The selected articles included four retrospective observational cohort studies [14, 16,17,18]one retrospective observational case series [19]one prospective observational case series [20]one prospective multicenter observational cohort study [13]and one systematic review of 14 retrospective studies [10]. Four reports were from the United States [13, 14, 18, 20]two reports from Europe [17, 19] (Sweden and France), one report from Brazil [10]and one from Australia [16]. These manuscripts were published between 2020 and 2024, covering the period between 2010 and 2022 [10, 13, 14, 16,17,18,19,20].

All cases regarding civilian and military tourniquet applications in extremities were retrieved, encompassing an entire sum of 5,016 patients, ranging from 29 to 57 years-old, mostly of male gender (Fig. 3). Regarding the injury mechanism (Fig. 4), penetrating trauma was the most common, with 2,247 cases, followed by blunt with 1,468 cases, blast with 45 cases, other non-traumatic or non-specific mechanisms were categorized as “other” (bleeding from arterio-venous hemodialysis fistulas, varicose veins, and abscesses) [10, 13, 14, 16,17,18,19,20].

Reported gender distribution

Mechanism of trauma distribution

Two studies did not utilize any standardized tools for injury evaluation [10, 14]. The most common used scores were the Injury Severity Score (ISS), the New Injury Severity Score (NISS), and the Mangled Extremity Severity Score (MESS) [13, 16,17,18,19,20]. Two of the articles that used ISS reported injury severities between 9 and 17 (moderate and severe injury). The third article that used ISS classified blunt and penetrating trauma separately, with, respectively, a median ISS of 13 (moderate) and of 4 (minor) [16,17,18]. One study used MESS, reporting for the majority of cases a score over 7, which is predictive of extremity amputation [19]. One paper used NISS, reporting scores between 4 and 32, which translate into minor to very severe injuries. One review used both ISS and MESS to assess injury severity reporting a mean ISS of 10 points (moderate) and a mean MESS of 4.4 (with no prediction of amputation) [13].

Regarding tourniquet placement, the vast majority were applied in the prehospital setting, one paper did not specify the location of placement, and most of the patients required a tourniquet according to their injuries [10]. Most of the tourniquets were applied to the lower extremities, although two studies did not specify the affected extremity [14, 20].

In most studies, commercial tourniquets were predominant over improvised ones and were mainly placed by an emergency medical technician or paramedic. Additionally, in most cases, improvised tourniquets were removed or replaced once the patient had been admitted to the hospital. The total tourniquet time ranged between 40 and 153 min (Fig. 5), with a reportedly higher incidence of complications with prolonged tourniquet use. One hundred and fifty-one patients required more than one tourniquet [10, 13, 14, 16,17,18,19,20].

Median tourniquet time (in minutes)

The studies selected for the literature review have documented a wide range of complications, (Fig. 6). Yañez et al. reported that 10.7% of patients (57/533) experienced nerve palsy, with other complications including rhabdomyolysis in 10.6% (17/164), fasciotomy in 9.8% (6/61), pulmonary complications in 7% (13/181), thromboembolic events in 5% (21/419), acute renal failure in 4% (18/455), compartment syndrome in 3.9% (36/917), and cardiac complications in 2.8% (5/181). Bleeding (1.1%) and shock (1%) were noted in a few cases, while one case of tourniquet-related amputation was described because of prolonged tourniquet time [10]. Mikdad et al. divided indicated and non-indicated tourniquet use, with significant variability in complications. Among the identified group with indicated tourniquet application, deep vein thrombosis (DVT) occurred in 40% (2/5), acute kidney injury (AKI) in 20% (1/5), nerve palsy in 20% (1/5), and compartment syndrome in 20% (1/5). Nevertheless, in the non-indicated tourniquet group, nerve palsy was more prevalent, affecting 50% (2/4) of patients, DVT, AKI, and compartment syndrome occurred with less frequency [14]. In Read et al.‘s study, complications included amputation in nine cases, compartment syndrome in one case, limb ischemia with or without reperfusion injury in two cases, and neurological impairment in two cases, one sensory only, and one motor and sensory [16]. Wellme et al. observed total complications in 17 patients (30.1%), including amputations following hospital admission (2), fasciotomies (4), acute kidney injury (1), and nerve damage in 13 cases. Of the 13 patients with nerve damage, 10 had loss of motor function, 11 had loss of sensory function, and 8 had both. Twelve patients recovered nerve function 2 weeks after the initial trauma, and one required 8 months to reach full recovery [17]. Schroll et al. documented initial complications, including 10.7% amputation (103/962), and 1.6% nerve palsy (14/962). In their subgroup analysis, nerve palsy increased to 19.6% (75/383), with other complications such as secondary infections (7.1%), compartment syndrome (6.3%), and ischemia-reperfusion injury (6.3%).13 Bedri et al. revealed amputation in 19.1% (18/94), rhabdomyolysis in 2.2% (2/94), acute kidney injury in 3.3% (3/94), and nerve palsy in 2.2% (2/94).18 Covey et al. found motor and sensory nerve palsy of the common peroneal nerve in one patient with a non-indicated tourniquet [20]. Jazottes et al. reported one patient that was affected by a combination of compartment syndrome, rhabdomyolysis, ischemia-reperfusion syndrome, and acute renal failure. Another experienced musculocutaneous nerve palsy, which was deemed to be caused by direct nerve compression. Additionally, one patient presented with rhabdomyolysis [19].

Distribution of reported complications