Hard signs gone soft: A critical evaluation of presenting signs of extremity vascular injury

Anna Noel Romagnoli*, Joseph Dubose, Anahita Dua, Richard Betzold, Tiffany Bee, Timothy Fabian, Jonathan Morrison, David Skarupa, Jeanette Podbielski, Kenji Inaba, David Feliciano, David Kauvar

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

19 Scopus citations


BACKGROUND Despite advances in management of extremity vascular injuries, "hard signs"remain the primary criterion to determine need for imaging and urgency of exploration. We propose that hard signs are outdated and that hemorrhagic and ischemic signs of vascular injury may be of greater clinical utility. METHODS Extremity arterial injuries from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment registry were analyzed to examine the relationships between hard signs, ischemic signs, and hemorrhagic signs of extremity vascular injury with workup, diagnosis, and management. RESULTS Of 1,910 cases, 1,108 (58%) had hard signs of vascular injury. Computed tomography angiography (CTA) was more commonly used as the diagnostic modality in patients without hard signs, while operative exploration was primarily used for diagnosis in hard signs. Patients undergoing CTA were more likely to undergo endovascular or hybrid repair (EHR) (10.7%) compared with patients who underwent exploration for diagnosis (1.5%). Of 915 patients presenting with hemorrhagic signs, CTA was performed 14.5% of the time and was associated with a higher rate of EHR and observation. Of the 490 patients presenting with ischemic signs, CTA was performed 31.6% of the time and was associated with higher rates of EHR and observation. Hemorrhagic signs were associated with arterial transection, while ischemic signs were associated with arterial occlusion. Patients with ischemic signs undergoing exploration for diagnosis received more units of packed red blood cells during the first 24 hours. There was no difference in amputation rate, reintervention rate, hospital length of stay, or mortality in comparing groups who underwent CTA versus exploration. CONCLUSION Hard signs have limitations in identification and characterization of extremity arterial injuries. A strategy of using hemorrhagic and ischemic signs of vascular injury is of greater clinical utility. Further prospective study is needed to validate this proposed redefinition of categorization of presentations of extremity arterial injury. LEVEL OF EVIDENCE Diagnostic, level III.

Original languageEnglish
Pages (from-to)1-10
Number of pages10
JournalJournal of Trauma and Acute Care Surgery
Issue number1
StatePublished - 2021
Externally publishedYes


  • Extremity arterial injury
  • Hard signs
  • Hemorrhagic signs
  • Ischemic signs
  • Vascular injury


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