American Journal of Emergency Medicine (2005) 23, 689 695

www.elsevier.com/locate/ajem

Diagnostics

Screening for extermity arterial injury with

the arterial pressure index
Bruce A. Levy MDa,1, Michael P. Zlowodzki MDb,2,
Matt Graves MDc,3, Peter A. Cole MDd,*
a

Sports and Knee Injuries, Regions Hospital, University of Minnesota, St Paul, MN 55101, USA
Department of Orthopaedic Surgery, Regions Hospital, University of Minnesota, St Paul, MN 55101, USA
c
Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center, Jackson,
MS 39216-4505, USA
d
Orthopaedic Trauma, Regions Hospital, University of Minnesota, St Paul, MN 55101, USA
b

Received 1 December 2004; accepted 22 December 2004

Abstract Certain extremity injuries presenting to the ED or Trauma Unit warrant increased suspicion
for underlying arterial trauma. Such injuries include knee dislocations, displaced medial tibial plateau
fractures and other displaced bicondylar fractures around the knee, open or segmental distal femoral shaft
fractures, floating joints, gunshot wounds in proximity to neurovascular structures, or mangled
extremities. Once the diagnosis of arterial trauma is made, a multi-disciplinary approach is warranted.
The diagnostic strategies for vascular injury have undergone an evolution over the past 2 decades. One
and a half percent to 4.6% of patients hospitalized with blunt extremity trauma have associated vascular
compromise [Bunt TJ, Malone JM, Moody M, et al. Am J Surg 1990;160(2):226-8; Reid JD, Weigelt
JA, Thal ER, et al. Arch Surg 1988;123(8):942-6; Applebaum R, Yellin AE, Weaver FA, et al. Am J
Surg 1990;160(2):221-4; discussion 224-5; Dennis JW, Frykberg ER, Veldenz HC, et al. J Trauma
1998;44(2):243-52; discussion 242-3]. An efficient and effective evidence-based approach to
diagnosing vascular injury is necessary, as the difficulty in diagnosis, the multiplicity of diagnostic
strategies, the limited time frame in which to initiate appropriate treatment, the limb threatening
complications of a missed diagnosis, and the increased awareness of health care expenditures make this
entity an intimidating diagnostic challenge [Johansen K, Lynch K, Paun M, et al. J Trauma
1991;31(4):515-9; discussion 519-22; Lynch K, Johansen K. Ann Surg 1991;214(6):737-41; Walker
ML, Poindexter Jr JM, Stovall I. Surg Gynecol Obstet 1990;170(2):97-105; Kendall RW, Taylor DC,
Salvian AJ, et al. J Trauma 1993;35(6):875-8].

T Corresponding author. Tel.: +1 651 254 0929; fax: +1 651 254 1519.
E-mail addresses: zlowi@web.de (M.P. Zlowodzki)8 mgraves@orthopedics.umsmed.edu (M. Graves), peter.a.cole@healthpartners.com (P.A. Cole).
1
Tel.: +1 651 254 1515; fax: +1 651 254 3247.
2
Tel.: +1 651 254 1513; fax: +1 651 254 1519.
3
Tel.: +1 601 984 6525.
0735-6757/$ see front matter D 2005 Published by Elsevier Inc.
doi:10.1016/j.ajem.2004.12.013

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B.A. Levy et al.

The purpose of this article is to present an evidence-based algorithm for patients who present with
either arterial injury or a high-risk of arterial injury. A diagnostic algorithm will be presented, and the
rationale for diagnostic interventions will be discussed in the context of current medical literature.
D 2005 Published by Elsevier Inc.

1. Introduction

2. Screening for arterial injury

The 4 bhard signsQ of extremity vascular injury include

pulsatile hemorrhage, an expanding hematoma, a palpable
thrill or audible bruit, or a pulseless limb. When a patient
presents with any of the 4 hard signs of vascular injury,
immediate surgical exploration and vascular repair are
warranted [1-4]. The exception to this rule is when the
patient presents with multilevel trauma to an extremity (eg,
a shotgun injury or an extremity with 2 fractures), in which
case the level of arterial injury may be in question and an
arteriogram is indicated.
A more difficult diagnostic problem occurs in patients
who present with more subtle clues of vascular injury. These
bsoft signsQ might include a history of severe hemorrhage at
the accident scene, subjectively decreased or unequal pulses,
decreased 2-point discrimination testing of an anatomically
related nerve deficiency, or a nonpulsatile hematoma [3].
Perhaps easier to define are the orthopedic injury patterns
that have been associated with a high incidence of arterial
damage. These orthopedic injuries include knee dislocations, certain displaced tibia plateau fractures, ipsilateral
fractures on either side of the knee (floating knee), gunshot
wounds in proximity to neurovascular structures, or
mangled extremities.
The physical examination alone is often inadequate for
accurate diagnosis and therefore is not a reliable predictor of
arterial trauma [3,5]. Palpation of a pulse is a subjective
measure prone to wide interobserver variation. Furthermore,
pulses have been reported to be palpable distal to major
arterial lesions, including complete arterial disruption
[3,6,7]. Despite the limitations of the physical examination,
a precise and well-documented examination serves as a
screening tool for vascular injuries.
Expeditious diagnosis is essential, given the urgent time
frame in which to treat a patient with an arterial lesion. An
extended diagnostic interval may result in the manifestations
of arterial damage. A warm ischemia time interval of less
than 6 hours is generally accepted as the standard interval
within which arterial continuity must be restored to avoid
permanent damage to the soft tissues [8-10]. A delay in
diagnosis may result in serious complications, such as an
arteriovenous fistula, compartment syndrome, ischemic
contractures, or loss of the limb [6,11].
Because of the inadequacy of the physical exam and the
need for prompt diagnosis and treatment, on-call and
ED physicians must prioritize patients who require evaluation for possible arterial injury from extremity trauma. A
safe, efficient, cost-effective, and evidence-based algorithm
is required.

For over 2 decades, it has been recognized that physical

examination alone is not a reliable method to detect the
presence or absence of arterial injury. Different methods of
screening have been developed according to historical
context, technology, cost, and efficiency. Each screening
tests limitations led to the next diagnostic modality. Initially,
nonoperative screening was used with an emphasis on
observation before further treatment. In time of war, operative
exploration based solely on proximity of the injury to
vascular structures became the screening method of choice.
This aggressive and invasive approach occurred most often in
the context of marked soft tissue destruction that accompanied high-velocity missile damage [12]. Such an approach did
not translate sensibly to low-energy civilian injuries, so the

Fig. 1 Example of the placement of the blood pressure cuffs on

the extremities for assessment of API.

Arterial pressure index (API)

691
investigated as a screening tool for clinically significant
arterial compromise [16,21,22]. To conduct an API examination, a blood pressure cuff is placed on the supine patient
proximal to the ankle or wrist of the injured limb, and a
systolic pressure is determined with a Doppler probe at the
respective posterior tibial artery or radial artery. The dorsalis
pedis or ulnar arteries may be used as well. The same
measurement is determined on the uninjured upper or lower
extremity limb (Fig. 1). The API is calculated as the systolic
pressure of the injured limb divided by the systolic pressure
of the uninjured limb:
API

Fig. 2 (A) Anteroposterior (AP) and (B) lateral radiographs

demonstrating typical Schatzker IV medial tibial plateau fracture.
Although the AP radiograph shows minimal displacement, the
lateral radiograph shows that this injury represents a fracture
dislocation of the knee.

Doppler systolic arterial pressure in injured limb

Doppler systolic arterial pressure in uninjured limb

In a controlled trial of 100 consecutive limbs, Lynch and

Johansen [16] demonstrated when this value is less than 0.9,
the sensitivity and specificity are 95% and 97% for major
arterial injury, respectively. The negative predictive value for
an API of greater than 0.9 in the same study was 99% [16].
Using the same clinical algorithm where arteriography was

mandatory operative approach was abandoned based on

invasiveness and high negative results [4,6,13].
Arteriography as a screening tool (exclusion arteriography) became popular in the late 1970s and 1980s as its
techniques were continually refined. With a published
sensitivity of 95% to 100%, and a specificity of 90% to
98%, arteriography quickly became the gold standard
[2,3,5,14]. However, the cost effectiveness of arteriography
created concern, as some authors noted the test to be overly
sensitive and management infrequently changed based on its
results [6,11,14-17]. In addition, arteriography was noted to
be time consuming and presented risks to the patient
including renal contrast toxicity, pseudoaneurysm, and even
death [14,18].
The duplex ultrasound was developed next, which
seemed to fulfill criteria for speed and accuracy, and its
effectiveness was demonstrated in multiple studies
[1,19,20]. However, the exam is operator- and interpreterdependent and requires a trained vascular technologist
available 24 hours a day. The best screening exam for an
arterial injury should be quick, noninvasive, portable, cost
effective, and reliable. These criteria have led to the current
standard of the arterial pressure index (API) as a screening
exam for extremity arterial injury.

3. The API
Determination of the API, also known in the literature as
the ankle brachial index or ankle arm index, requires the use
of a Doppler machine and a blood pressure cuff. It has been

Fig. 3 (A) Sagittal and (B) coronal computed tomography scan

showing dissociation of the articular surface of both medial and
lateral portions of the tibial plateau from the diaphysis (shaft) of the
tibia (Schatzker type VI). The sagittal view shows significant
posterior displacement, placing the popliteal artery at risk.

692

B.A. Levy et al.

Fig. 4 A, Anteroposterior radiograph of the knee showing complete knee dislocation. B and C, Angiography shows postreduction AP view
with complete occlusion of the popliteal artery.

limited to patients with an API less than 0.9, Johansen et al

then evaluated 100 injured limbs. In this study, 84 limbs
sustained penetrating injuries and 16 sustained blunt trauma.
Of the 17 limbs with an API of less than 0.9, 16 had positive
arteriographic findings and 7 required surgical exploration
and repair. Among the 83 limbs with an API of greater than
0.9, clinical follow-up revealed 5 minor arterial lesions but
no major injuries requiring surgical intervention. In addition,
duplex ultrasonography tests performed on 64 of the limbs
with an API of greater than 0.9 were all negative. The costeffectiveness of the API was also examined and showed that
over the 6O- month period, exclusion arteriograms were
reduced from 14% to 5.2% of all contrast studies and
resulted in a net savings of $65 175 [21].
Before this study, the API was primarily used on patients
with penetrating injuries. Orthopedists and other practitioners were left to question the usefulness of the API in the
bluntly injured limb, such as a fracture or dislocation. More
recently, its efficacy has been extended to the management of
blunt extremity injury. In a controlled trial of 75 consecutive
blunt high-risk orthopedic injuries, the negative predictive
value of a Doppler API of greater than 0.9 was 100%.
Seventy percent of the 75 injured limbs had an API of greater
than 0.9, and clinical follow-up revealed no major or minor
arterial injuries. Among the 30% with an API of less than
0.9, 70% had lesions detected by arteriogram, and half of the
patients had the lesion surgically repaired [22,23].

suspicion in the young patient who has sustained a knee

injury from high-energy trauma. Suspicion should be further
heightened with radiographic evidence of marked fracture
displacement and/or comminution. It should be kept in mind
that the displacement of the fracture was likely much worse at
the time of injury than the static x-ray shows, as the soft
tissues return the fragments toward their original position
during recoil.
The tibial fractures that have a particular propensity for
association with arterial damage include the isolated medial
tibial plateau (Schatzker IV) fracture, as well as the
associated medial and lateral plateau fractures that dissociate
the articular surface from the tibial diaphysis (Schatzker VI).

4. High-risk injuries
Certain fracture patterns around the knee have a high
associated incidence of arterial injury. The popliteal artery is
tethered at the adductor hiatus in the medial distal thigh, and
again distal to the knee joint at the soleus arch. The tethered
artery becomes vulnerable to stretch, tear, or intimal damage
when the knee becomes displaced by dislocation or widely
displaced fracture. The clinician should have a high index of

Fig. 5 Lateral radiograph of the femur showing segmental distal

femur fracture.

Arterial pressure index (API)

693

The medial plateau fracture can behave in a similar manner

as a knee dislocation. While the typical medial tibial fragment is attached to the distal femur by the medial collateral
and cruciate ligaments, the shaft of the tibia displaces freely
with its lateral plateau and endangers the popliteal artery
(Fig. 2A and B). The combined medial and lateral plateau
fractures that dissociate the articular surface from the
diaphysis displace the shaft in a similar fashion, which
threatens the artery just proximal to or at the popliteal artery
trifurcation (Fig. 3A and B).
A purely ligamentous knee dislocation is associated with
a high risk of arterial injury, despite having no sharp fracture
fragments (Fig. 4A and C) [11,24,25]. This is possibly
because more energy is imparted to the soft tissues rather

Fig. 7 (A) Anteroposterior and (B) lateral radiograph examples

of a bfloating knee.Q Note the ipsilateral femoral and tibial fractures.

than fracturing the tibia. Some authors have noted as high as

a 40% risk of popliteal injury associated with knee
dislocations [26-28].

Fig. 6 A, Lateral radiograph showing significantly displaced,

comminuted distal femur fracture. B, Intraoperative photo demonstrating the open wound.

Fig. 8 Example of a gunshot wound to the lower extremity at the

level of the knee.

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B.A. Levy et al.

wound, an arteriogram is warranted if the API is less than 0.9
because the possibility of multiple level injuries exists.
Another situation of concern regarding limb viability is
the mangled extremity (Fig. 9A and B). The mangled
extremity is not clearly defined with objective criteria and
represents the end of an injury spectrum that involves trauma
that destroys soft tissue and leaves limb survival in question.
Although the likelihood of arterial injury is high in these
patients, it may be overlooked because of the extensive soft
tissue and skeletal injuries.

5. Special considerations

Fig. 9 A 41-year-old male pedestrian struck by train, sustaining

a mangled lower leg with (A) significant soft tissue injury and (B)
comminuted, segmental distal femur fracture.

The widely displaced distal femur fracture yields a

similar threat to the vascular tree because the popliteal
artery is tethered to the femur at its transition from the
femoral artery in Hunters canal. The open femur fracture
(Fig. 5) and the distal segmental femur shaft fracture (Fig.
6A and B) imply greater energy and displacement. Clinical
judgment must be exercised in every case, as there may be
other suspicious fracture variants around the knee. However,
these are the injuries that should prompt an immediate API
examination.
The entity of the floating joint is defined as ipsilateral
long bone fractures occurring on both sides of a joint
(Fig. 7A and B). Other authors have included the ipsilateral
articular and long bone fracture in the definition of the
floating joint. These fractures are likely associated with
arterial injury for the reasons previously described [29].
Gunshot wounds are also associated with an increased
incidence (around 20%) of arterial injury (Fig. 8) [7,30]. It is
traditionally taught that gunshot wounds in proximity to
neurovascular structures ought to be screened. However, the
path of missiles is often not known and additional
precautions should be taken in these cases. It is important
for the clinician to screen such extremities given the quick
and inexpensive approach of the API. In the event hard signs
of vascular injury are present in the context of a gunshot

The use of the API should be approached with certain

caveats in mind. It may not detect injuries to the profunda
femoris, profunda brachii, or peroneal arteries, as no direct
extension of flow is measured in the distal arteries [16].
Lesions that do not decrease blood flow (eg, a minor intimal
flap) may not be detected [21]. Certain clinical situations
may preclude cuff placement, such as massive injury around
the wrist or ankle or the presence of splints on the injured
site. Traction ought to be applied to the extremity and gross
limb alignment restored before measuring the API to avoid
false-negative results. Finally, in a case where determination
of the pulse by physical exam may be inadequate or
compromised (hypovolemic shock or isolated venous
injury), the API should be used with caution.

6. Conclusion
The API has fulfilled the requirements of a useful
screening tool, is both sensitive and specific with an outstanding negative predictive value, and is reproducible, noninvasive, and inexpensive. The clinician should approach
the patient who has a high-risk vascular injury with a clear
diagnostic algorithm (Fig. 10).
In addition to patients with one of the 4 hard signs of
vascular arterial injury, a patients API should dictate the

Arterial hemorrhage, distal ischemia,

shotgun injury
Yes

No
Doppler arterial pressure index
< 0.90

> 0.90

Duplex sonography
Operation
(or arteriography)

(+)

(-)

Serial clinical
examination

Fig. 10 Proposed treatment algorithm for vascular assessment in

lower extremity trauma.

Arterial pressure index (API)

next step. If the API is greater than 0.9, the patient may be
followed clinically without further workup. If the API is less
than 0.9, an arteriogram or duplex ultrasound should be
completed and will dictate the final plan of action. It is
impossible to define every possible clinical scenario that
could manifest arterial trauma. However, if the clinician
bears these red flags in mind, the vast majority of vascular
problems are likely to be detected.

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