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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
