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Mangled Extremity and its Management PRESENTED BY DR. SIDDHARTHA NARUPGT ,MEDICAL COLLEGEDEPT. OF ORTHOPEDICS

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:Soft tissue lossFracture/bone lossVascular injuryNerve injury

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

CausesMotor vehicle accidentFall from heightFarm/industrial injuryClose range shotgun woundCrush injuryExplotion injury

Life threatening complicationsHypovolemic shockRhabdomyolysisAcute renal failureSIRSMODSSevere sepsisARDSArrhythmiaReperfusion injury

Initial EvaluationRoutine 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

Vascular AssessmentArterial injuries usually present with either hard or soft signs suggestive of injury. Hard signs-pulsatile bleeding,presence of a rapidly expanding hematoma,a palpable thrill, or audible bruit,presence of any of the classic signs of obvious arterial occlusion (pulselessness, pallor, paresthesia, pain, paralysis, poikilothermia )

Soft signs history of arterial bleeding,a nonexpanding hematoma,a pulse deficit without ischemia,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 extremityArterial pressure indices (APIs)-if the API < 0.90 or distal pulses remain absent despite reduction, angiography and/or vascular surgery consultation is indicated.

Decision-Making Protocols and Limb Salvage ScoresLimb Salvage Decision-Making VariablesPatient VariablesAgeUnderlying chronic diseases (e.g., diabetes)Associated VariablesOccupational considerationsMagnitude of associated injury (Injury Severity Score)Patient and family desiresSeverity and duration of shockExtremity VariablesWarm ischemia timeMechanism of injury (soft tissue injury kinetics)Fracture patternArterial/venous injury (location)Neurological (anatomic status)Injury status of ipsilateral footIntercalary ischemic zone after revascularization

Index DomainsMESSNISSSA/HFSPSILSIIschemia Nerve injuryIschemiaIschemiaBone/tissueIschemiaBoneBoneShockSoft tissue injuryMuscleMuscleAgeSkeletal injuryTimingSkinShockNerveAgeVein

Mangled Extremity Syndrome Index(MESI).. Gregory et al.Criterion ScoreInjury Severity Score503Integument injuryGuillotine1Crush/burn2Avulsion/degloving3Nerve injuryContusion1Transection2Avulsion3

Bone injurySimple1Segmental2Segmental comminuted3Bone loss 90 mm Hg0SBP transiently 20)b)Severe ipsilateral foot traumac)Prolonged course to provide soft tissue and tibial reconstruction incompatible with personal ,social, and economic consequences of the patient.

Risk factors for amputationGustilo Type IIIC injuriesSciatic/tibial nerve or two of the three major upper extremity nerves anatomically transectedProlonged ischaemia time/muscle necrosisCrush injury,significant wound contaminationMultiple/severely comminuted fractures/segmental bone lossOld age/sever co-morbidityFailed revascularisation

Principles of amputationUnless amputation in a damage control situation(guillotine),goal is a functional extremity with residual limb that successfully interacts with patients 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 limbPeriosteum is reflected proximal to skin incision and bones are transected where periosteum is adherent to boneSuture ligation are preferred to electrocautery for control of transected.

Periosteum is reflected proximal to skin incision,and bones are transected where periosteum is adherent to boneSuture 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

Level of transfemoral amputationsLevel of transtibial amputations

Amputation In childrenAttempts 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.

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.

The mangled upper extremityCritical time for reperfusion is longer in the upper (810 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.

Limb salvage versus AmputationIn limb salvage procedure-Important issues includepatient's ability to handle uncertainty,deal with prolonged immobilization,accept social isolation,bear the financial burden,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

Early amputation and prosthetic fitting associated with decreased morbidity,fewer operations,a shorter hospital course,decreased hospital costs,shorter rehabilitation,earlier return to work.treatment course and outcome are more predictable,Modern prosthetics often provide better function than many successfully salvaged limbs.

SUMMARYThe 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.

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