The “life over limb” principle demands that efforts to salvage a limb must be balanced with the overall trauma burden. From the time the patient presents, start asking yourself how he or she is doing. Are there multiple other injuries? Has there been a large volume of blood loss? Is the lethal triad of hypothermia, coagulopathy, and acidemia present or incipient? Extremity injuries offer many different damage control alternatives to definitive treatment. Putting yourself and your team in a damage control mindset early on is essential.

Once immediately life-threatening injuries have been addressed, attention is turned to the limb. Any anatomic structure in the path of the penetrating instrument is in jeopardy. Your top priority is to revascularize the extremity to optimize the patient’s functional outcome and to minimize tissue loss and amputation rates. Once perfusion has been regained, limb stability is obtained. Further details regarding the sequence of these events are provided below in Operative Strategies. Next, the nonviable tissue is debrided, and finally consideration is made to repair injured nerves.

The decision to operate can be based on the need to repair the vasculature, bones, soft tissue, or nerves. In terms of vascular injury, your physical exam is the gatekeeper to the operating room. Focus on the hard signs. As a reminder, the hard signs include an expanding or pulsatile hematoma, a thrill or bruit, loss of distal pulses, or distal ischemia. Also, measure an ankle-brachial index (ABI) or brachio-brachial index (BBI). If hard signs are not present and the ABI or BBI is >0.9, the patient does not have a surgically significant lesion and requires neither the operating room nor further workup. Most of the time, the hard signs indicate an operative vascular lesion. The exceptions to this rule are complex soft tissue injuries or blunt mechanism, which have an elevated false-positive rate on physical exam; shotgun or shrapnel wounds, which can present with multiple injuries; chronic vascular disease, in which there may be absent pulses to begin with; or thoracic outlet lesions, in which the hard signs can be hidden around the shoulder girdle. If you find hard signs of vascular injury in the setting of one of these exceptions, obtain an angiogram.