Critical Evaluation of Assessment and Decision-Making in Complex Limb Fracture Management: A Review of Current Practice and Emerging Trends.

Complex limb injury involves severe trauma to the bone, muscle, nerves, and vessels, typically resulting from high-energy incidents such as road traffic collisions, falls, or explosions. Prompt assessment and stabilisation are critical due to the life- and limb-threatening nature of these injuries. Management requires a multidisciplinary approach involving orthopaedic, vascular, and plastic surgeons. The decision between limb salvage and amputation depends on numerous factors, including the mechanism of injury, soft tissue damage, ischaemia time, and patient-specific considerations such as age, comorbidities, and psychological impact. Although several scoring systems (such as the Mangled Extremity Severity Score; Nerve Injury, Ischemia, Soft Tissue Injury, Skeletal Injury, Shock, and Age of Patient; and the Ganga Hospital Open Injury Severity Score) exist to guide clinical decision-making, they have limited predictive value for outcomes and are not universally applicable, particularly in upper limb injuries. Advances such as CT angiography and modern trauma networks have improved assessment, but no single tool reliably dictates management. Systematic reviews and cohort studies show similar long-term physical outcomes between amputation and salvage, though psychological results may favour salvage. Ultimately, decisions must be individualised, integrating clinical judgment, patient values, and multidisciplinary expertise to achieve the best functional and holistic outcomes.