Management of mangled Extremities, MESS, Principles for Limb Salvage

1. Department of Orthopaedics
MH Kirkee
SEMINAR
MANGLED EXTREMITY
Maj Rohit Vikas
Resident

2. MANGLED EXTREMITY
INTRODUCTION

6. COMPONENTS
•Soft tissue loss
•Fracture/bone loss
•Vascular injury
•Nerve injury

10. RESUSCITATION
Place in context of ATLS protocol
ABC
Fluid and Blood Replacement
Examination
IV antibiotics
Tetanus
Gross debridement and wound wash
Sterile dressing
Splint limb

11. LIFE THREATENING COMPLICATIONS
HYPOVOLEMIC SHOCK
RHABDOMYOLYSIS
ACUTE RENAL FAILURE
SIRS
SEVERE SEPSIS
ARDS
MODS
REPERFUSION INJURY
ARYHTHMIAS

12. ASSESSMENT
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.)?
VASCULAR
Palpable pulses? Asymmetry?
Doppler pulses? Asymmetry? Wave form?
Color, temperature of limb
Compartments
Expanding hematoma, pulsatile bleeding
NEUROLOGICAL
Sciatic --> Tibial + Peroneal
Femoral --> Saphenous

13. DECISION TO AMPUTATE
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

14. MANGLED EXTREMITY SCORES
How we decide on salvage versus amputation?
Predictive Salvage Index (PSI)
Mangled Extremity Severity Score (MESS)
Limb Salvage Index (LSI)
Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age (NISSSA)
Score
Hannover Fracture Scale-97 (HFS-97)
Trauma Scores:
Do not correlate well with final limb function

15. MESS <= 6 – Limb salvageable

17. LIMB SALVAGE
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

18. MANGLED EXTREMITY
PRIMARY AMPUTATION

19. Amputation: Replantation
Mangled and Crushed – Poor Candidate

20. DECISION TO AMPUTATE
Indications for Primary Amputation in Lower Extremity Open Fractures*
Absolute:
a. complete disruption of the posterior tibial nerve in an adult
b. crush injury with warm ischemia >6H or nonreparable vascular injury
Relative:
a. life threatening polytrauma (ISS > 20)
b. severe ipsilateral foot trauma
c. prolonged course to provide soft tissue and tibial reconstruction incompatible
with personal,sociologic and economic consequences for the patient
*civilian world

21. RISK FACTORS FOR AMPUTATION
Gustilo III-C injuries � comminuted,
Open tib-fib fractures with vascular disruption.
Sciatic or tibial nerve, or two of the three major upper extremity nerves,
anatomically transected
Prolonged ischemia (>4-6 hours)/muscle necrosis
Crush or destructive soft tissue injury
Significant wound contamination
Multiple/severely comminuted fractures/segmental bone loss
Old age/severe co-morbidity
Lower vs. upper extremity
Apparent futility of revascularization/failed revascularization

22. HARD SIGNS OF VASCULAR INJURY
Active hemorrhage
Large, expanding or pulsatile hematoma
Bruit or thrill over the wound(s)
Absent palpable pulses distally
Distal ischemic manifestations
(pain, pallor, paralysis, paresthesias, poikilothermy,
or coolness)

24. PRINCIPLES OF AMPUTATION
Principles:
o Unless amputation is in a damage control situation (“guillotine”), the goal is a functional
extremity with a residual limb that successfully interacts with the patient’s future
prosthetic mgt.
oStaged amputation - In a patient not been adequately resuscitated, or with significant
Contamination/ infection, blast or crush mechanism, may improve functional results by
preserving length.
o Incisions through soft tissue and bone are at right angles to the longitudinal axis
of limb with few exceptions. Do not bevel the incision as this may create ischemic flaps.
o The periosteum is reflected proximal to skin incisions, and bones are transected
where the periosteum is adherent to the bone to decrease the chance for an avascular
sequestrum. Bone edges are filed after transection.
o Suture ligatures are preferred to electrocautery for control of transected vessels.

25. PRINCIPLES OF AMPUTATION
Principles:
o Risk of postoperative neuroma is minimized with simple sharp transection of nerves
while maintaining distal traction. Judicious use of sutures to control bleeding and
minimizing the use of clamps also decrease neuroma formation.
o Multilayered closure of the incisions to ensure soft tissue coverage of bones is essential.
Drains are recommended for larger amputations.
o Skin grafts should be used to preserve limb length and joints as long as adequate muscle
coverage is present to cover bone.
o Extremities are splinted to prevent contractures during healing and range of motion
exercises instituted early

27. IRRIGATION DEBRIDEMENT
With the exception of tendon and nerve, if it does not bleed it is dead.
If it is dead, get rid of it.
If you cannot get rid of it, think amputation.
Serial debridements and washouts are desirable
Assess viability in OT – Color/ contractility/ bleeding
Debridement Amputation
When life over limb is the issue or in certain extremity injuries where there is no
means of limb salvage

28. guillotine-style transfemoral amputation

29. myodesis to the anteriordistal
aspect of the tibia

30. myodesis to the anteriordistal
aspect of the tibia

31. a sciatic nerve that had been included in the
amputation myoplasty.
The resulting neuroma was symptomatic and
precluded prosthetic wear and walking

32. MANGLED EXTREMITY
LIMB SALVAGE

33. DEBRIDEMENT
With the exception of tendon and nerve,
if it does not bleed it is dead.
If it is dead, get rid of it.
If you cannot get rid of it, think
amputation.
Serial debridements and washouts are
desirable
Assess viability in OT – Color/
contractility/ bleeding

34. INVESTIGATIONS
DOPPLER
No signal = no perfusion
Signal ≠ normal arteries

35. FASCIOTOMY

36. DAMAGE CONTROL
Hemodynamic instability,
Coagulopathy,
Acidosis,
Hypothermia of the patient
Unstable skeleton
Major wound contamination/infection or soft tissue deficits precluding wound
coverage
Requirement for any definitive repair more complex than lateral suture or end
to end anastomosis (i.e. extra-anatomic bypass, interposition graft)
Austere environment with no resources for definitive management
Other life threatening injuries requiring urgent management

39. DEFINITIVE REPAIR
Definitive repair should be performed provided:
Hemodynamic and physiologic stability of patient
Stable skeleton
Clean wound with adequate viable soft tissue
Availability of necessary time and resources
No other injuries requiring more urgent management

40. VASCULAR SHUNTS
Angiography
In theatre
Diagnostic
Therapeutic
Covered stent
Embolisation
Open exploration
Repair
Bypass

41. SKELETAL STABILIZATION
Uniplanar fixator
Circular fixator
Delayed ORIF

42. EXCLUDE ANY CLINICALLY SIGNIFICANT
VASCULAR INJURY

43. WOUND MANAGEMENT
TIMING FOR WOUND CLOSURE
ALL MAJOR STUDIES HAVE SHOWN EARLY FLAP CLOSURE WITHIN 7 DAYS LEADS TO
LOWEST COMPLICATION RATES
BOTTOM LINE: IF YOU ARE INVOLVED IN MANGLED EXTREMITY CARE A
COMMITMENT MUST BE MADE TO ACHIEVE COVERAGE WITHIN A WEEK WITH
HEALTHY VASCULARIZED TISSUE
VAC USE DOES NOT CHANGE THIS DICTUM
Soft Tissue Coverage
Primary closure
Skin grafts
Local or free flaps

45. NERVE INJURY
Nerve Injury
Nerve repair
Tendon transfers
Bracing/aids

46. TISSUE ENGINEERING
Issues that can be addressed with tissue engineering
Missing or injured nerve
Neuromas in-continuity
Missing bone, enhanced bone healing
Wound vascularity
Delayed wound healing

47. TISSUE ENGINEERING
TISSUE ENGINEERING CONSIDERATIONS
Bioabsorbable nerve guides supplemented by growth factors
Bone matrix to replace need for microsurgical transplantation
Angiogenic factors
Acellular tissue matrix to enhance wound healing

48. MANGLED EXTREMITY
SECONDARY AMPUTATION

49. SECONDARY AMPUTATION
“Life over Limb”
Metabolic burden Reassess, reassess, reassess
Continuous dialogue w/ patient and family
Septic source (esp. osteo)
Use Psych, pastoral care, clergy
Extensive tissue necrosis/ skin loss
Assess home environmental & personal factors
Associated MODS 2nd Opinion – Ortho, Plastics, Vascular, Neuro,
Rehab, Intensivist
Profound neurologic impairment
Earlier the better
Extensive functional impairment

51. MANGLED EXTREMITY
CLINICAL EXAMPLES

56. Rectus abdominus flap
With skin mesh over the flap

58. MANAGEMENT OF AMPUTEE
• Preparation PROSTHETICS
• Good Surgical Technique
• Rehabilitation • Passive
• Early Prosthetic Fitting – Cosmetic
• Team Approach • Body Powered
• Vocational and Activity – Harnesses and cables
Rehabilitation • Myoelectric
– Surface EMG
– Activation delay
• Neuroprosthetics
– Investigational

59. MANGLED EXTREMITY
CONCLUSION

60. 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

61. World record for the 100m sprint - 9.58 sec

62. World Record for 100m sprint for an amputee - 10.91 sec
Oscar Pistorius

63. Record for a limb salvage
patient?