In the developed world model in this decade, individuals are exposed to ever-increasing levels of energy when injured. Pedestrian injuries continue to be a large injury burden globally in both developed and more so in developing countries. Motor vehicle crash mitigation in developing countries has concentrated on protecting the head, abdomen, and thorax, resulting in high-energy extremity injuries attached to survivors who would previously not survive the same level of injurious energy. In a related demographic, our war fighters have the benefit of continual improvement in ballistic armor, primarily protecting the head and trunk of our combat troops.

At the same time, the level of serious extremity musculoskeletal/vascular injuries are increasing; the demographics, clinical experience, and changing technology have had a profound effect on the type and depth of experience of those physicians and surgeons responsible for diagnosing, treating, and rehabilitating combined vascular and musculoskeletal injury.

Today, fewer general surgery house staff have orthopedic rotations or basic clinical experience in the diagnosis of high-energy musculoskeletal injury, especially when combined with significant vascular injury. Vascular surgical training has recently focused on the endovascular treatment of both core and peripheral vascular pathology. A decade of conflict has exposed many of our war fighters to both central and peripheral vascular injury, resulting in a core of experienced general, vascular, and orthopedic military surgeons, familiar with severe extremity injuries, often in polytraumatized patients with issues of timing, severe contamination, and debridement. This has resulted in significant experience in some civilian trauma centers with senior or military veteran general/vascular clinicians familiar with the use of vascular shunts.

But the overall effect is many civilian centers have fewer clinicians with significant gross anatomical knowledge to diagnose, surgically approach, release associated compartments, and adequately debride associated soft tissue injury, especially without a former military surgeon on staff.

The environment surrounding combined musculoskeletal-vascular injury may be as important as the injury itself. Timely, accurate diagnosis and treatment is dependent on single versus mass casualties, isolated injury versus multiply injured patient, closed versus open injury, and penetrating versus blunt trauma. The most straightforward injury complex might be a low-velocity gunshot resulting in a midshaft long bone fracture and a single vessel injury and degree of collateral perfusion: the most challenging, a proximal extremity crush, blast, high-velocity skeletal/vascular disruption with a potentially viable distal extremity, further complicated by additional, and occasionally more life-threatening, injuries elsewhere [3].

For purposes of this discussion, we will assume the patient has been appropriately assessed and managed at the scene with skilled extrication, splinting, and immobilization for transport. Further assessment during transport would include assessment of blood pressure and extremity perfusion, including color, temperature, and quality of pulse.

Emergency department assessment would repeat the basics of extremity assessment begun by EMS in a more controlled environment, X-rays and CAT studies, more precise alignment of associated fractures and dislocations, Doppler studies, and comparative pulses, including comparison with non-injured extremities. This work-up will usually identify vascular pathology regarding location, whether it is presently hemorrhaging, and most importantly to the success of comanagement, the location of vascular injury in relationship to fracture pathology and significant soft tissue injury. The association of fracture/dislocation pattern, soft tissue pathology, and vascular injury type and location yields a concept long referred to as “zone of injury.” Integration of zone of injury, mechanism, and time since injury and evaluation of the patient’s overall status regarding associated injuries should form the basis of planning comanagement of the patient with combined orthopedic and vascular injury.

With these evaluations and patient stabilization under way in the context of the ABCs of trauma care, the management of the combined injury begins. Most levels of trauma care will know at any given time or immediately ascertain if the clinical resources needed to manage such combined injuries are available in an appropriate time context since time since injury is such a crucial factor. The need for timely treatment of life-threatening injury may have to take place at the initial receiving institution, further (but appropriately) delaying management of the vascular-compromised extremity.

The avoidable delays accompanying such circumstances will be minimized by a preestablished transfer agreement with trauma centers having established expertise in management of such injury available at all times.

In the best case scenario, these combined injuries would be isolated, transported and diagnosed rapidly, and have no open wounds or gross contamination or closely associated mass of nonviable soft tissue. The worst-case scenario is exemplified by extreme high-energy military blast wounds, occurring most frequently in multiply injured patients, often with multiple extremity injuries, with transport compromised by distance and time, and the vascular-orthopedic injury to be managed part of a grossly contaminated, mangled “zone of injury” (Fig. 5.1a). As would be expected, many of these military-type injuries as well as severe highway, industrial, and agricultural injuries with similar clinical presentations are best managed by early amputation, but a significant amount have potentially functional components distally and are candidates for vascular and concurrent orthopedic repair.

A typical scenario might involve a motorcycle crash or pedestrian bumper strike injury resulting in fracture of the proximal tibia (often segmental), a dislocated knee joint, and a distal femur fracture, either individually or in combination. Frequently these fracture patterns are associated with femoral or popliteal vascular injury, just proximal to, involving, or immediately distal to the trifurcation. Assuming transport and emergency department work-up are rapid, excluding other life-threatening injury, combined vascular-orthopedic treatment should commence. If it has been 2 h or less from injury to beginning treatment, one may suggest rapid transport to the operating theater; placement on an appropriate table, permitting vascular and orthopedic imaging; rapid careful prepping of the injured as well as the non-injured leg (expectantly managing donor needs); and proximal vascular control if hemorrhage is still active. In a closed injury, this author suggests rapid external fixation in the presence of skeletal instability, placed to permit uncompromised vascular access and to provide mechanical stability to the surgical field. This often accomplished in the scenario described, prior to vascular repair, simplifying and protecting the vascular procedure. It is appropriate to consider fasciotomy as a default component in the scenario described: they may be deemed unnecessary only if the leg has had a significant component of collateral flow or time from injury to revascularization has been short. It is common to underestimate the potential time from injury to restoration of flow even in the most experienced institutions, as these interventions are begun. If an endovascular repair is indicated, the sequence of vascular repair versus skeletal stabilization may be individualized.