External Iliac artery injury in severe pelvic ring trauma: Limb salvage or early hemipelvectomy? A case series.

PURPOSE: External iliac artery (EIA) injury associated with pelvic ring injury (PRI) is rare but represents a particularly devastating pattern of pelvic trauma, combining life-threatening hemorrhage and critical limb ischemia. Although vascular reconstruction is generally recommended, limb salvage may be unrealistic when severe soft-tissue destruction and contamination coexist. Guidance on abandoning salvage attempts and proceeding to early amputation or hemipelvectomy remains limited.

METHODS: We reviewed our institutional experience with patients sustaining combined PRI and EIA injury between 2013 and 2026. The injury characteristics, treatment strategies, and outcomes were analyzed. The severity of vascular injury, limb ischemia status, and pelvic fracture patterns were classified using established systems. Management decisions were examined within a staged surgical strategy focusing on damage control, stabilization, and reconstruction.

RESULTS: Five patients with high-energy trauma were identified. All patients had severe EIA injuries associated with major soft-tissue damage. Revascularization was attempted in two patients, but limb salvage was unsuccessful in all 5 cases. Despite repeated debridement, four patients ultimately required hemipelvectomy following progressive necrosis and infection. All patients survived after prolonged multidisciplinary treatment.

CONCLUSION: Combined EIA injury and PRI represents an extreme form of pelvic trauma in which vascular patency alone does not ensure limb survival. When severe soft-tissue destruction is present, prolonged salvage attempts may only delay definitive management. Early recognition of a non-salvageable limb and consideration of timely hemipelvectomy may be important in selected patients.