Mangled extremity and its management by Dr Shorifuddin Ahmed , Medical College, Kolkata

2. Overview
• Definition
• Components
• Assessment
• Decision Making:
Salvage v/s
Amputate
• Management

3. Definition
• “Mangled extremity” refers to an injury to an
extremity so severe that viability of the limb is
often questinoble and loss of the limb a likely
outcome.
• Caused by some combination of crush , shear,
blast,bending forces.

4. Components
1. Skin /Soft tissue loss
2. Fracture /bone loss
3. Vascular injury
4. Nerve injury

5. Assessment
Initial Evaluation :
• ATLS protocols
• Time and mechanism of
injury
• Any medical comorbidities
• Vascular and neurological
examniation
• Presence of compartment
syndrome
• Photograph of extremity
• Radiographic evaluation

6. Assessment …
SOFT TISSUE:
• How big is the
laceration?
• Is there loss of skin ,
muscle?
• How contaminated is it?
• What environment did
the injury occure in (i.e
barnyard, aquatic, etc)?

7. Vascular Assessemnt
• Hard Sign:
I. Pulsatile bleeding
II. Presence of rapidly
expanding heamatoma
III. A palpable trill, or audible
bruit,
IV. Sign of arterial occlusion(
Pulselessness, Pallor,
Paresthesia, Pain,
Paralysis, Poikilothermia)

8. Vascular Assessment cont…
• Soft sign:
I. h/o arterial bleeding
II. Nonexpanding heamatoma
III. Pulse deficit without ischemia
IV. A neurological defcit
• Skin colour and Capillary Refilling Time
• API : if API < 0.90 or distal pulse remain absent
despit reduction , angiography and/or vascular
surgery is indicated.

9. Potential scenarios in mangled limb
• Successful salvage
• Attempted salvage with early amputation
• Immediate amputation
• Unsuccessful salvage with late amputation
D

11. 6. Ganga Hospital Open Injury Score (GHOIS)

13. Mangled Extremity Severity Score

14. Ganga Hospital Open Injury Score

15. Ganga Hospital Open Injury Score
•Score ≤ 14
advised salvage.
•Score ≥ 17 end
up in
amputation.
•Score 15 & 16
gray zone ,
decision to be
made on patient
to patient basis.

16. Decision Making: Salvage vs
Amputate
 Do scoring system help?..... Not really
 No scoring is predictive of salvage or
amputation
 Lower score has specificity for limb salvage
potential , but the low sensitivity of these
scoring system did not validate them as
predictor of amputation.
 Scoring system are used for documentation
and as guides in clinical decision making , not
as absolute indicators for salvage or
ampuation .
 Not able to predicts outcomes.

17. Decision Making: Salvage vs
Amputate
 Should tibial nerve injury/ planter sensation
impact the decision?... No
 Initial plantar sensation was not predictive of
long term tibial nerve function.
 Historically lack of plantar sensation was a
critical factor contributing to decision to
amputate

18. Decision Making: Salvage
vs Amputate
 Does condition of ankle matter? …. Yes
 Patients needing an ankle /foot free flap or
ankle arthrodesis do poorly with savage .

19. Decision Making: Salvage vs
Amputate
Lower Extremity Assessment Project ( LEAP)
 Prospective multicenter, 8 level 1 trauma center,
569 patients salvage or amputation lower
extremity
 7 yr follow up did not demonstrate difference
 Both generally poor
 Scoring system do not reliably predict functional
outcome
 Lifetime cost of amputaion 3x higher

20. Decision Making: Salvage
vs Amputate
Interpretation:
1. Scoring system do not help predict which
patient will get amputation.
2. Tibial nerve fucntion should not play a role in
the decision to salvage vs amputation.
3. Patient needing an ankle/ foot free flap or
ankle arthrodosis do poorly with salvage.
4. Take patient, surgeon, and community factors
into consideration.

21. Emergent Management
Life before limb
ATLS protocols
Antibiotics ASAP

22. Emergent Management ..
ATLS COMPONENTS
Primary survey
Identify what is killing the patient
Resuscitation
Treat what is killing the patient
Secondary survey
Proceed to identify other unjuries
Definitive care
Develop a definitive management plan

23. Before going to definitive
treatment….
• Proper counselling of patient and party regarding all
aspect of further course of management ...

24. Definitive Management
• Wash, wash, wash
• Debride , debride ,
debride
• Repeat as necessary
• Wound swab for C & S

25. Debridement

26. Skeletal Stabilization
• Stabilzation options :
- Splint immobilization
- Skeletal traction
- External fixation
- Internal fixation

27. Skeletal Stabilization
• Most limb thretening injuries present as
Gustilo type IIIB & IIIC open fracture are
managed with temporizing external fixation

28. Soft Tissue Coverage
Options for coverage:
• Skin graft
• Local flap or
• Free flaps
Hemisoleus flap

29. Soft Tissue Coverage…
• Early reconstruction (within72 hr) reduces
postoperative infection, flap failure, and non-union
rate, development of osteomyelitis.
• Negative Pressure Wound therapy(NPWT) . Very
effective , decreses infection rate.

30. Managing Vascular Injury
• Angiography ..once location identified…
• Patients with prolong ischemia – temporary
intraluminal vascular shunting

31. Managing Vascular Injury…
• Fracture relatively stable -
arterial repair precede
bony stabilization.
• Fracture exessively
communated
/displaced/shorted- rapid
bony stabilization
followed by arterial repair.

32. Nerve Injury
• Nerve repair
• Tendon transfer
• Bracinng /aid

33. Dealing with bone loss
Options includes:
 Autograft
 Masquelet technique
 Distraction osteogenesis
-”Ilizarov technique”

34. Dealing with bone loss
Masquelet Technique: up to 25cm
PLGA: Poly lactic co glycolic acid

35. Hyperbaric Oxygen Therapy
• HBO enhance oxygen delivery to injured tissue
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 tissue .
• Increases oxygen delivery at the periphery of
wound.

36. Decision to amputation
Discussion with patients :
• Present all objective information and
recommendation .
• Discuss outcome data of amputation vs
salvage .
• Psychological factor to consider type of
employment support system, access to
medical and rehabilitation facilities.
• Self efficacy.

37. Decision to amputation
Indication to primary amputation lower limb open #-
Absolute :
a. Complete disruption of post tibial nerve
b. Crush injury with warm ischemia > 6hr , non
repairable vascular injury
Relative
a. Life threatenig polytrauma
b. Severe ipsilateral foot trauma
c. Prolong course to provide soft tissue and tibial
reconstruction incompatible with personal , social,
and economic consequences of the patients.

38. Principle of amputation
• Determine appropriate level of amputation.
• The goal is a functional extremity with residual
limb.
• Staged amputation in heamodynamically
unstable pt, with significant contamination
/infection, blast/crush mechanism, may
improve functional result by preserving
length.

39. Principle of amputation
• Incision right angle to the longitudinal axis of limb .
• Muscles usually are divided at least 5 cm distal to the
intended bone resection., stabilized by myodesis or by
myoplasty
• The periosteum is reflected proximal to skin incision,
and bones are transected where the periosteum is
adherent to the bone to decrease the chance of
avascular sequestrum.
• Bone edge are filed after transection.
• Major vessels should individually isolated and ligated.

40. Principle of amputation..
• A drain should be kept for 48hr to 72hr
• Risk of post operative neuroma is minimized
with simple sharp transection of nerve while
maintaining distal traction.
• Multilayer closure of incision to ensure soft
tissue coverage of bones is essential.
• Extremity are splinted to prevent contracture
during healing and range of motion instituted
early .

41. Levels of amputation

42. Energy consumption following
amputation

43. Energy of Ambulation
Level matters!!

44. Energy of Ambulation
• Knee motion minimizes vertical rise during
ambulation
•Bilateral trans tibial amputation expend 24% less energy
than unilateral trans femoral !!

45. Advantage of early amputation
• Decreases morbidity
• Fewer operation
• A short hospital course
• Decreases hospital cost
• Shorter rehabilitation
• Earlier return to work
• Treatment course and outcome are more predictable
• Modern prosthesis and outcome are provide better
function than many successfully salvaged limb.

46. Predictor of Poor Outcome
after adjusting for extent of injury
• Major complication
• HS education or less
• Non-white
• Low income and no private insurance
• Current smoker
• Low self efficacy and social support
• Involvement of legal system

47. Mangled upper extremity
• Critical reperfusion time is longer in upper (8-10hr)
versus lower extremity ( 6hr).
• A transtibial amputation carries a much better
functional prognosis than a transradial amputation.
• Shortening of humerus to reduce soft tissue defect is
tolerated well upto 5cm.
• 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.

48. Amputation in children
• Attempt should generally be made to preserve all
extremities , even with type IIIC open fracture.
• Preservation of limb length and physis are
important in young children.
• MESS correlates well with the need for
amputation in adult , 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
grows.

49. Summary
• Mangled extremity are becoming more prevalent due to
increased high velocity accident.
• Emergent management
-life before limb
-ATLS protocol
- antibiotics
• The decision to amputate v/s salvage is complex.
• If salvage is chosen , there is multiple option for dealing with
soft tissue and bone loss.
• If amputation is chosen it may provide better functional
outcome than many successfully salvaged limb.