A 29-year-old female was seen in the emergency department with a chief complaint of laceration. Earlier in the day while surfing she sustained a laceration from the fin of her surfboard and was subsequently dragged in the water. Bystanders helped her out of the ocean, at which point she reported significant hemorrhage from her left thigh and feeling near-syncopal. She described pulsatile bleeding of her leg, but upon arrival of paramedics there was no active bleeding. Her review of systems was positive for numbness of the left leg.
She had a past medical history notable for asthma. She was on no medications. She had no past surgical history or significant family history. She was a non-smoker.
Upon arrival to the emergency department, her vital signs were a temperature of 98.7 F (37.1 C), blood pressure of 108/76 mm Hg, heart rate of 89 beats per minutes, respiratory rate of 20 breaths per minute, and oxygen saturation of 98% on room air. She was in no acute distress, alert and oriented, head atraumatic, heart regular rate and rhythm, breath sounds normal, abdomen soft and non-tender. Her musculoskeletal exam was notable for an 8 cm linear laceration over the left medial thigh with subcutaneous fat and muscle belly exposed and no active hemorrhage. She had palpable Dorsalis Pedis and Posterior Tibial artery pulses, brisk capillary refill, and intact sensation to light touch.
In the emergency department, she had an x-ray of her left femur with no evidence of fracture or foreign body. Her hemoglobin was 10.1 g/dl. Asymmetric DP pulses were then noted and an injured extremity index (IEI, formerly known as an ABI) was obtained, which revealed an IEI of 0.58 (normal >0.9). A CTA of the left lower extremity demonstrated 5 cm of segmentally absent flow in the femoral artery at the level of the medial thigh soft tissue laceration (Figure 1). The distal femoral artery appeared normal, filled by collateral vessels.
Vascular surgery was consulted for evidence of femoral artery transection, and the patient was taken to the operating room for a superficial femoral artery interpositional bypass graft with contralateral reversed saphenous vein. Her hospital course was uncomplicated, and she was discharged to home on hospital day 6.
Discussion:
To date, there have been no published accounts in the literature of femoral arterial injuries from surfing. A recent large study characterizing acute surfing injuries using an online survey described the shoulder, ankle, and head/face regions as having the highest frequencies for acute injury. Injuries were predominantly of muscle, joint, and skin in origin. Forty-seven percent of injuries were due to direct trauma from a surfer’s board or the ocean floor1. Another survey-based descriptive study found that lacerations accounted for 42% of all injuries with 37% to the lower extremity. Sixty-seven percent of injuries were due to contact with a surfboard; and of those injuries, 41% were caused by the fin of the board2.
Our patient’s mechanism of injury is fairly typical for the sport of surfing, but she suffered an unusual limb-threatening vascular injury. Upon arrival to the emergency department, she was well-appearing with a wound that was not actively bleeding. She had palpable distal pulses. An abnormal IEI prompted consultation with Vascular Surgery and a CTA of the lower extremity, which ultimately led to the correct diagnosis of femoral artery transection and timely operative treatment.
Vascular assessment of an injured extremity benefits from a systematic approach. The first step is to determine whether there are any “hard” or “soft” signs of arterial injury. Hard signs of arterial injury include active hemorrhage, expanding or pulsatile hematoma, bruit or thrill over wound, absent distal pulses, or signs of extremity ischemia (pain, pallor, paralysis, cool to touch). In a prospective study that included 366 penetrating extremity wounds, all 21 patients with “hard” signs of arterial injury were taken to the operating room and found to have significant arterial injury requiring repair3. Thus, for any patient with penetrating trauma found to have one of the “hard” signs of arterial injury, Vascular Surgery should be consulted for operative exploration.
If there are no “hard” signs, then the next step is to assess for “soft” signs of arterial injury. These include a history of significant bleeding, proximity to vessels, posterior knee or anterior elbow dislocation, diminished (but palpable) pulses, peripheral nerve deficit, and non-expanding hematoma. In this patient cohort, an injured extremity index (also known as an ankle brachial index or arterial pressure index) should be performed. In a prospective study with 100 consecutive injured limbs, an injured extremity index of < 0.9 was found to be 95% sensitive and 97% specific for clinically significant arterial injuries when compared to the gold standard of arteriography4.
An injured extremity index requires taking the systolic pressures of the injured extremity and uninjured extremity. A blood pressure cuff is inflated distal to the site of the injury and pressure is released until a brachial or pedal doppler signal has returned. This number from the injured extremity is divided by the number from the uninjured extremity. A value of < 0.9 is suggestive of vascular injury, and these patients should receive Vascular Surgery consultation. Imaging studies such as CTA are not usually required, especially if obtaining the study would lead to delay in treatment. Nerve and muscle become progressively unsalvageable after 4-6 hours of ischemia.
Finally, patients with no “hard” or “soft” signs of arterial injury and a normal IEI may be either observed or discharged.
In conclusion, our patient did not demonstrate any “hard” signs of arterial injury but did have 3 out of the 6 “soft” signs. An IEI of 0.58 correctly identified the underlying femoral arterial injury. As evident in this case, the presence of a pulse does not exclude vascular injury. Estimation of blood loss in the water or on a sandy beach is nearly impossible because blood will not pool as it would on a non-porous surface. Surfboard fin-induced lacerations have the potential to cause life and limb threatening penetrating trauma and a high index of suspicion is required to methodically assess for vascular injury.
Figure 1:
References:
Furness, J. Hing, W. Walsh, J. Abbott, A. Sheppard, J. Climstein, M. “Acute Injuries in Recreational and Competitive Surfers.” The American Journal of Sports Medicine. 2015 May;43(5): 1246-54.
Nathanson, A. Haynes, P. Galanis, D. “Surfing Injuries.” American Journal of Emergency Medicine. 2002 May;20(3): 155-60.
Frykberg, ER. Dennis, JW. Bishop, K. Laneve, L. Alexander, R. “The Reliability of Physical Examination in the Evaluation of Penetrating Extremity Trauma for Vascular Injury: Results at One Year.” The Journal of Trauma. 1991 April;31(4): 502-11.
Lynch, K. Johansen, K. “Can Doppler Pressure Measurement Replace “Exclusion” Arteriography in the Diagnosis of Occult Extremity Arterial Trauma?” Annals of Surgery. 1991 Dec;214(6): 737-41.