Hard signs such as active hemorrhage, absence of distal pulse, palpable thrill or expanding hematoma require immediate management in the operating room, generally with exploration of the injury site with wide exposure to enable vascular control. Ischemia in this situation is defined as the absence of Doppler signal in the extremity on multiple attempts, including after initiation of resuscitation and warming, and initial fracture stabilization. When hard signs of injury are present, there is limited need for other diagnostic tests (i.e. CTA or angiography) which take extra time and may provide findings which cloud decision making.4,17,18 Massive transfusion should be activated if the patient is in hemorrhagic shock.