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Devascularised lower limb following a long-bone fracture — MRCEM SBA MCQ

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HardTraumaDevascularised lower limb following a long-bone fractureMRCEM SBA

A 29-year-old motorcyclist arrives at a major trauma centre 2 hours after a collision. He is haemodynamically stable and has a closed, displaced proximal tibial shaft fracture. After gentle realignment and splinting, his foot remains pale and cool, with no palpable pedal pulses or detectable ankle Doppler signal. He can move his toes but has reduced distal sensation. There is no other time-critical injury, and orthopaedic and vascular surgeons are immediately available. The limb is considered potentially salvageable. Which operative sequence is most appropriate?

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Correct answer: C — Temporary arterial shunting, skeletal stabilisation, then definitive arterial reconstruction.

The foot remains clinically devascularised despite restoration of limb alignment. Persistent absence of palpable pulses is a hard sign of vascular injury requiring immediate surgical exploration; the absent Doppler signal reinforces the concern but is not a prerequisite for that decision. NICE recommends a temporary vascular shunt as the **first surgical intervention** for a devascularised limb following a long-bone fracture. Restoring flow first limits further ischaemia; skeletal stabilisation and definitive vascular reconstruction follow. Angiography must not delay revascularisation. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations)) **A** delays reperfusion while the fracture is stabilised. **B** may appear attractive for defining the arterial injury, but CT angiography would delay treatment when hard signs persist after realignment. **D** restores flow promptly, but definitive reconstruction before stabilising this unstable fracture risks disruption during subsequent skeletal work; the recommended initial vascular procedure is a shunt. **E** presumes an isolated thrombotic occlusion that has not been established and does not provide the recommended operative sequence for this devascularised fractured limb. This patient needs immediate coordinated operative care, not further emergency-department imaging.

Reference: NICE NG37: Fractures (complex): assessment and management — recommendations 1.2.1–1.2.3 (23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations NICE NG37: Fractures (complex): assessment and management — recommendation 1.2.4 (23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations NICE NG37: Fractures (complex): assessment and management — recommendation 1.2.5 (23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations