Synopsis
Document named arterial and peripheral-nerve function before and after every limb intervention, restore alignment immediately when deformity compromises perfusion, distinguish arterial, compartment and nerve emergencies, and secure time-critical revascularisation or nerve-pathway advice.
- Record what each named nerve and artery does, not the phrase neurovascularly intact: test individual motor actions, autonomous sensory areas, pulse quality, Doppler, temperature and capillary refill.
- Examine at first opportunity and again after analgesic injection, manipulation, reduction, splintage, casting, before and after surgery and whenever pain, swelling or function changes.
- Control haemorrhage immediately with direct pressure, wound packing or the most distal effective tourniquet; do not use blind clamping inside the wound.
- Urgently realign and splint a deformed pulseless limb and repeat the timed arterial examination. Persistent pulse inequality means suspected arterial injury until shown otherwise.
- CT angiography is recommended for suspected arterial injury and should run with whole-body CT when appropriate, but uncontrolled bleeding or a persistently ischaemic limb must not wait for imaging.
- Current BOASt expects emergency revascularisation to commence within one hour of hospital arrival; use a temporary vascular shunt when it restores flow fastest, then achieve rapid skeletal stability before definitive repair.
- For a new nerve deficit, release circumferential bandages and plaster fully to skin and gently reposition. Persistent postoperative deficit requires immediate specialist contact.
- Seek peripheral-nerve advice within 24 hours for penetrating injury with deficit or a nerve injury without planned fracture surgery, and before fixation when a deficit accompanies the fracture.
Key red flags
Active haemorrhage, expanding pulsatile haematoma, bruit or thrill, a cold pale pulseless limb or rapidly progressive neurological loss requires immediate operative haemorrhage control or revascularisation rather than delayed diagnostic observation.
A deformed pulseless limb must be realigned and splinted urgently; failure of pulses and perfusion to normalise makes arterial injury presumptive until CT angiography or surgery proves otherwise.
New severe pain, passive-stretch pain, tension, paraesthesia or weakness with preserved pulses may be compartment syndrome and needs the separate immediate decompression pathway.
A new nerve deficit after reduction, casting or surgery requires release of bandages and plaster to skin, gentle repositioning and immediate specialist contact if it persists; documentation of the previous examination is critical.
Investigation priorities
Establish arterial and named-nerve status before and after every intervention.
Management branches
A fractured or dislocated limb is pulseless, cold, poorly perfused or actively bleeding.
- Resuscitate and control haemorrhage with pressure, packing or a distal tourniquet while documenting timed arterial and nerve findings.
- Urgently realign and splint the deformity, repeat comparison and activate consultant orthopaedic and vascular or plastic care.
- Use CT angiography concurrently with trauma CT when suspected injury remains and perfusion permits, without delaying operative control.
- Commence revascularisation within one hour of arrival, using a temporary shunt for rapid flow and stabilising bone before definitive repair.