical explorations. Thirty-four out of 48 patients with LL PET had no examination findings. All 34 patients had negative surgical explorations. The sensitivity (0.61 vs 1.00, p = 0.005), specificity (0.82 vs 0.97, p = 0.043) and negative predictive value (NPV; 0.41 vs 1.00, p < 0.001) were lower for UL PET than for LL PET examinations. There were no statistically significant differences in sensitivity, specificity as well as NPV and positive predictive value between plastic surgery residents and emergency medicine residents for UL and LL examinations.


CONCLUSION
This is the first UK evaluation of SNOM-PET. It may be safely utilised for LL PET. UL PET should be surgically explored. SNOM-PET may avoid unwarranted surgical exploration, associated complications and cost.
['Khajuria|Ankur|A|', 'Geoghegan|Luke|L|', 'Solberg|Yasmin|Y|', 'Reissis|Dimitris|D|', 'Jain|Abhilash|A|', 'Ives|Matthew|M|', 'Simmons|Jonathan|J|', 'Lawton|Graham|G|', 'Hettiaratchy|Shehan|S|']
D000328:Adult D001134:Arm Injuries D000072700:Conservative Treatment D019468:Disease Management D005260:Female D006801:Humans D015601:Injury Severity Score D007869:Leg Injuries D008297:Male D012189:Retrospective Studies D014057:Tomography, X-Ray Computed D014193:Trauma Centers D014950:Wounds, Penetrating D055815:Young Adult
Trauma Arm injuries Leg injuries Penetrating wounds