The Mangled Lower Extremity - London Health Sciences … · 2011-10-24 · Level of Amputation Below knee Through knee Above knee Energy of ... Salvage had longer rehab, higher cost,

The Mangled Lower

Extremity Dr. Marlis Sabo

Orthopaedic Trauma Fellow

2011.04.28

Objectives

To review emergency assessment and care of the

open fracture

To review the components of the mangled extremity

and discuss treatment considerations

To briefly outline the advantages/disadvantages of

limb salvage compared with amputation

Open Fractures Is that the bone sticking out?!?

Components: Soft tissue loss

Fracture/bone loss

Vascular injury

Nerve injury

Immediate Care

Place in context of ATLS

protocol

Examination

IV antibiotics

Tetanus

Gross debridement

Sterile dressing

Splint limb

Exam: Soft Tissue

How big is the laceration?

Is there loss of skin, muscle?

How contaminated is it? What environment did the

injury occur in (ie: barnyard, aquatic, etc.)?

Exam: Vascular

Palpable pulses? Asymmetry?

Doppler pulses? Asymmetry? Wave form?

Color, temperature of limb

Compartments

Expanding hematoma, pulsatile bleeding

Exam: Neurologic

Sciatic --> Tibial + Peroneal

Femoral --> Saphenous

Exam: Neurologic

• Light touch & Sharp/Dull

Exam: Neurologic Sciatic - knee flexion

Tibial - ankle and great toe

plantarflexion

Peroneal

Superficial - foot

inversion/eversion

Deep - ankle and great toe

dorsiflexion

Femoral - quads contraction/knee

extension

The Mangled Extremity What a M.E.S.S.!

Considerations:

• 1. Is the limb salvagable?

• 2. If salvaged, will a functional limb

result?

Potential Scenarios

Immediate amputation

Attempted salvage with early amputation

Successful salvage

Unsuccessful salvage with late amputation

Components of Salvage

Bone

stabilization

Uniplanar fixator

Circular fixator

Delayed ORIF

Components of Salvage

Soft Tissue

Coverage

Primary closure

Skin grafts

Local or free flaps

Components of Salvage

Nerve Injury

Nerve repair

Tendon transfers

Bracing/aids

How do we know if the limb

can be saved?

Trauma Scores: MESS

Energy

Low

Medium

High

Very High

1

2

3

4

Limb Ischemia Pulse reduced, perfused

Pulse absent

Cool, paralyzed, insensate

1

2

3

Shock SBP > 90

Transient Hypotension

Persistent Hypotension

0

1

2

Age (years) < 30 YO

30-50 YO

> 50 YO

0

1

2

Trauma Scores: NISSSA

Nerve Injury Up to 3

Ischemia Up to 6

Soft Tissue Injury Up to 3

Skeletal Injury Up to 3

Shock Up to 2

Age Up to 2

Trauma Scores

Several other examples

Similar principles

Variable ability to predict amputation

Do not correlate well with final limb function

Other factors: Other injuries

• Scenario: open tibia fracture, distal limb pulseless,

bone and soft tissue loss, partial plantar sensation

Patient 1: 20 YO non-smoker, isolated injury

Patient 2: 40 YO, bilateral flail chest with pulmonary

contusions, aortic arch injury, hemodynamic

instability in extremis

Patient 3: 80 YO, known DM, known PVD, prior

history of MI, chest injury

Other Factors: Proposed

Level of Amputation

Below knee

Through knee

Above knee

Energy of

ambulation goes

up with the level

of amputation.

When to consider salvage?

Anatomically intact sciatic/tibial nerve

Can reconstruct vascular supply: proximal injury,

warm ischemia < 6 hrs

Moderate soft tissue injury or loss

Moderate bone loss

Functional ankle, foot and knee

Younger patients

If salvaged, will a functional

limb result?

Bosse, NEJM 2002

Limb salvage v. amputation at 24 month F/U

SIP scores similar between amp and salvage groups

Reconstruction group more OR and hospitalization

Neither group reflected population norms

Approx. 50% had returned to work at 24 months

Outcome more determined by social factors than

treatment choice

Busse, JOT 2007 Meta-analysis (9 eligible studies)

Hospital stay same

Salvage had longer rehab, higher cost, more

complications, more surgery

Salvage failed in 10-20%

Return to work similar (50%)

Results deteriorated over time in both groups

Patient self-image may be better in limb salvage

group

So...

To sum up:

Mangled limb belongs to a

patient - keep things in context

Few indications for immediate

amputation - time to consult,

assess patient factors, educate

Limb salvage and amputation

have similar long-term outcomes

Long-term disability common

Thank-You