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The Primary Survey of the Advanced Trauma Life Support (ATLS) only lists pelvic and femur fractures among the extremity injuries. The aim of this study was to evaluate the role of multiple extremity injuries in terms of lethality, progression, and complications in multiple trauma patients and the actual influence of concomitant blood loss. The Extremity Severity Score (ESS) was developed as a central instrument for this purpose.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Material &amp; methods<\/jats:title>\n                    <jats:p>This investigation is a retrospective single center study at a Level I trauma center over the period 2008\u20132019. The study cohort was identified as patients who met an Injury Severity Score (ISS) of at least 16. People who were &lt;\u200916 years old at the time of the accident, patients who were primarily treated in other hospitals or transferred directly from the trauma bay, and cases without a Revised Injury Severity Classification Score 2 (RISC2) were excluded. Similar to the calculation of the ISS or NISS, the three most severe limb injuries (including the bony pelvis, corresponding to the ISS region of the extremities) were squared and added together to calculate the ESS. The study cohort was divided into the groups ESS\u2009\u2265\u200916 and ESS\u2009&lt;\u200916 and these were examined with regard to the primary endpoint of lethality and several secondary endpoints. In addition to the univariate analysis of the data set, a logistic regression model was calculated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Out of 3.101 cases 1.227 patients and 5.824 extremity injuries met the inclusion criteria. Both unadjusted lethality and Standardized Mortality Rate (SMR) were not significantly different for the EES\u2009&lt;\u200916 vs. ESS\u2009\u2265\u200916 group overall (22.5% vs. 18.0%; 0.97 vs. 0.84,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&gt;\u20090.05). Patients in both groups died most frequently from Traumatic Brain Injury (TBI) (72.9%\/47.4%), followed by exsanguination (9.8%\/19.3%) and Multi Organ Failure (MOF) (6.8%\/17.5%). More patients in the ESS\u2009\u2265\u200916 group died of exsanguination (4.6% vs. 23.1%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.007), while patients in the ESS\u2009&lt;\u200916 group died more frequently of TBI (77.0% vs. 30.8%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.002). For the secondary endpoints, there were significantly more surgical interventions (2.5 vs. 7.6,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009\u2264\u20090.001), an increased blood transfusion rate (20.3% vs. 50.6%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009\u2264\u20090.001) and longer ICU (8.9 d vs. 12.1d,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009\u2264\u20090.001) and total hospital stay (8.9 d vs. 12.1 d,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009\u2264\u20090.001) for the ESS\u2009\u2265\u200916 group.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>In this study multiple severe extremity injuries did not influence lethality but the clinical course. ATLS is right for the first moment. However, treating more extremity injuries requires more resources. The result of comparable lethality can only be achieved, if a hospital can provide these resources for this vulnerable patient group. Patients with injuries to several extremities therefore still require special attention.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00068-025-02987-4","type":"journal-article","created":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T10:56:39Z","timestamp":1761648999000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Are multiple limb injuries in severely injured patients negligible? 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