Life saving or limb saving? A clinical dilemma in the management of pelvic fracture patients with external iliac arterial injuries

External iliac artery (EIA) injuries associated with pelvic fractures are uncommon yet serious. High mortality rates due to hemorrhage and the risk of necrosis from disrupted blood flow during hemostasis present significant challenges. Physicians often grapple with the choice between prioritizing life-saving measures and limb salvage. This study seeks to establish a treatment protocol for managing pelvic fracture-related EIA injuries that is both effective and readily implementable. In this retrospective case series and literature review, we examined patients who sustained pelvic fractures with EIA injuries from May 2008 to May 2021, using data from our trauma registry system. Additionally, we conducted a review of the available literature on the subject. We retrieved and analyzed the data regarding patient demographics, clinical presentation, associated injuries, pelvic fracture type, arterial injury location and management, salvage of limbs and mortality. Characteristics of survivors and patients with preserved limbs were analyzed. In the current study, we identified 5 patients from our institution and 22 patients from previous literature that suffered from pelvic fracture with EIA injuries. There was an overall mortality rate of 25.9%. Sixteen patients underwent revascularization of the injured vessels. Eight patients underwent ligation of injured vessels as part of the hemostasis or damage control procedure. The limb preservation rate in survivors was 45.0%. Compared with nonsurvivors, survivors had a significantly higher chance of undergoing revascularization (70.0% vs. 28.6%, p = 0.044). Among survivors, open fracture was associated with a 21.277-fold higher odds of need for amputation (p = 0.015, odds ratio = 21.277). When balancing life-saving efforts with limb preservation, the loss of limbs can sometimes seem unavoidable to save lives. Nevertheless, once hemostasis is attained, we recommend pursuing aggressive revascularization. We observed a poor prognosis in patients with open pelvic fractures and EIA injuries.