[VASCULAR INJURIES].

Open extremity fractures occur in an environment of high energy transfer. Consequently, systemic injuries should be suspected in all cases and emergency management approached in accordance with advanced trauma life support (ATLS) principles. Rarely, an open extremity fracture is associated with major haemorrhage. Importantly, control of exsanguinating haemorrhage is now addressed at the first stage of the primary survey by applying direct pressure to the source of major bleeding or application of a tourniquet. Only hard signs (lack of palpable pulses, continuing blood loss, or expanding haematoma) should be used to diagnose vascular injury. A devascularised limb is a surgical emergency and vascularity should be restored as soon as possible, and definitively within 3–4 hours, using vascular shunts. Pre-operative angiography causes unnecessary delays and should be avoided except in patients undergoing CT scan for polytrauma or multi-level injuries, where CT angiography may be helpful.