CASE 10 – LIMB SALVAGE FOLLOWING HIGH-ENERY TRAUMATIC FOREARM VASCULAR INJURY
Introduction
A 43-year-old father of three presented following a high-energy traumatic injury to his non-dominant left upper limb, resulting in a severely contaminated fracture-dislocation of the forearm associated with acute limb ischemia.
This case highlights the importance of multidisciplinary decision-making, rapid vascular reconstruction, meticulous debridement, skeletal stabilization, and soft tissue management in achieving successful limb salvage following complex extremity trauma.
Initial Presentation
The patient was brought to the Emergency Department approximately two hours following injury.
On arrival,
* Hemodynamically compromised but responsive to resuscitation
* Stabilized following intravenous fluids and transfusion of one unit of packed red blood cells
* Assessed according to Advanced Trauma Life Support (ATLS) principles by the trauma team
No other life-threatening injuries were identified.
Limb Assessment
Examination of the left upper limb demonstrated:
* Grossly contaminated fracture-dislocation of the forearm
* Severe soft tissue injury
* Cold ischemic hand
* No palpable radial pulse
* No palpable ulnar pulse
* Absent distal Doppler signals
* No detectable oxygen saturation waveform distally
* Clinical evidence of acute limb ischemia
The limb was considered threatened but potentially salvageable.
A multidisciplinary discussion involving,
* Vascular Surgery
* Orthopaedic Surgery
* Plastic and Reconstructive Surgery
* Anaesthesia and Critical Care Teams
Considering:
Relatively short ischemia time
Hemodynamic stabilization
Preserved potential for functional recovery
Young age and family circumstances
A decision was made to proceed with limb salvage rather than primary amputation.
Operative Management
Initial Measures
Prior to reconstruction:
* Broad spectrum intravenous antibiotics administered
* Tetanus prophylaxis administered
* General anaesthesia induced
Debridement and Irrigation
The wound underwent,
* Extensive washout
* Removal of contaminants
* Radical debridement of devitalized tissue
The aim was to convert a heavily contaminated traumatic wound into a viable reconstructive field while preserving all salvageable structures.
Skeletal Stabilization
External fixation was performed to restore,
* Limb length
* Alignment
* Stability
and to facilitate vascular reconstruction without tension.
Vascular Reconstruction-
Following exposure of the injured vessels, both Radial artery and Ulnar artery were found to require reconstruction.
Given the segmental vascular injury and tissue loss, direct repair was not feasible.
Conduit Selection-Autologous reversed great saphenous vein graft was harvested from the left thigh.
Advantages included,
* Excellent handling characteristics
* Superior infection resistance
* Long-term patency
* Availability in the trauma setting
Arterial Repair
Reversed saphenous vein graft interposition was performed for,
* Radial artery reconstruction
* Ulnar artery reconstruction
Following completion of the anastomoses,
* Excellent inflow obtained
* Good distal runoff confirmed
* Immediate restoration of hand perfusion achieved
The hand demonstrated:
* Improved colour
* Improved temperature
* Restoration of distal pulses
Nerve and Soft Tissue Reconstruction
Following successful reperfusion,the Plastic Surgery team proceeded with
* Nerve repair
* Soft tissue reconstruction
* Coverage of exposed structures
This stage was crucial to maximize future functional recovery.
Immediate Outcome
At completion of surgery:
* Limb perfusion restored
* Distal pulses palpable
* No evidence of ongoing ischemia
* Hemodynamically stable
* No immediate complications
The patient was transferred for postoperative monitoring and continued multidisciplinary care.
Discussion
Major upper limb vascular trauma remains relatively uncommon but poses a significant threat to both limb viability and long-term function.
Unlike lower limb trauma, successful upper limb salvage may still result in excellent functional outcomes even when complex reconstruction is required.
Several factors favored successful salvage in this case:
1.Short Ischemia Time
Revascularization was initiated before prolonged irreversible tissue injury developed.
2.Early Multidisciplinary Involvement
Coordination between trauma, vascular, orthopaedic, plastic, and anaesthetic teams enabled a structured limb salvage strategy.
3.Aggressive Debridement
Removal of all non-viable tissue reduced infection risk and optimized reconstructive success.
4.Autologous Vein Grafting
Reversed saphenous vein graft remains the conduit of choice in contaminated trauma due to its superior resistance to infection compared with prosthetic materials.
5.Restoration of Dual Vessel Supply
Reconstruction of both radial and ulnar arteries maximized distal perfusion and provided redundancy in circulation.
Key Learning Points
✓ Follow ATLS principles before focusing on the limb.
✓ Hemodynamic stabilization always precedes vascular reconstruction.
✓ Early multidisciplinary discussion is essential in complex limb trauma.
✓ Thorough debridement is one of the most important determinants of success.
✓ Skeletal stabilization should precede definitive vascular repair whenever feasible.
✓ Autologous vein graft remains the conduit of choice in contaminated traumatic vascular injuries.
✓ Restoration of blood flow should be assessed clinically and with Doppler evaluation.
✓ Limb salvage requires restoration of bone, vessels, nerves, muscles, and soft tissue—not simply arterial repair.
Take-Home Message
Successful limb salvage is rarely the result of a single vascular repair. It is the outcome of timely decision-making, meticulous debridement, stable skeletal fixation, durable vascular reconstruction, and coordinated multidisciplinary care. In complex extremity trauma, saving the limb is only the first step;the ultimate goal is preserving meaningful function.
Patient details anonymized. Images shared for educational purposes with appropriate consent.
