The unique anatomy and flexibility of the cervical spine predispose it to a risk of injury. Trauma to the cervical spine encompasses a wide range of injuries from minor muscular strains to life-threatening fracture-dislocations associated with spinal cord lesions. Initial assessment and management should follow the Advanced Trauma Life Support (ATLS) protocols with adequate protection of the cervical spine through triple immobilisation to prevent any unnecessary movement, which can make the patient susceptible to further neurological injuries. Although the presence of cervical spine injury is very often overt, reliance on clinical examination alone is sometimes not sufficient and potentially requires further imaging. Clinical decision rules such as the Canadian C-Spine Rule are frequently used to risk-stratify patients needing radiography. The level of cervical spine instability and knowledge of their unique classification systems is of paramount importance and assists in the decision-making process to guide definitive management. In this review, we also propose an algorithm to aid the initial management of a patient with suspected cervical spine injury in the emergency department.

In the setting of acute severe limb injury, the clinical decision to either attempt limb salvage or to perform a primary amputation presents a significant challenge to the trauma team. The initial step in the management of a mangled limb is invariably resuscitation and stabilisation of the patient and an evaluation of the limb. However, the decision-making process on whether to amputate vs attempt limb salvage is dependent on a range of complex factors. This includes assessing the degree of injury to the components of the limb architecture, essential skeletal stability, soft tissues, vasculature, and neurological structures. Whether or not the patient would survive an attempt to limb salvage is of course not the only variable to be taken into account. The likely and expected outcomes of attempted salvage in each individual case must be considered and furthermore, what the acceptable side-effect profile including the risk of failure would be for each individual patient should be assessed against the importance, real or perceived, that limb function is maintained. Finally, the patient's choice should also be taken into account alongside their occupation and pre-morbid functional status. How the surgeon makes this life-changing, or life-threatening decision, is of great clinical significance, and there are myriad scoring systems published that purport to assist in this matter. However, the changing structures of the trauma system, expansion and advancement of skillsets and technology means an updated review is required to help weigh up the challenging decision of limb amputation vs salvage, which usually takes place in a time-pressured and highly emotional emergency setting. An evidence-based, standardised structure to assist in these calculations could support surgeons and improve outcomes for these patients.

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