SAVING THE LIMB, SAVING THE LIFE : PRACTICAL APPROACHES TO VASCULAR INJURY, DIAGNOSIS AND MANAGEMENT

Abstract

Vascular injuries associated with musculoskeletal trauma are relatively rare, occurring in 1% to 2% of extremity 
trauma cases, but carry a disproportionately high risk of limb loss and mortality. Blunt vascular trauma, 
frequently resulting from high-energy mechanisms like motor vehicle accidents, often presents with complex 
indirect damage such as intimal flaps or thrombosis, leading to worse functional deficits compared to sharp 
penetrating injuries. This literature review aims to evaluate the contemporary evidence-based diagnostic 
algorithms and management strategies for peripheral vascular injuries associated with orthopaedic trauma 
through a comprehensive analysis of epidemiology, vascular anatomy, mechanisms of injury, diagnostic 
approaches, surgical algorithms, and postoperative complications. Clinical triage relies heavily on distinguishing 
between "hard signs" mandating immediate operative exploration and "soft signs" of vascular compromise. An 
Arterial Pressure Index (API) threshold of less than 0.9 effectively indicates arterial injury and serves as a 
definitive trigger for Multi-Detector Computed Tomography Angiography (MDCTA), which offers 95%–100% 
diagnostic accuracy. Contemporary surgical management has shifted from historical ligation toward limb
preserving damage-control orthopaedics. The utilization of rapid skeletal stabilization via external fixation, 
coupled with temporary intravascular shunts (TIVS), successfully minimizes warm ischemia time. Furthermore, 
proactive fasciotomy is critical when ischemia exceeds 4 to 6 hours, as the failure to perform timely 
compartmental decompression is the primary cause of preventable limb loss. Delayed vascular complications, 
such as pseudoaneurysms and arteriovenous fistulas, develop in 1% to 4% of initially occult presentations. In 
conclusion, successful limb salvage and optimal long-term functional recovery necessitate a high index of clinical 
suspicion, rapid diagnostic profiling using API and MDCTA, a flexible repair sequence tailored via damage
control principles, and timely fasciotomies within a coordinated multidisciplinary team framework.