Approach to Extremity Vascular Injury 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction: 
 
Trauma to the extremities represents one of 
the most common injury patterns seen in emergency 
medical and surgical practice. Unfortunately, the 
extent of injury is often underestimated, incorrectly 
treated, and occasionally undiagnosed leading to 
preventable morbidity and mortality. All providers 
caring for victims of trauma must be aware of the 
likely extremity injuries based on mechanisms of 
injury, and proficient in their initial management to 
ensure optimal outcomes. Patients with extremity 
trauma often have other associated and potentially 
life-threatening injuries that must be identified and 
treated 
following 
accepted 
principles. 
Every 
standardized approach to the trauma patient, 
whatever the country of origin, teaches a systematic, 
stepwise approach to the trauma patient that 
minimizes the chance of a missed injury or of 
inappropriate management.  
As extremity injuries are evaluated, each of 
the four functional components (nerves, vessels, 
bones, and soft tissues) must be considered 
individually and together. Initial treatment (after 
correction of other life-threatening injuries) is 
focused on stopping bleeding, stabilizing fractures, 
restoring or maintaining perfusion, and prevention or 
treatment 
of 
compartment 
syndromes. 
Best 
outcomes are achieved with a standardized 
multidisciplinary approach overseen by the general 
surgeon with specialist input from orthopedic, 
vascular, plastic, and rehabilitation specialists as 
needed. In resource-limited environments, some or 
all of these specialists may be unavailable, so it is 
crucial for the treating surgeon to understand all 
aspects of care. Our goal is to teach principles of 
initial and definitive management when timely 
referral to specialist care is impossible. 
 
Etiology 
Extremity injuries can result from a myriad 
of etiologies including falls, motor vehicle collisions, 
industrial and sports injuries, penetrating injuries and 
blast. The nature and severity of extremity injury 
differs between civilian and military settings.  
Civilian extremity injuries most often occur 
due to falls (50-60%), industrial or work-related 
accidents, and motor vehicle crashes, though 
penetrating trauma is found in up to 12% of reported 
civilian series. In civilians with nonfatal trauma, 
extremity injuries are the most common reason for 
hospitalization, with 1/3 of those having serious or 
limb-threatening injuries.  
In contrast, over 50% of the injuries recorded 
in the recent conflicts in Iraq and Afghanistan 
involve the extremities with up to 25% of those 
having associated serious non-extremity injuries. 
Military 
combat 
wounds 
are 
predominately 
penetrating in nature with 81% from explosions and 
17% from gunshot wounds. Many of these injuries 
involve multiple functional components and are at 
high risk of both compartment syndrome and 
amputation. 
 
Initial Evaluation and Management 
The 
initial 
resuscitation, 
diagnostic 
evaluation, and management of any trauma patient 
regardless of mechanism is done in a standardized 
approach- we advocate using the principles taught in 
the Advanced Trauma Life Support (ATLS®) 
program established by the American College of 
Surgeons Committee on Trauma. Evaluation begins 
with a primary survey and assessment. Resuscitation 
and management of life-threatening injuries of the 
head, thorax, abdomen, and pelvis take precedence 
over 
extremity 
injuries. 
Following 
and 
in 
conjunction with airway (A) and breathing (B), 
evaluation and management in the primary survey, 
prompt attention should be turned to control of 
hemorrhage (C). External bleeding from the 
extremity, and especially bleeding from junctional 
areas (axillary or common femoral arteries) can be 
life threatening and should be controlled as soon as 
possible. 
Bleeding from lower extremity vascular 
injuries can generally be controlled with direct 
pressure, though prolonged application of direct 
pressure is not always practical. A number of other 
approaches have been endorsed in the pre-hospital 
setting, including topical hemostatic agents, external 
compression clamps, and endovascular occlusion 
devices. “Blind” clamping of vessels (applying a 
clamp in poor visibility due to excessive bleeding) is 
not recommended. The use of tourniquets has 
recently emerged as a standard for pre-hospital and 
initial hospital control of bleeding. A prospective 
study of 232 combat casualties found a significantly 
Approach to Extremity Vascular Injury 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
improved survival rate (77% vs 0%) when using a 
tourniquet (prehospital or emergency department) 
vs. no tourniquet, with no amputations required as a 
result of tourniquet usage. Similar results have been 
reported in civilian trauma patients for both pre-
hospital and in-hospital tourniquet application. It is 
important to diagnose arterial bleeding early, so a 
detailed vascular assessment of injured extremities 
must be performed. It is important to recognize the 
“hard” signs of vascular injury, which are:  
● Active hemorrhage  
● Expanding or pulsatile hematoma  
● Bruit or thrill over the wound  
● Absent distal pulses  
● Extremity ischemia  
 
In penetrating trauma the presence of a hard 
sign of arterial injury is nearly 100% predictive of 
vascular injury warranting surgical repair. Such 
patients should be taken directly to the operating 
room 
for 
surgical 
exploration 
and 
on-table 
angiogram if indicated. 
With blunt trauma, the hard signs are less 
reliable and false positives are common. It must be 
kept in mind that long bone fractures of humerus, 
femur, and/or tibia, even when not open, may 
provoke massive bleeding and hypovolemic shock as 
well as increasing the risk of compartment 
syndrome. Correct fracture immobilization can 
significantly reduce bleeding and provide pain relief. 
This should be performed during the resuscitation 
period. Usually reduction of fractures is done 
without the benefit of X-rays, in the acute phase of 
the evaluation. Repeat the physical examination after 
resuscitation, warming and reduction and splinting. 
Evaluate for any injuries with CT or conventional 
angiogram if there are persistent diminished pulses 
or other signs of vascular injury. 
In 
a 
resource-limited 
setting, 
where 
angiogram is not available, decision-making can be 
difficult. Certainly blunt trauma patients with hard 
signs of vascular injury distal to an extremity 
laceration should be treated as penetrating trauma 
and taken to the operating room. 
 
This patient was referred to a tertiary facility 36 hours after 
sustaining an open pelvic fracture and this right groin 
laceration in a motorcycle accident. The right leg was cold and 
pulseless; the laceration had been sewn shut. On exploration of 
the wound, the thrombosed external iliac artery (Black arrow) 
was seen. Because of the duration of time since the injury, 
revascularization was not considered and he underwent a hip 
disarticulation.  
 
Patients with significant blood loss should be 
rapidly resuscitated with balanced blood products 
(packed cells, platelets, and fresh frozen plasma) or 
whole blood utilizing massive transfusion protocols 
if indicated. If bleeding is not yet controlled, the goal 
of such resuscitation should be “permissive 
hypotension” with a goal of a systolic pressure not 
less than 90. 
Patients with significant extremity trauma 
have a high likelihood of associated pelvic fracture, 
which can be a source of 
exsanguinating 
hemorrhage. A diligent search for pelvic fractures 
should be part of the primary survey, with 
management as described elsewhere in this Manual.  
 
Secondary Assessment 
Once the primary survey is complete and the 
life-threatening problems addressed, perform a 
secondary survey to include a full assessment of the 
musculoskeletal system as part of a head-to-toe 
evaluation. More information about the mechanism 
of injury as well as the past medical history should 
be obtained. The first step of the physical exam is to 
make sure the patient is completely exposed 
(avoiding 
hypothermia); 
any 
bandages 
or 
immobilization devices (except femoral traction 
splints) are removed and reapplied after examination.  
During the secondary assessment, it is 
important to measure an injured extremity index 
(IEI) which is the ratio of the systolic pressure of the 
Approach to Extremity Vascular Injury 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
injured extremity to an uninjured one. This 
measurement was previously known as “Ankle-
Brachial Index” and involves measuring the systolic 
blood pressure of the injured limb, divided by the 
systolic pressure of a normal limb. Both values are 
measured with a manual blood pressure cuff and a 
doppler ultrasound.  
 
Injured extremity index (IEI) measurement. This has also been 
called the Arterial Pulse Index (API) and the Ankle Brachial 
Index (ABI) in the past. The blood pressure cuff should not be 
applied directly over a fracture. Source: By Jmarchn - Own 
work, CC BY-SA 3.0 
https://commons.wikimedia.org/w/index.php?curid=31168075  
 
A normal IEI (>.9) has a high negative 
predictive value for vascular injury and will allow for 
that patient to be observed or managed without 
immediate vascular imaging. In the absence of hard 
signs of vascular injury, an abnormal IEI (< .9) may 
indicate an occult vascular injury which warrants 
further investigation (ie CT angiogram) if persistent 
after warming and resuscitation of the patient. 
It is also important during the secondary 
survey to look for “soft signs” of vascular injury 
which warrant further diagnostic evaluation or 
continued close observation. The soft signs include: 
● A history of significant hemorrhage at the scene 
● Proximity of penetrating wound, bony injury or 
blunt trauma to a major artery 
● Decreased pulse compared to the contralateral 
extremity 
● Peripheral nerve deficit 
● Small non-pulsatile hematoma 
● Abnormal Injured Extremity Index (<0.9) 
● Abnormal flow-velocity waveform on Doppler 
ultrasound 
● Shock that is not the result of other injuries 
 
A distal femur fracture, adjacent to where the superficial 
femoral artery passes through the adductor muscles, should 
raise suspicion of a vascular injury. This is an example of 
proximity of a bony injury to a major vascular structure. 
Source: 10.7759/cureus.16613 
 
 
A posterior knee dislocation is often caused by a low-speed 
impact below the knee, such as the bumper of a car. This injury 
is classically associated with a popliteal artery intimal tear, 
complete vascular occlusion, and a high risk of limb loss if not 
correctly managed. Source: Kael Duprey and Michelle Lin  - 
CC BY 4.0 
https://commons.wikimedia.org/w/index.php?curid=69378236  
 
A 
systematic 
musculoskeletal 
exam 
of 
the 
extremities should include: 
Approach to Extremity Vascular Injury 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
1. Inspection: The patient should be examined 
from head to toe searching for any swelling, 
abrasions, injuries, hyperemia, or deformity 
suggesting a fracture or dislocation, comparing to 
the other limb when possible. Lacerations should 
be assessed for proximity to fracture sites and 
joint spaces. If joint injury is suspected CT is the 
preferred way to assess, but if not available or 
practical, injecting the joint with saline may 
assist with identifying these injuries. Lacerations 
in close proximity to fractures should be assumed 
to be open and treated as such.  
2. Active motion: If the patient is able to cooperate, 
the patient is asked to flex and extend joints 
noting any asymmetry or inability to perform. 
3. Palpation: A careful search is made for tender 
points, bony protrusions, and crepitus or 
crackles. The muscle compartments of the 
affected extremity should also be carefully 
inspected, maintaining a high index of suspicion 
for compartment syndromes. 
4. Passive motion: The limbs are moved through 
their range of motion with any pain or 
abnormality noted and further investigated. 
 
If the patient is unconscious, disoriented or 
under the influence of drugs or alcohol, injuries can 
be missed. It is even more important to perform a 
comprehensive examination of the extremities with 
visualization, 
palpation, 
and 
passive 
motion 
identifying and imaging any abnormalities. It is also 
important to perform a tertiary survey in the 
subsequent inpatient setting once the life and limb 
threatening injuries have been identified and treated. 
 
Initial Radiographic Imaging 
All patients with significant blunt trauma 
should have a chest and pelvis X-ray as an adjunct to 
the primary survey to rule out life threatening injuries 
in the thorax or serious pelvic fractures. Any obvious 
long bone fractures (especially with vascular 
compromise) should be reduced and immobilized 
prior to imaging. If there is suspicion of traumatic 
pathology in the head, neck, chest, abdomen or 
pelvis, the patient should undergo CT and or CTA (if 
this is available) of these regions prior to obtaining 
plain films of suspected extremity injuries. 
Radiographs should and can be taken with radio-
transparent immobilization devices. The radiographs 
should include joints adjacent to the affected 
segment. In children and adolescents, it is important 
to image the contralateral limb as well- epiphyseal 
growth plates can sometimes be misdiagnosed as 
fractures. 
In the right hands, Duplex ultrasound, which 
is highly operator dependent, can detect arterial 
disruption or occlusion, intimal flaps, venous 
occlusion, 
hematoma, 
pseudoaneurysm, 
or 
arteriovenous fistula. If CT is not available to you, 
try to build this capacity in your facility.  
 
Principles of Immobilization 
Immobilization of fractures is an important 
skill that should be mastered by all caring for victims 
of trauma. It starts in the prehospital setting. Proper 
immobilization 
will 
decrease 
pain, 
restore 
circulation, and limit additional injury from 
movement. Upon receiving a polytrauma patient 
with extremity fractures, the receiving provider 
should, in the secondary survey, remove and then 
replace all immobilization devices to perform a full 
exam and confirm adequate immobilization. It is also 
important to remove any items that may cause 
constriction of the injured extremity. 
The basic principle of fracture management 
is to immobilize the joint above and below the 
injured 
bone. 
Specific 
injuries 
should 
be 
immobilized as follows: 
● Hand and wrist: Immobilize in the anatomic 
position, with a volar splint for the wrist and/or 
fingers, discrete wrist dorsiflexion, and slight 
flexion of the fingers. 
● Forearm: Immobilization should include the 
elbow at 90° flexion and the wrist in neutral 
position with a “sugar tong” splint. 
● Elbow: Immobilize the elbow in a flexed 
position with a double “sugar tong” splint. 
● Arm and shoulder: The shoulder and elbow are 
immobilized by bandaging close to the chest or 
using a “swath and sling.” 
● Clavicle: A “Figure of 8 bandage” can be a 
definitive treatment for middle third fractures, 
the patient can be placed in an arm sling for 
transport. 
Approach to Extremity Vascular Injury 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
● Femur: A femur fracture can be immobilized 
with a traction device applied on the ankle or by 
bandaging one leg to another. 
● Tibia and Fibula: Splinting with a rigid or 
pneumatic splint extending from above the knee 
to below the ankle. 
● Knee: The knee should be splinted with slight 
traction or discrete flexion to include a pad under 
the knee to reduce discomfort. 
● Ankle: Ankle injuries can be immobilized with 
padded splints with 90° of dorsiflexion (Posterior 
ankle or Stirrup splint), avoiding pressure on the 
bony prominences. 
 
An improvised lower extremity splint in a low-resource setting 
made from a crutch, padding, and bandage material. This splint 
is 
described 
elsewhere 
in 
this 
Manual. 
Source: 
https://doi.org/10.1016/j.afjem.2021.02.007   
 
Open Fractures 
Open 
fractures 
occur 
when 
there 
is 
communication between the fracture and the external 
environment. As such any open wound in close 
proximity to a fracture should be considered an open 
fracture until proven otherwise. The presence of air 
in the soft tissue near a fracture on radiographic 
evaluation also suggests exposure of the injury to the 
environment and as such contaminated. Open 
fracture classification attributed to Gustilo and 
Anderson (Table) is a useful tool to help plan 
management. 
 
Table: Open fracture classification (Gustilo and Anderson) 
 
The management of open fractures should 
begin at the trauma scene with isolation from the 
contaminated external environment as soon as 
possible. Patients with open fractures should receive 
antibiotics, anti-tetanus immunization and prompt 
(within 6 hours of injury) washout, debridement, and 
stabilization of the fracture. The associated wounds 
should NOT be initially sutured regardless of the size 
and degree of contamination. 
 
Fractures associated with Vascular Injuries- 
General Principles 
The prognosis of fractures associated with 
vascular injury depends on the duration and degree 
of ischemia. Prompt diagnosis and direct treatment 
of vascular injury reduces further damage. Maintain 
a high index of suspicion for fracture-associated 
vascular injury. There are certain injuries that have a 
risk of associated vascular injury such as:  
● Shoulder dislocation – axillary artery; 
● Supracondylar humerus fracture – brachial 
artery;  
● Femur fracture – superficial femoral artery;  
● Posterior knee dislocation – popliteal artery.  
 
The general surgeon (without vascular 
surgical expertise) tasked with caring for patients 
with fracture-associated vascular injury of the 
extremities should be well versed in obtaining 
proximal and distal control of major extremity 
vessels, performing damage control vascular 
shunting, and performing fasciotomies of the 
extremities. 
If available, in patients who are not actively 
bleeding and in need of operative intervention, CT 
angiogram is the diagnostic modality of choice in 
patients with suspected vascular injury. 
 
Operative strategy for vascular injury of the 
extremities 
● Restoration of flow (via shunting or vascular 
reconstruction) that occurs within 3 hours of 
injury has the best outcome. 
● The patient must be properly positioned (and 
prepared) on the operating table to expose all 
relevant vessels, allow for harvesting of veins, 
assessment of distal perfusion, and on-table 
angiogram. 
Approach to Extremity Vascular Injury 
Mark W. Bowyer 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
● Proximal control should be obtained proximal to 
the injury where possible. Proximal and distal 
control may require separate incisions. Keep in 
mind that proximal control can be obtained with 
a tourniquet in selected extremity injuries. 
● Selected use of balloon tamponade is useful for 
temporary control of hemorrhage from junctional 
or deep, difficult to access areas. 
● Control of vessels is best achieved by vessel 
loops passed twice around the vessel (Potts 
Technique). If clamps are used, they should be 
atraumatic and applied with a minimum of force. 
● In the setting of polytrauma with physiologic 
compromise or a surgeon not experienced in 
vascular repairs, the initial management should 
be damage control shunting. This procedure is 
addressed in another chapter of the Manual. 
● Systemic anticoagulation should be avoided in 
patients with polytrauma. 
● Fasciotomy 
should 
be 
liberally 
used 
in 
extremities with vascular injury. This procedure 
is described in another chapter of the Manual. 
 
Disclaimer 
The opinions or assertions expressed herein are those 
of the author and are not to be construed as official 
or reflecting the views of the Department of Defense, 
the Uniformed Services University of the Health 
Sciences, or any other agency of the U.S. 
Government. The author has nothing to disclose. 
 
Mark W. Bowyer, MD, FACS, FRCS 
Uniformed Services University of the Health 
Sciences 
Maryland, USA 
 
November 2023 
