A Stab Wound to the Femoral Triangle: Scan or Open?

Do not scan him. He has hard signs of vascular injury: an expanding hematoma, active arterial bleeding, absent pedal Doppler signals and haemorrhagic shock. In a patient with hard signs, the pre-test probability of a significant vascular injury is extremely high and management is operative regardless of what imaging shows, so imaging changes nothing except the clock. A CT would cost at least 15–20 minutes of transfer, scanning and interpretation in a patient who is actively bleeding and already in class III shock; he could exsanguinate in the scanner. Imaging is for the stable patient with soft signs - a palpable pulse with a reduced ankle-brachial index, a small non-expanding hematoma, a neurological deficit out of proportion to the injury, or proximity alone. It is also reasonable in the stable patient when the level of injury is unclear and endovascular planning is contemplated.

Yes, the limb is worth saving. The ischemia interval is short - roughly 25 minutes from injury plus transport - and the limb is threatened by hypoperfusion from haemorrhage rather than by established thrombosis. Warm ischemia of this duration rarely produces irreversible muscle loss. A cool, pulseless foot in a young trauma patient with an expandable collapsible artery is the most salvageable scenario in vascular surgery. The correct framing for anaesthesia is that limb perfusion is a secondary objective: the primary objective is haemorrhage control, and the limb is very likely to survive once hemostasis and arterial repair are achieved.

Immediate actions. Direct pressure on the wound (not blind clamping), two large-bore lines, activate the massive transfusion protocol, tranexamic acid 1 g, keep him warm, and move to the operating room.

Incision and control. A longitudinal incision centred on the wound, extendable proximally and distally. Proximal control of the common femoral artery can be obtained at its origin under the inguinal ligament, but if the injury extends above the ligament I need external iliac control - either by dividing the inguinal ligament (repairing it later) or through a separate retroperitoneal or lower midline approach. I apply direct digital pressure while getting control, and avoid blind clamping in a bloody field, which is how the femoral nerve and vein get injured. Once proximal and distal control are secure, give systemic heparin if the patient is not coagulopathic.

Arterial repair. Debride the vessel edges. A small, clean laceration involving less than about half the circumference can be closed primarily, transversely where possible to avoid stenosis. Anything larger or contused needs an interposition graft - reversed great saphenous vein from the contralateral leg is the conduit of choice in a young patient with a potentially contaminated wound; PTFE is acceptable if speed matters more than durability. Patch repair with vein is an option for a tangential injury.

Venous repair. The common femoral vein should be repaired if at all possible - lateral suture or a vein patch - because ligation carries a substantial risk of chronic venous hypertension and phlegmasia in a young man. Superficial femoral vein ligation is much better tolerated if the common femoral can be preserved.

If he becomes unstable. Place a temporary intraluminal shunt (a Pruitt shunt or a large-bore Argyle catheter secured with ties) to restore flow while the team addresses a more immediately lethal injury, and return for definitive repair. Finish with an on-table completion angiogram and check Doppler signals in the foot.

Fasciotomy - do it prophylactically, at the time of repair. The indications in this patient are additive: shock with massive transfusion, combined arterial and venous injury (venous ligation or repair both raise compartment pressure), prolonged ischemia once you add injury time plus operative time, and a tense calf on examination. Waiting for a measured pressure in a young trauma patient with a swollen leg is how limbs are lost; if I do use pressures, a compartment pressure above 30 mmHg or a delta under 30 mmHg is an indication. Use a two-incision, four-compartment technique, and leave the wounds open with a vacuum dressing for delayed closure or grafting.

First 48 hours.

• Intensive care, with attention to the lethal triad: keep him warm, correct coagulopathy with blood products rather than crystalloid, and correct acidosis.
• Monitor creatine kinase and potassium for reperfusion injury and myoglobinuria; maintain urine output.
• Heparin infusion or aspirin for graft patency; in a polytrauma patient balance this against bleeding.
• Re-examine the leg frequently for compartment syndrome of the thigh (rare but real with a femoral injury and a large hematoma) and for expanding hematoma or ongoing bleeding.
• Look for a missed injury: a bruit suggesting an arteriovenous fistula, or a neurological deficit suggesting femoral or sciatic injury.
• Plan surveillance duplex at 6 weeks and then at 6 and 12 months to detect anastomotic stenosis or pseudoaneurysm.

If the limb is clearly non-viable at the end of the case - muscle that does not contract on stimulation, no capillary refill, a hard mottled foot - then primary amputation is kinder than a failed revascularisation, but with a 25-minute warm ischemia time this should essentially never be the outcome.