Strategies for Assessment and Decision Making in Complex Limb Fracture Management: A Review

Complex limb injury (CLI) denotes extremity trauma, involving damage to bone, soft tissue, blood vessels, and nerves, most often caused by high-energy blunt impact. These injuries necessitate urgent, structured assessment and close collaboration between multiple specialties (i.e., orthopaedics, plastics, and vascular). Initial priorities focus on preserving life, controlling bleeding, and restoring circulation, followed by stabilising fractures and preventing complications such as compartment syndrome. Deciding whether to attempt limb salvage or proceed to amputation remains one of the most difficult judgments in trauma care. While scoring systems such as the Mangled Extremity Severity Score (MESS), Nerve injury, Ischemia, Soft tissue, Skeletal injury, Shock, Age of patient (NISSSA), Limb Salvage Index (LSI), Predictive Salvage Index (PSI), and Ganga Hospital Open Injury Severity Score (GHOISS) can help guide decisions, their accuracy is limited in modern practice, and no single tool has gained universal acceptance. Evidence indicates that both salvage and amputation can achieve similar long-term functional or quality of life outcomes, although salvage is often associated with a heavier treatment burden. Current guidance emphasises individualised decision-making, taking into account the patient's overall health, preferences, and circumstances, and ensuring that discussions involve both the patient and their family. There is still a clear need for more reliable, validated, and patient-centred decision aids that incorporate advances in trauma care and prioritise long-term quality of life.