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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
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 - knee flexion
Tibial - ankle and great toe
plantarflexion
Peroneal
Superficial - foot
inversion/eversion
Deep - ankle and great toe
dorsiflexion
Femoral - quads contraction/knee
extension
Potential Scenarios
Immediate amputation
Attempted salvage with early amputation
Successful salvage
Unsuccessful salvage with late amputation
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
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
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
Recommended