In this Selleckchem Caspase Inhibitor VI series all patients needing emergency repairs for ischaemia had a fasciotomy to assess limb viability because of delayed presentation and difficulties in assessing neuromuscular function in an injured limb. Compartment pressure measurement may have prevented preliminary fasciotomy in some, but serial measurements would then be necessary to prevent delays in the management of reperfusion Eltanexor order induced compartment hypertension. The low threshold for early open fasciotomy

in our practice may have contributed to the good outcomes. The timing of orthopaedic fixation in concomitant bone injury is another source of debate. Prior skeletal fixation is strongly advocated in some series [14, 15] while more recent reports have highlighted the importance of reducing ischaemia time by proceeding with vascular reconstruction first [16, 17]. Wolf et al reduced ischaemia time by employing temporary shunts and then performing orthopaedic fixation before vascular reconstruction [18]. In our practice, most orthopaedic fixations being external, delays were minimal facilitating vascular

repairs on a stable base. In other instances where time consuming AZD1080 internal fixation were deemed necessary the order was reversed. In our series we observed three patterns of presentation viz. acute ischaemia, bleeding and traumatic pseudoaneurysms. This often had significant implications both on the nature and subsequent course of management. In bleeding injuries the vessels involved mainly those of upper limb vessels and over 60% underwent revascularization before 6 hours. However injuries causing acute ischaemia often presented the real challenge, the majority involving popliteal or femoral vessels with prolonged periods of ischaemia. These were often transferred from peripheral hospitals including those in the war zones. The presence of multiple fragmentation injuries from explosive devices made identification of the site of damage, difficult. Nonetheless, we had a limb salvage rate of 92%. Our policy to revascularize all this website viable limbs with

continued ischaemia in otherwise stable patients even with long periods of ischaemia seems justified. The risk of reperfusion injury has been cited as a reason for conservative management in prolonged ischaemia. However we did not encounter clinically significant systemic effects from reperfusion in this series despite accepting those with non contractile muscles in up to two compartments (Table 3). Similarly, Menakuru describing a series of 148 patients in North India reports excellent results despite a median delay of 9.3 hours in presentation to casualty [19]. This raises an issue regarding the value of “”ischaemia time”" in predicting outcome and determining intervention. Wagner et al. found a lack of correlation between ischaemia time and outcome in vascular injury [20].