Management of the Mangled Extremity

Mangled extremities represent one of the most challenging injuries. They indicate the need for a comprehensive trauma assessment to rule out coexisting injuries. Treatment options include amputation and attempts at limb salvage. Although both have been associated with chronic disability, new surgical techniques and evolving rehabilitation options offer hope for the future.

Vascular Trauma in the Extremities: Factors Associated with the Outcome and Assessment of Amputation Indexes

BACKGROUND

Traumatic vascular injury in the extremities may be associated with a low mortality rate but can lead to limb loss that seriously affects patients' functionality. Multiple scoring systems have been designed to evaluate the prognosis, but none are 100% predictive. The management of traumatic vascular injury remains challenging and depends mostly on the surgeon's experience.

OBJECTIVES

We identified the risks associated with limb loss and further investigated the utility of current amputation indexes.

METHODS

We retrospectively reviewed 53 cases of traumatic vascular injury in the extremities at a tertiary referral medical center over the past ten years (January 2011-December 2020). The mangled extremity severity score (MESS), limb salvage index (LSI), and predictive salvage index (PSI) were used to assess the traumatized limbs. The injury characteristics and outcomes were evaluated using regression analysis.

RESULTS

The incidence of limb loss was 20.8% (n = 11), and open fractures were the most related factor. Extensive involvement of soft tissue, vascular injury combined with tibia or fibula fractures, initial shock status, and the amount of transfusion were associated with limb loss.

CONCLUSIONS

Our study identified the risk factors and clinical utility of MESS, PSI, and LSI. While both LSI and PSI had acceptable diagnostic accuracy, amputation should be decided based on a variety of criteria and clinical features. Salvaging any limb that has not become apparently futile seems logical, yet the presence of certain factors may suggest a worse outcome.

Update in combined musculoskeletal and vascular injuries of the extremities

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient’s medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.

Mangled extremity- Modern concepts in treatment

A mangled extremity is the most devastating limb injury and presents a challenge for the orthopedic surgeon. There are two main treatment options, reconstruction or amputation, but sometimes indications for either are not clear. There are many pro and contra arguments for both options. To make the decision easier numerous score systems have been introduced, but the final decision is based on the judgment and experience of the treating surgeon. Early extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. The goal in reconstruction of a lower extremity is to restore and maintain balance and ambulation, while restoration of an upper extremity's numerous functions is more demanding. In this paper the authors describe and suggest treatment approaches in patients with a severely mangled extremity, including assessment and treatment of all injured tissues, using defined protocols, with special attention to bone stabilization, revascularization, soft-tissue coverage and nerve reconstruction. These have a great impact on the outcome and function of the injured extremity. Rehabilitation and return to the preinjury level is slow and sometimes uncertain.

Primary amputation versus limb salvage in upper limb major trauma: a systematic review

PURPOSE

Severe upper limb injuries can result in devastating consequences to functional and psychological well-being. Primary objectives of this review were to evaluate indications for amputation versus limb salvage in upper limb major trauma and whether any existing scoring systems can aid in decision-making. Secondary objectives were to assess the functional and psychological outcomes from amputation versus limb salvage.

METHODS

A systematic review was carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool. The review protocol was registered in PROSPERO.

RESULTS

A total of 15 studies met inclusion criteria, encompassing 6113 patients. 141 underwent primary amputation and 5972 limb salvage. General indications for amputation included at least two of the following: uncontrollable haemodynamic instability; extensive and concurrent soft tissue, bone, vascular and/or nerve injuries; prolonged limb ischaemia; and blunt arterial trauma or crush injury. The Mangled Extremity Severity Score alone does not accurately predict need for amputation, however, the Mangled Extremity Syndrome Index may be a more precise tool. Comparable patient-reported functional and psychological outcomes are seen between the two treatment modalities.

CONCLUSIONS

Decision regarding amputation versus limb salvage of the upper limb is multifactorial. Current scoring systems are predominantly based on lower limb trauma, with lack of robust evidence to guide management of the upper extremity. Further high-quality studies are required to validate scoring systems which may aid in decision-making and provide further information on the outcomes from the two treatment options.

Clinical outcome of staged surgery after primary amputation for mangled extremity

INTRODUCTION

Amputation for a mangled extremity is an effective and reliable life-saving treatment method, which requires a relatively shorter duration for treatment than limb salvage. However, only a few studies have focused on treatment with amputation. Herein, we report good clinical outcomes achieved through staged surgery performed after amputation.

MATERIALS AND METHODS

This study included 47 patients (38 men, 9 women; average age, 52.4 years) diagnosed with mangled extremity, who underwent primary amputation between March 2014 and January 2019. The patients were divided into the initial closure (IC) groups (including 26 patients who underwent IC after amputation) and staged surgery (SS) (including 21 patients who underwent SS after amputation) groups. The presence of complications including necrosis and infection, consequent additional surgery, duration of hospitalization and expense for treatment, and functional scores of upper and lower extremities were assessed.

RESULTS

No specific postoperative complication was found in the SS group. However, additional surgeries were performed in the IC group because of complications including three cases of infection and two cases of necrosis. The differences between the hospitalization period, treatment cost, and functional examination conducted 1 year after surgery of the two groups were not statistically significant. The patients in the IC group who underwent additional surgery were hospitalized for a longer period and presented with lower functional scores due to delayed rehabilitation.

CONCLUSION

Staged surgery is a definitive and safe treatment option that can effectively reduce complications including infection and necrosis in patients with mangled extremity.

Complex upper limb reconstruction using dorsoepigastric flap. Case report of a convenient resource

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Dorsoepigastric flap is a variant of the classic lattisimus dorsi flap that utilizes less muscle tissue.

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It is an appropriate reconstructive alternative and has the advantage of functional preservation of the lattisimus dorsi muscle.

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It must be considered as part of the repertoire of the reconstructive surgeon when fixing complex defects of the upper limb.

Introduction

Dorsoepigastric flap (DF), first described by. Haddad and Jimenez, is a variant of the classic lattisimus dorsi musculocutaneous flap that only utilizes a minimum quantity of muscle tissue, through which the vascular pedicle passes by. It has been used primarily as an acceptable alternative in mammary reconstruction when the use of thoraco abdominal muscles is not viable, and offers several advantages such as adequate flap volume with generous cutaneous island dimensions and functional preservation of the latissimus dorsi.

Presentation of a case

We report the case of a 12 year old male, who suffered a left upper limb injury secondary to high power firearm shot. He presented extensive damage to the skin, soft tissues and bone structures and was treated with primary reconstruction using DF and peroneal grafts. Three years later, a shoulder prosthesis was placed to improve limb function with unobjectionable results.

Conclusion

DF is a useful resource that has been merely used in the context of complex upper limb reconstruction, and must be considered essential in the repertoire of the reconstructive surgeon when facing traumatic defects of the upper extremity.

Fast and slow myosin as markers of muscle regeneration in mangled extremities: a pilot study

Mangled extremities were classically managed by amputation. But over the past few decades, with the advancement in surgical techniques, an increased number of limb salvages have been possible. As muscles usually get damaged in such grievous injuries, a thorough understanding of muscle regeneration may give a better insight into muscle healing in these injuries. Muscles are composed of slow and fast fibers which can be represented by slow and fast myosin, respectively. There are some animal studies which reported differential regeneration of slow and fast muscle fibers during muscle healing. We conducted this pilot study to find out whether the same holds true for muscle healing in mangled extremities also. This pilot study is designed in 15 patients with lower limb mangled extremities presenting to trauma center of PGIMER, Chandigarh, who were operated within 24 h of injury to see whether muscle healing in mangled extremities follows the same pattern. Biopsies were taken during initial surgery conducted within 24 h of injury and on the 7th day of injury when patient was posted again for secondary wound closure procedure or revision amputation. The biopsy samples were subjected to histopathological and immunohistochemistry examination using antibodies against fast and slow myosin. We found that the regenerating muscle fibers in the biopsy sample taken on the 7th day of injury showed only slow muscle fibers with the absence of fast muscle fibers when compared with the initial biopsy results showing differential regeneration of slow muscle fibers.

The role of negative pressure wound therapy in salvaging a six-year-old child's crushed foot - A case report

Crushed extremity is an infrequent injury in children and represents a major challenge for the orthopaedic surgeon. Sometimes the decision making process, whether to amputate or save a limb, is very difficult. Several scoring systems have been developed in order to determine the fate of crushed extremities, but they are not always predictive when patients are children. In the past few years, advances in bone and soft tissue reconstruction techniques have improved outcomes, even in the most extreme cases. Negative Pressure Wound Therapy has become an accepted option in the treatment of crushed limbs. We report a 6-year-old child with a crushed left foot from the running chain of his father's motorcycle. Early revascularization and stabilization along with multiple debridement and the application of Negative Pressure Wound Therapy leaded to salvage of the child's limb. At the end of one year follow up, he presented a very good functional and aesthetic result.

LEVEL OF CLINICAL EVIDENCE

"4".

Initial injury severity and social factors determine ability to deploy after combat-related amputation

OBJECTIVE

While many recent publications have examined the ability of amputees to return to active duty, it remains largely unknown why few amputees deploy after amputation and many amputees do not. The purpose of this study is to examine what predictor(s) exist for whether or not an amputee will deploy after sustaining a combat-related amputation.

METHODS

All U.S. Service members who sustained major extremity amputations from September 2001 through July 2011 were analysed. Amputation level(s), mechanism of injury, time interval to amputation, age, rank, Physical Evaluation Board (PEB) disposition and ability to deploy after amputation were determined.

RESULTS

Deployment information after amputation was obtained for 953 amputees. There were 47 (5%) amputees who deployed. There were no significant differences amongst service branches for the deployment of amputees (p > 0.2). Amputees who underwent their amputation on the same day of their injury were significantly less likely to deploy after amputation than those who had their amputation on the day of injury (p = .01). Deployed amputees had significantly lower Injury Severity Scores than amputees who did not deploy (15.98 vs 20.87, p < 0.01) and officers were significantly (p < .01) more likely to deploy and the average age of amputees who deployed was significantly higher than those who did not (27.5 vs 25.1, p < .01). Lastly, those amputees who sustained a transtibial amputation were significantly more likely to deploy than all other amputation levels (p < .01). Nine out of 19 (47%) Special Forces amputees were able to deploy.

DISCUSSION

The vast majority of amputees do not able to deploy after undergoing amputation. The main predictors of deploying after sustaining a combat-related amputation appear to be: sustaining a transtibial amputation, being of senior rank or age and being a member of the Special Forces. Many of these factors appear to be non-treatment related and highlight the importance that individual and social factors play in the recovery of severe injuries.