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Extremity vascular trauma

In limb injury "hard signs" — pulsatile bleeding, an expanding haematoma, absent distal pulses, a thrill or bruit, and signs of ischaemia — lead straight to the operating room; "soft signs" lead to measuring the arterial pressure index (API), and a value below 0.9 requires CTA; in a fracture with arterial injury a temporary shunt is inserted first, the fracture is fixed and then the artery is repaired.

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Why it matters in the exam

Questions on this topic turn on the decision "operate, image or observe". Hard signs almost certainly indicate an arterial injury requiring repair, so the patient goes to the operating room without prior imaging (except for multiple injuries along the limb, such as shotgun wounds, where on-table angiography helps). Soft signs — bleeding that has stopped, a small stable haematoma, injury to an adjacent nerve, a diminished pulse or a wound close to a major vessel — require measurement: the API is the systolic pressure in the injured limb divided by the pressure in the uninjured limb; a value of 0.9 or more allows observation, and below 0.9 CTA is done. Knee dislocation, especially posterior, endangers the popliteal artery even when the pulse is palpable, so ABI is measured in every knee dislocation.

Life-threatening limb bleeding is stopped by direct pressure and a tourniquet placed high and tight, with the time of application recorded. In the operating room: proximal and distal control, clot removal, and local heparin as needed. With an unstable fracture or complex injury, a temporary intravascular shunt is inserted to restore flow quickly, then the fracture is fixed, and finally definitive repair is done — usually with reversed saphenous vein from the opposite leg, because veins in the injured leg may be damaged. Repair of major veins (popliteal, femoral) is preferred over ligation when the patient is stable. Fasciotomy of all 4 leg compartments, through two incisions, is done when ischaemia has lasted several hours (usually above 4–6 hours), when there is combined arterial and venous injury, or when there are signs of raised compartment pressure.

In a mangled extremity the decision between salvage and amputation is made by the patient's condition and the nerve and soft tissue injury, not by a single score alone.

Key points

• Hard signs — surgery.
• API below 0.9 — CTA.
• Knee dislocation — always ABI.
• Shunt, fixation, repair.
• Fasciotomy after prolonged ischaemia.

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Sources

• EAST Practice Management Guideline: Evaluation and management of penetrating lower extremity arterial trauma, 2012 — Recommendations
• ATLS Advanced Trauma Life Support Student Course Manual, 10th edition (2018) — Musculoskeletal trauma
• Western Trauma Association critical decisions in trauma: Management of peripheral vascular injuries, 2011 — Algorithm

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.