2. Introduction
“Mangled extremity” refers to an injury to an extremity so
severe that salvage is often questionable and amputation is a
possible outcome.
This injury is always a result of high-energy trauma caused by
some combination of crush, shear, blast, and bending forces.
Component:
1. Soft tissue loss
2. Fracture/bone loss
3. Vascular injury
4. Nerve injury
3.
4. Characteristic features
The skin – often degloved with large areas of loss
The fascial compartments - incompletely opened by
explosion or tear.
Muscle tissues - damaged at both local and regional levels by
direct as well as indirect injury.
Soft tissue planes - extensively disrupted and contaminants
infiltrate all of these planes
Associated fractures - exhibiting extensive comminution
patterns
5. Causes
Motor vehicle accident
Fall from height
Farm/industrial injury
Close range shotgun wound
Crush injury
Explotion injury
7. Initial Evaluation
Routine trauma protocols (ATLS) should be followed.
Once the patient has been stabilized and the primary and
secondary trauma surveys have been completed, a thorough
orthopaedic evaluation is mandatory.
This should include a
-determination of the time and mechanism of injury
-presence of any medical comorbidities
-a detailed vascular and neurological examination
-presence of an associated compartment syndrome
-photographs of the extremity
-radiographic evaluation
8. Vascular Assessment
Arterial injuries usually present with either hard or soft signs
suggestive of injury.
Hard signs-
i. pulsatile bleeding,
ii. presence of a rapidly expanding hematoma,
iii. a palpable thrill, or audible bruit,
iv. presence of any of the classic signs of obvious arterial
occlusion (pulselessness, pallor, paresthesia, pain,
paralysis, poikilothermia )
9. Soft signs –
i. history of arterial bleeding,
ii. a nonexpanding hematoma,
iii. a pulse deficit without ischemia,
iv. a neurological deficit originating in a nerve adjacent to a
named artery and the proximity of a penetrating wound,
fracture or dislocation near to a named artery
The skin color and capillary refilling time of the distal
extremity
Arterial pressure indices (APIs)-if the API < 0.90 or distal
pulses remain absent despite reduction, angiography and/or
vascular surgery consultation is indicated.
10. Decision-Making Protocols and Limb
Salvage Scores
Limb Salvage Decision-Making Variables
Patient Variables
Age
Underlying chronic diseases (e.g., diabetes) Associated Variables
Occupational considerations
Magnitude of associated injury (Injury
Severity Score)
Patient and family desires Severity and duration of shock
Extremity Variables Warm ischemia time
Mechanism of injury (soft tissue injury
kinetics)
Fracture pattern
Arterial/venous injury (location)
Neurological (anatomic status)
Injury status of ipsilateral foot
Intercalary ischemic zone after
revascularization
11. Index Domains
MESS NISSSA/HFS PSI LSI
Ischemia Nerve injury Ischemia Ischemia
Bone/tissue Ischemia Bone Bone
Shock Soft tissue injury Muscle Muscle
Age Skeletal injury Timing Skin
Shock Nerve
Age Vein
13. Bone injury
Simple 1
Segmental 2
Segmental comminuted 3
Bone loss <6 cm 4
Articular 5
Articular with bone loss <6 cm 6
Lag time to operation
One point is given for each hour over
6 hours …
Age (yr)
<40 0
40-50 1
50-60 2
>60 3
Preexisting disease 1
Shock 2
MESSI score >20 amputation
14. Predictive Salvage Index System (PSI)
Criterion Score
Level of arterial injury
Suprapoliteal 1
Popliteal 2
Infrapopliteal 3
Degree of bone injury
Mild 1
Moderate 2
Severe 3
Degree of muscle injury
Mild 1
Moderate 2
Severe 3
Interval from injury to operating room
<6 hr 0
6-12 hr 2
>12 hr 4
15. Mangled Extremity Severity Scoring System(MESS)..
Johansen et al.and Helfet et al
Criterion Score
Skeletal/soft tissue injury
Low energy 1
Medium energy 2
High energy 3
Very high energy 4
Limb ischemia
Pulse reduced or absent but
normal perfusion 1*
Pulseless, diminished capillary
refill 2*
Cool, paralyzed, insensate,
numb 3*
*Double value if duration of ischemia exceeds 6 hours
16. Shock
SBP always >90 mm Hg 0
SBP transiently <90 mm Hg 1
SBP persistently <90 mm Hg 2
Age (years)
<30 0
30-50 1
>50 2
In both the prospective and retrospective studies, all salvaged limbs had had scores of 6 or
lower and an MESS score of 7 or greater had a 100% positive predictive value for
amputation.
17. Limb Salvage Index (LSI)…Russel et al
Criterion Score
Arterial injury
Contusion, intimal tear, partial
laceration
0
Occlusion of 2 or more shank
vessels, no pedal pulses
1
Occlusion of femoral,
popliteal, or three shank
vessels
2
Nerve injury
Contusion, stretch, minimal
clean laceration
0
Partial transection or avulsion
of sciatic nerve
1
Complete transection or
avulsion of sciatic nerve
2
18. Bone injury
Closed fracture or open
fracture with minimal
comminution
0
Open fracture with
comminution or large
displacement
1
Bone loss >3 cm; type IIIB or
IIIC fracture
2
Skin injury
Clean laceration, primary
repair, first-degree burn
0
Contamination, avulsion
requiring split-thickness skin
graft or flap
1
Muscle injury
Laceration involving single
compartment or tendon
0
Laceration or avulsion of 2 or
more tendons
1
19. Deep vein injury
Contusion, partial laceration
or avulsion
0
Complete laceration or
avulsion, or thrombosis
1
Warm ischemia time (hr)
<6 0
6-9 1
9-12 2
12-15 3
>15 4
LSI score of 6 or greater amputation
20. NISSSA Scoring System.. McNamara et al
Criterion Score
Nerve injury
Sensate 0
Loss of dorsal sensation 1
Partial plantar sensation 2
Complete loss of plantar
sensation 3
Ischemia
None 0
Mild 1*
Moderate 2*
Severe 3*
Soft tissue injury/contamination
Low 0
Medium 1
High 2
Severe 3
21. Skeletal injury
Low energy 0
Medium energy 1
High energy 2
Very high energy 3
Blood pressure
Normotensive 0
Transient hypotension 1
Persistent hypotension 2
Age (yr)
<30 0
30-50 1
>50 2
* Double value if duration of ischemia exceeds 6 hours.
22. Drawback of scoring systems
No scoring system is predictive of salvage or amputation.
Lower scores has specificity for limb salvage potential, but
the low sensitivity of these scoring systems did not validate
them as predictors of amputation.
Scoring systems are used for documentation and as guides in
clinical decision-making, not as absolute indicators for
salvage or amputation.
Scoring system is not able to predict functional outcome.
Injury severity score can not predict functional outcome in
patients who underwent limb salvage.
23. Potential scenarios in mangled limb
Immediate amputation
Successful salvage
Attempted salvage with early amputation
Unsuccessful salvage with late amputation
24. Limb salvage
when to consider
Young patients
Anatomically intact sciatic /tibial nerve
Moderate soft tissue loss/injury
Moderate bone loss
Can reconstruct vascular supply :proximal injury
,warm ischemia<6hrs
Functional ankle ,foot
25. Limb salvage procedure-
Operative Debridement
In the operating room, “irrigation and débridement,” the first
and most important step.
The skin wounds have been extended.
All necrotic muscle, fat, fascia, skin, and other nonviable
tissue within the central zone of injury should be removed.
Muscle should be tested for viability based on its
contractility, consistency, color, and capillary bleeding (the
four c’s), and if nonviable, it should be debrided, regardless
of the expected functional loss.
Serial débridements will be required until removal of all
nonviable tissue achieved.
26. Skeletal Stabilization
Stabilization options –
i. splint immobilization,
ii. skeletal traction,
iii. External fixation,
iv. internal fixation
Most limb-threatening injuries present as Gustilo typeIIIB or
IIIC open fractures and managed with temporizing external
fixation.
27.
28. Vascular injury
Angiography
Once the location of an arterial injury has been identified,
attempts at vascular repair.
Patient with prolonged ischemia, restoration of arterial
inflow should be the highest priority with temporary
intraluminal vascular shunting.
i. rapidly restore arterial inflow
ii. allow for a more detailed examination to better determine
the extent of the injury and whether the limb is indeed
salvageable.
iii. allow for a more thorough débridement and appropriate
stabilization of the bone and soft tissues.
29. Vascular repair can then either proceed immediately or in a
delayed fashion if the patient remains in extremis.
o Fasciotomies should be performed after any revascularization
procedure in the mangled extremity.
30. Soft Tissue Coverage
Options for coverage-
i. skin grafts,
ii. local flaps, or
iii. free flaps.
Early reconstruction (within 72 hours) -reduces
postoperative infection, flap failure, and nonunion rates,
development of osteomyelitis.
Many authors recommended muscle flap coverage on a more
delayed basis (7 to 14 days).
Negative pressure wound therapy (NPWT) -very effective
tool in the initial soft tissue management of high energy
open fractures.
Use of NPWT before definitive soft tissue reconstruction had
significantly decreased infection rates.
32. Hyperbaric Oxygen
HBO enhance oxygen delivery to injured tissues affected by
vascular disruption, thrombosis, cytogenic and vasogenic
edema, and cellular hypoxia as a result of trauma to the
extremity.
patients breathe 100% oxygen in a chamber under increased
barometric pressure
supraphysiological arterial oxygen saturation level
expanded diffusion for oxygen into tissues
increased oxygen delivery at the periphery of wounds.
33. Decision to amputation
Indication to primary amputation l0wer limb open #
Absolute :
a)Complete disruption of post.tibial nerve
b)Crush injury with warm ischemia >6hrs,nonrepairable
vascular injury
Relative :
a)Life threatening poly trauma (ISS>20)
b)Severe ipsilateral foot trauma
c)Prolonged course to provide soft tissue and tibial
reconstruction incompatible with personal ,social, and
economic consequences of the patient.
34. Risk factors for amputation
• Gustilo Type IIIC injuries
• Sciatic/tibial nerve or two of the three major upper extremity
nerves anatomically transected
• Prolonged ischaemia time/muscle necrosis
• Crush injury,significant wound contamination
• Multiple/severely comminuted fractures/segmental bone
loss
• Old age/sever co-morbidity
• Failed revascularisation
35. Principles of amputation
Unless amputation in a damage control
situation(guillotine),goal is a functional extremity with
residual limb that successfully interacts with patient’s future
prosthetic management.
Staged amputation-in a patient not adequately resuscitated
,or with significant contamination/infection,blast or crush
mechanism,may improve functional results by preserving
length.
Incision through soft tissue and bone are at right angle to
long axis of the limb
Periosteum is reflected proximal to skin incision and bones
are transected where periosteum is adherent to bone
Suture ligation are preferred to electrocautery for control of
transected.
36. Periosteum is reflected proximal to skin incision,and bones
are transected where periosteum is adherent to bone
Suture ligation are preferred to electrocautery for control of
transected.
Risk of postoperative neuroma is minimized with simple
sharp transection of nerve while maintaining distal traction.
Multilayered closure of the incision to ensure soft tissue
coverage of bones is essential.drain is recommended.
Extremity is spinted and range of motion excerises instituted
early
38. Amputation In children
Attempts should generally be made to preserve all
extremities, even with type IIIC open fractures.
Preservation of limb length and physis are important in
young children.
Mangled extremity severity score (MESS) correlates well with
the need for amputation in adults, the correlation is less in
children.
Bony overgrowth after amputation can be a significant
problem, especially due to the need for children to obtain
multiple prostheses as they grow.
39.
40. Disarticulate when possible. Disarticulation completely
eliminates the problem of terminal overgrowth and
subsequent revision surgery.
Preserve stump shape- The pediatric amputation stump becomes
conical with growth, so preservation of bony architecture such as
a short segment of proximal fibula or the distal condyles of the
humerus will assist in subsequent rotational control of the
prosthesis.
The split-thickness skin graft can hypertrophy and become
sufficiently strong to withstand the shear forces of prosthesis use.
41. The mangled upper extremity
Critical time for reperfusion is longer in the upper (8–10 h)
versus the lower extremity (6 h).
A transtibial amputation carries a much better functional
prognosis than a transradial amputation.
Shortening of the humerus to reduce soft-tissue defects is
tolerated well up to 5 cm.
Nerve reconstruction in the upper extremity done with
reasonable success, whereas major nerve injury is an
indication for primary amputation in the lower extremity.
The rehabilitation process -more imperative.
42.
43. Limb salvage versus Amputation
In limb salvage procedure-
Important issues include
i. patient's ability to handle uncertainty,
ii. deal with prolonged immobilization,
iii. accept social isolation,
iv. bear the financial burden,
v. worst-case scenario occurs when a limb must be
amputated after the patient has endured multiple
operations of an unsuccessful salvage or after years of pain
following a “successful” salvage
44. Early amputation and prosthetic fitting associated with
i. decreased morbidity,
ii. fewer operations,
iii. a shorter hospital course,
iv. decreased hospital costs,
v. shorter rehabilitation,
vi. earlier return to work.
vii. treatment course and outcome are more predictable,
viii. Modern prosthetics often provide better function than
many “successfully” salvaged limbs.
45.
46.
47. SUMMARY
The decision to amputate or salvage a severely injured
Extremity is a difficult one.
The decision to reconstruct or amputate an extremity cannot
depend on limb salvage scores.
Results of limb reconstruction are equal to those of
amputation following severe lower extremity trauma.
The “correct” decisions are based on the patient as a whole,
not solely on the extent of the limb injury.
Patient with a mangled extremity should be directed to an
experienced limb injury center, where strategies to minimize
complications, address related posttraumatic stress disorder,
improve the patient's self-efficacy, and target early
vocational retraining may improve the long-term outcomes.
