Title : Assessment and decision-making in complex limb fracture management: Limb salvage versus primary amputation
Abstract:
Complex limb injuries present a major challenge in trauma and orthopaedic practice due to the extent of damage involving bone, soft tissue, nerves, and vascular structures. These injuries create a critical decision point between limb salvage and primary amputation, both of which have significant implications for patient outcomes and quality of life.
A narrative review of the literature was undertaken to examine current approaches to assessment and management. Studies evaluating clinical assessment strategies, injury severity scoring systems, and treatment outcomes were analysed. Commonly used scoring systems include the Mangled Extremity Severity Score (MESS), Mangled Extremity Syndrome Index (MESI), Predictive Salvage Index (PSI), Limb Salvage Index (LSI), and the Ganga Hospital Open Injury Severity Score (GHOISS). Key studies comparing outcomes following limb salvage and amputation were also reviewed.
The evidence highlights the importance of structured trauma assessment, particularly early identification of vascular injury, in determining limb viability. While scoring systems provide useful frameworks for evaluating injury severity, their ability to predict long-term functional outcomes is limited. Advances in orthoplastic surgery, microsurgical reconstruction, and trauma care have improved limb salvage success. However, salvage often involves prolonged recovery, multiple procedures, and higher complication rates.
Importantly, studies such as the Lower Extremity Assessment Project demonstrate that long-term functional outcomes following limb salvage and primary amputation are often comparable. Therefore, management should rely on clinical judgement, multidisciplinary input, and patient-centred decision-making. Scoring systems should support, but not dictate, treatment decisions, with priority given to functional outcomes and overall quality of life.
