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Complex extremity trauma involving both arterial and skeletal injuries remains challenging.
Combined arterial and skeletal extremity trauma imparts a substantially higher risk of limb loss and limb morbidity than do isolated skeletal and arterial injuries. Prompt diagnosis is essential if rapid treatment and optimal limb salvage is to be achieved in these complex extremity injuries. Appropriate prioritization of the management of the vascular and skeletal injuries is a major determinant of limb salvage.
The presence of any one or more hard signs mandates immediate arterial imaging to confirm or exclude vascular injury.

A 2-incision, 4 compartment fasciotomy of the distal extremity should be performed liberally in complex extremity trauma at the time of initial revascularization due to the high risk of compartment syndrome.
Only skeletal stabilization by splint or external fixation should be done after reperfusion in those settings found in 7a above. The absence of any hard sign in an injured extremity excludes a surgically significant vascular injury as reliably as any imaging modality.
Amputation after initial attempts at limb salvage should be considered if risk factors for limb loss persist. Continue limb salvage efforts and monitor patient closely for changes that may warrant secondary amputation.

Understand the clinical manifestations of vascular injury and the diagnostic approaches to confirm or exclude vascular injury in complex extremity trauma.

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