Assessment and Decision-Making in Complex Limb Fracture Management

Abstract

Complex limb fractures, particularly those resulting from high-energy trauma, pose significant challenges in orthopaedic trauma care due to the severity of bone and soft tissue damage, risk of infection, and the need for coordinated multidisciplinary management. This narrative review explores the comprehensive assessment and decision-making process involved in managing these injuries, including clinical evaluation, radiological imaging, and functional considerations. It critically examines factors influencing the choice between limb salvage and primary amputation, such as haemodynamic stability, injury severity, predictive scoring systems like the Mangled Extremity Severity Score (MESS), infection risk, functional outcomes, psychological well-being, and economic implications. Although limb salvage offers the potential to retain the native limb, it is often associated with prolonged recovery, multiple surgical interventions, and higher complication rates. Conversely, amputation may enable a more predictable and expedited return to function, particularly when extensive soft tissue loss or neurovascular compromise is present. The review emphasises that no single scoring system or algorithm can fully dictate management decisions, which must be individualised and guided by both clinical judgment and patient-centred goals. A multidisciplinary approach involving orthopaedic, vascular, and plastic surgeons, along with rehabilitation and mental health support, is essential to optimise outcomes. Future directions should focus on improving predictive tools and rehabilitation strategies to support evidence-based, holistic decision-making in complex limb trauma.

Keywords: complex fractures; complex lower limb trauma; limb salvage; orthopaedics; trauma.