Literature Review on Assessment and Decision-Making in Complex Limb Fracture Management: A Critical Evaluation of Evidence-Based Approaches

Aim: This review aims to provide a comprehensive and up-to-date overview of the assessment and management of complex limb trauma, focusing on factors influencing the decision between limb salvage and primary amputation. Method: A structured literature review was conducted using current guidelines and peer-reviewed evidence. Emphasis was placed on initial assessment protocols, validated scoring systems, and multidisciplinary involvement. Clinical assessment tools, imaging modalities, classification systems, and advances in orthopaedic, vascular, and plastic surgical techniques were reviewed to inform best practice. Results: Complex limb trauma, including mangled extremities, presents significant challenges requiring rapid haemorrhage control, neurovascular evaluation, and prioritisation of life-threatening injuries. Imaging with MDCT and angiography supports surgical planning. Scoring systems such as MESS, PSI, and NISSA provide objective assessment but have limitations in predicting outcomes. Successful limb salvage depends on three key tenets: revascularisation, soft tissue coverage, and bone fixation. Techniques such as the Ilizarov method, free flap reconstruction, and endovascular interventions have improved salvage rates. However, primary amputation remains optimal when salvage criteria are unmet, particularly in cases of prolonged ischaemia, severe soft tissue loss, or poor bone stock. Long-term studies show comparable functional outcomes between limb salvage and amputation, with higher psychological benefits but increased complication and rehospitalisation rates associated with salvage. Conclusion: Optimal management of complex limb trauma requires early multidisciplinary involvement and adherence to evidence-based protocols. Scoring systems offer valuable guidance but should not replace clinical judgement. With modern advances in limb reconstruction, salvage is increasingly feasible, yet timely amputation remains appropriate in select cases. Future work should focus on refining decision-making tools and promoting patient-centred care to optimise functional recovery and quality of life.