Physical examination plus chest radiography in penetrating periclavicular trauma: the appropriate trigger for angiography.

BACKGROUND: To determine the role of physical examination, chest radiography, and angiography in the management of periclavicular penetrating trauma.

METHODS: A retrospective review of the last 100 patients who suffered periclavicular penetrating trauma was performed. Patients with hard signs of vascular injury went either directly to the operating room or first to the angiography suite depending on their hemodynamic stability. All others underwent angiography and subsequent intervention if needed. The results were examined to determine the role of arteriography in the absence of hard signs of vascular injury.

RESULTS: Of the 100 patients in the study, there were 81 without hard signs of vascular injury. All underwent angiography, with 11 "occult" injuries discovered. Each of these patients exhibited some physical examination or chest radiographic finding that may have predicted the presence of vascular injury. Using clinical criteria, physical examination was found to have a sensitivity of 82%, a specificity of 91%, a positive predictive value of 60%, and a negative predictive value of 96%. When coupled with the chest radiographic findings, these numbers were 100%, 80%, 44%, and 100%, respectively. Using these criteria would have eliminated the need for angiography in 56 (69%) patients and would not have missed any injuries.

CONCLUSIONS: In patients with periclavicular penetrating trauma, a normal physical examination and chest radiographic excludes vascular injury. Proximity alone does not warrant angiography, although the test may be useful for therapeutic interventions or to plan operative approaches. A prospective study is essential to validate these findings.