{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T00:42:56Z","timestamp":1787013776536,"version":"build-2736575974"},"reference-count":52,"publisher":"Wiley","issue":"8","license":[{"start":{"date-parts":[[2017,8,10]],"date-time":"2017-08-10T00:00:00Z","timestamp":1502323200000},"content-version":"vor","delay-in-days":9,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Academic Emergency Medicine"],"published-print":{"date-parts":[[2017,8]]},"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n \n Penetrating Extremity Trauma (\n PET<\/jats:styled-content>\n ) may result in arterial injury, a rare but limb\u2010 and life\u2010threatening surgical emergency. Timely, accurate diagnosis is essential for potential intervention in order to prevent significant morbidity.\n <\/jats:p>\n <\/jats:sec>\n \n Objectives<\/jats:title>\n \n Using a systematic review\/meta\u2010analytic approach, we determined the utility of physical examination, Ankle\u2010Brachial Index (ABI), and Ultrasonography (\n US<\/jats:styled-content>\n ) in the diagnosis of arterial injury in emergency department (\n ED<\/jats:styled-content>\n ) patients who have sustained\n PET<\/jats:styled-content>\n . We applied a test\u2013treatment threshold model to determine which evaluations may obviate\n CT<\/jats:styled-content>\n Angiography (\n CTA<\/jats:styled-content>\n ).\n <\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n We searched PubMed, Embase, and Scopus from inception to November 2016 for studies of\n ED<\/jats:styled-content>\n patients with\n PET<\/jats:styled-content>\n . We included studies on adult and pediatric subjects. We defined the reference standard to include\n CTA<\/jats:styled-content>\n , catheter angiography, or surgical exploration. When low\u2010risk patients did not undergo the reference standard, trials must have specified that patients were observed for at least 24 hours. We used the Quality Assessment Tool for Diagnostic Accuracy Studies (\n QUADAS<\/jats:styled-content>\n \u20102) to evaluate bias and applicability of the included studies. We calculated positive and negative likelihood ratios (\n LR<\/jats:styled-content>\n + and\n LR<\/jats:styled-content>\n \u2013) of physical examination (\u201chard signs\u201d of vascular injury),\n US<\/jats:styled-content>\n , and\n ABI<\/jats:styled-content>\n . Using established\n CTA<\/jats:styled-content>\n test characteristics (sensitivity\u00a0= 96.2%, specificity\u00a0= 99.2%) and applying the Pauker\u2010Kassirer method, we developed a test\u2013treatment threshold model (testing threshold\u00a0= 0.14%, treatment threshold\u00a0= 72.9%).\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n We included eight studies (\n n\u00a0=<\/jats:italic>\n \u00a02,161, arterial injury prevalence\u00a0= 15.5%). Studies had variable quality with most at high risk for partial and double verification bias. Some studies investigated multiple index tests: physical examination (hard signs) in three studies (\n n\u00a0=<\/jats:italic>\n \u00a01,170),\n ABI<\/jats:styled-content>\n in five studies (\n n\u00a0=<\/jats:italic>\n \u00a01,040), and\n US<\/jats:styled-content>\n in four studies (\n n\u00a0=<\/jats:italic>\n \u00a0173). Due to high heterogeneity (I\n 2<\/jats:sup>\n \u00a0>\u00a075%) of the results, we could not calculate\n LR<\/jats:styled-content>\n + or\n LR<\/jats:styled-content>\n \u2013 for hard signs or\n LR<\/jats:styled-content>\n + for\n ABI<\/jats:styled-content>\n . The weighted prevalence of arterial injury for\n ABI<\/jats:styled-content>\n was 14.3% and\n LR<\/jats:styled-content>\n \u2013 was 0.59 (95% confidence interval [\n CI<\/jats:styled-content>\n ]\u00a0= 0.48\u20130.71) resulting in a posttest probability of 9% for arterial injury.\n Ultrasonography<\/jats:styled-content>\n had weighted prevalence of 18.9%,\n LR<\/jats:styled-content>\n + of 35.4 (95%\n CI<\/jats:styled-content>\n \u00a0= 8.3\u2013151), and\n LR<\/jats:styled-content>\n \u2013 of 0.24 (95%\n CI<\/jats:styled-content>\n \u00a0= 0.08\u20130.72); posttest probabilities for arterial injury were 89% and 5% after positive or negative\n US<\/jats:styled-content>\n , respectively. The posttest probability of arterial injury with positive\n US<\/jats:styled-content>\n (89%) exceeded the\n CTA<\/jats:styled-content>\n treatment threshold (72.9%). The posttest probabilities of arterial injury with negative\n US<\/jats:styled-content>\n (5%) and normal\n ABI<\/jats:styled-content>\n (9%) exceeded the\n CTA<\/jats:styled-content>\n testing threshold (0.14%). Normal examination (no hard or soft signs) with normal\n ABI<\/jats:styled-content>\n in combination had\n LR<\/jats:styled-content>\n \u2013 of 0.01 (95%\n CI<\/jats:styled-content>\n \u00a0= 0.0\u20130.10) resulting in an arterial injury posttest probability of 0%.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n \n In\n PET<\/jats:styled-content>\n patients, positive\n US<\/jats:styled-content>\n may obviate\n CTA<\/jats:styled-content>\n . In patients with a normal examination (no hard or soft signs) and a normal\n ABI<\/jats:styled-content>\n , arterial injury can be ruled out. However, a normal\n ABI<\/jats:styled-content>\n or negative\n US<\/jats:styled-content>\n cannot independently exclude arterial injury. Due to high study heterogeneity, we cannot make recommendations when hard signs are present or absent or when\n ABI<\/jats:styled-content>\n is abnormal. In these situations, one should use clinical judgment to determine the need for further observation,\n CTA<\/jats:styled-content>\n or catheter angiography, or surgical exploration.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1111\/acem.13227","type":"journal-article","created":{"date-parts":[[2017,5,11]],"date-time":"2017-05-11T15:04:56Z","timestamp":1494515096000},"page":"994-1017","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":44,"title":["Accuracy of Physical Examination, Ankle\u2010Brachial Index, and Ultrasonography in the Diagnosis of Arterial Injury in Patients With Penetrating Extremity Trauma: A\u00a0Systematic Review and Meta\u2010analysis"],"prefix":"10.1111","volume":"24","author":[{"given":"Ian S.","family":"deSouza","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine SUNY Downstate Medical Center Brooklyn NY"},{"name":"Department of Emergency Medicine Kings County Hospital Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roshanak","family":"Benabbas","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine SUNY Downstate Medical Center Brooklyn NY"},{"name":"Department of Emergency Medicine Kings County Hospital Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sean","family":"McKee","sequence":"additional","affiliation":[{"name":"SUNY Downstate College of Medicine Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bardiya","family":"Zangbar","sequence":"additional","affiliation":[{"name":"Department of General Surgery SUNY Downstate Medical Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashika","family":"Jain","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine SUNY Downstate Medical Center Brooklyn NY"},{"name":"Department of Trauma and Critical Care Kings County Hospital Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorenzo","family":"Paladino","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine SUNY Downstate Medical Center Brooklyn NY"},{"name":"Department of Emergency Medicine Kings County Hospital Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leon","family":"Boudourakis","sequence":"additional","affiliation":[{"name":"Department of Trauma and Critical Care Kings County Hospital Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Sinert","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine SUNY Downstate Medical Center Brooklyn NY"},{"name":"Department of Emergency Medicine Kings County Hospital Center Brooklyn NY"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2017,8,10]]},"reference":[{"key":"e_1_2_8_2_1","first-page":"941","volume-title":"Trauma","author":"Frykberg ER","year":"2008"},{"key":"e_1_2_8_3_1","doi-asserted-by":"publisher","DOI":"10.1177\/1538574411415125"},{"key":"e_1_2_8_4_1","doi-asserted-by":"publisher","DOI":"10.1097\/TA.0b013e31827018e4"},{"key":"e_1_2_8_5_1","doi-asserted-by":"publisher","DOI":"10.1097\/TA.0b013e31821b5bdd"},{"key":"e_1_2_8_6_1","doi-asserted-by":"publisher","DOI":"10.1097\/TA.0b013e3182994b48"},{"key":"e_1_2_8_7_1","doi-asserted-by":"publisher","DOI":"10.1097\/00005373-199104000-00009"},{"key":"e_1_2_8_8_1","doi-asserted-by":"publisher","DOI":"10.1097\/00000658-199112000-00016"},{"key":"e_1_2_8_9_1","doi-asserted-by":"publisher","DOI":"10.1097\/TA.0b013e3182118384"},{"key":"e_1_2_8_10_1","doi-asserted-by":"publisher","DOI":"10.1016\/0741-5214(90)90332-5"},{"key":"e_1_2_8_11_1","doi-asserted-by":"publisher","DOI":"10.1097\/00005373-199802000-00001"},{"key":"e_1_2_8_12_1","doi-asserted-by":"publisher","DOI":"10.1097\/00005373-199104000-00011"},{"key":"e_1_2_8_13_1","doi-asserted-by":"publisher","DOI":"10.1001\/archsurg.1993.01420210097013"},{"key":"e_1_2_8_14_1","doi-asserted-by":"publisher","DOI":"10.1148\/radiology.160.1.3520645"},{"key":"e_1_2_8_15_1","doi-asserted-by":"publisher","DOI":"10.1001\/archsurg.1984.01390170064013"},{"key":"e_1_2_8_16_1","doi-asserted-by":"publisher","DOI":"10.1097\/TA.0b013e3181a51bf9"},{"key":"e_1_2_8_17_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.g7647"},{"key":"e_1_2_8_18_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.283.15.2008"},{"key":"e_1_2_8_19_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejvs.2013.04.034"},{"key":"e_1_2_8_20_1","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2288-6-31"},{"key":"e_1_2_8_21_1","doi-asserted-by":"publisher","DOI":"10.1016\/0197-2456(86)90046-2"},{"key":"e_1_2_8_22_1","doi-asserted-by":"publisher","DOI":"10.1002\/sim.1186"},{"key":"e_1_2_8_23_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2005.01.016"},{"key":"e_1_2_8_24_1","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-155-8-201110180-00009"},{"key":"e_1_2_8_25_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM198005153022003"},{"key":"e_1_2_8_26_1","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1016\/0741-5214(93)90015-E","article-title":"Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis","volume":"17","author":"Schwartz MR","year":"1993","journal-title":"J Vasc Surg"},{"key":"e_1_2_8_27_1","doi-asserted-by":"crossref","first-page":"784","DOI":"10.1177\/000313489906500817","article-title":"The utility of physical examination in proximity penetrating extremity trauma","volume":"65","author":"Gonzalez RP","year":"1999","journal-title":"Am Surg"},{"key":"e_1_2_8_28_1","doi-asserted-by":"publisher","DOI":"10.1097\/00005373-199009000-00001"},{"key":"e_1_2_8_29_1","doi-asserted-by":"publisher","DOI":"10.1097\/00005373-199512000-00026"},{"key":"e_1_2_8_30_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0735-6757(96)90122-9"},{"key":"e_1_2_8_31_1","doi-asserted-by":"publisher","DOI":"10.1097\/00005373-199209000-00010"},{"key":"e_1_2_8_32_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0967-2109(97)00166-X"},{"key":"e_1_2_8_33_1","doi-asserted-by":"publisher","DOI":"10.1111\/acem.12255"},{"key":"e_1_2_8_34_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.injury.2008.02.043"},{"key":"e_1_2_8_35_1","doi-asserted-by":"publisher","DOI":"10.1016\/S0741-5214(95)70070-6"},{"key":"e_1_2_8_36_1","doi-asserted-by":"publisher","DOI":"10.1097\/TA.0000000000000520"},{"key":"e_1_2_8_37_1","unstructured":"U.S. Food and Drug Administration.What Are the Radiation Risks From CT?Aug 2009. Available at:https:\/\/www.fda.gov\/radiation-emittingproducts\/radiationemittingproductsandprocedures\/medicalimaging\/medicalx-rays\/ucm115329.htm. Accessed July 19 2013."},{"key":"e_1_2_8_38_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jamcollsurg.2009.09.010"},{"key":"e_1_2_8_39_1","doi-asserted-by":"publisher","DOI":"10.1097\/00005373-200202000-00008"},{"key":"e_1_2_8_40_1","doi-asserted-by":"publisher","DOI":"10.1016\/0741-5214(91)90087-B"},{"key":"e_1_2_8_41_1","doi-asserted-by":"publisher","DOI":"10.1001\/archsurg.1993.01420240076015"},{"key":"e_1_2_8_42_1","doi-asserted-by":"publisher","DOI":"10.1001\/archsurg.1990.01410220040006"},{"key":"e_1_2_8_43_1","doi-asserted-by":"publisher","DOI":"10.1097\/00005373-198908000-00001"},{"key":"e_1_2_8_44_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10140-009-0805-y"},{"key":"e_1_2_8_45_1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra072149"},{"key":"e_1_2_8_46_1","first-page":"85","article-title":"Nonoperative observation of clinically occult arterial injuries: a prospective evaluation","volume":"109","author":"Frykberg ER","year":"1991","journal-title":"Surgery"},{"key":"e_1_2_8_47_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.324.7340.783"},{"key":"e_1_2_8_48_1","doi-asserted-by":"publisher","DOI":"10.1111\/acem.12820"},{"key":"e_1_2_8_49_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.326.7379.41"},{"key":"e_1_2_8_50_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jss.2013.03.090"},{"key":"e_1_2_8_51_1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1553-2712.2012.01414.x"},{"key":"e_1_2_8_52_1","doi-asserted-by":"publisher","DOI":"10.1017\/S0266462312000086"},{"key":"e_1_2_8_53_1","doi-asserted-by":"publisher","DOI":"10.1002\/sim.4780060402"}],"container-title":["Academic Emergency Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.wiley.com\/onlinelibrary\/tdm\/v1\/articles\/10.1111%2Facem.13227","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/acem.13227","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,10,3]],"date-time":"2023-10-03T07:02:12Z","timestamp":1696316532000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/acem.13227"}},"subtitle":[],"editor":[{"given":"Christopher R.","family":"Carpenter","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2017,8]]},"references-count":52,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2017,8]]}},"alternative-id":["10.1111\/acem.13227"],"URL":"https:\/\/doi.org\/10.1111\/acem.13227","archive":["Portico"],"relation":{},"ISSN":["1069-6563","1553-2712"],"issn-type":[{"value":"1069-6563","type":"print"},{"value":"1553-2712","type":"electronic"}],"subject":[],"published":{"date-parts":[[2017,8]]},"assertion":[{"value":"2017-01-06","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2017-04-13","order":1,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2017-08-10","order":2,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}