Mangled extremities: assessment scoring and management

Presentation on mangled extremities and its scoring for better management and outcomes

1. Mangled Extremity Dr. Mehroze Zamir

2. Acknowledgement AO Trauma Prof. Zaki Idrees

3. Objectives Definition Upper vs lower limb for amputation Emergency Assessment Care at trauma site Care & assessment at the hospital Mangled extremity severity score Decision making amputation vs salvage Good amputation stump Analysis of Outcomes Conclusion

4. Definition “ Mangled extremity is a limb with an injury to at least three out of four systems (soft tissue, bone, nerves, and vessels) ”   Resuscitation and management of all life-threatening injuries always must take precedence over any extremity injury (life before limb)

5. Differences considered in managing Mangled Upper and Lower Limbs Upper Limb Longer warm ischemia time – 8 hours Non-weight bearing Nerve repair gives better results Can function with decreased sensation Assistive upper limb often functions better than prosthesis Lower Limb Shorter ischemia time – 6 hours Weight bearing is mandatory Nerve repair result not as good Increased risks with decreased sensation Modern prosthesis often better than salvaged lower limb

6. Basis of Salvage Decision ofMangled Upper and Lower Limbs Upper Limb The technical possibility The chance of providing some useful function Lower Limb Tolerance of weight bearing Have some protective Sensation Have durable skin and soft tissue Salvage is the goal in both upper limb and lower limb. However salvage is no guarantee of functionality. Amputation should not be considered a treatment failure but rather a means of meeting goals of treatment

7. History : Stimson 1883 Immediate amputation is indicated when : Main blood vessels are damaged The main nerves are severely damaged Extensive damage to the soft parts When the bone is literally smashed

8. As time passed History changed In 1987, Hansen : Any amount of damage can be repaired by Orthopaedics , Vascular, Nerve, Micro & Plastic surgery team.

9. Emergency assessment Assessment of patient ATLS guidelines Manage life threatening injuries first. Examination of the injury Wound (photos) Neurological status Vascular status Look for compartment syndrome

10. ATLS ATLS has its origins in the United States in 1976, when James K. Styner , an orthopedic surgeon piloting a light aircraft, crashed his plane into a field in Nebraska. His wife Charlene was killed instantly and three of his four children, Richard, Randy, and Kim sustained critical injuries. His son Chris suffered a broken arm. He carried out the initial triage of his children at the crash site. Dr. Styner had to flag down a car to transport him to the nearest hospital; upon arrival, he found it closed. Even once the hospital was opened and a doctor called in, he found that the emergency care provided at the small regional hospital where they were treated was inadequate and inappropriate. Upon returning to Lincoln, Dr. Styner declared: "When I can provide better care in the field with limited resources than what my children and I received at the primary care facility, there is something wrong with the system and the system has to be changed”

11. In a Trauma Scene Care of Patient With A Mangled limb or Traumatic Amputation Care of the Amputated Part Care of Amputation Stump Wound

12. Care of Patient With a Mangled Limb or Traumatic Amputation Control Hemorrhage 1. Compression Dressing 2. Dangers of Tourniquet 3. Dangers of Clamping General life support measures Medical control of pain Splints 1. Decrease Pain 2. Protect Soft Tissues 3. Help Control Hemorrhage

13. Care of the Amputated Part Place part in plastic bag and seal it Put bag in Ice:Water (1:3) - Do Not soak in Water ( Maceration ) - Do Not place part Directly in Ice ( Direct Thermal Injury ) This is important where reimplantation of the limb or a part maybe possible

14. Care of Wound Wound packing with sterile dressing Major vessels hemorrage control by adequate manual pressure Gentle handling of skin flapes Gentle pressure bandage

15. Decision Making: Amputate or Not Very difficult Needs an experienced and a senior staff Many scoring systems None is a ‘diamond crystal’ and gives an absolute decision Needs patient’s opinion !!!!

16. Mangled Extremity Severity Score ( MESS ) MESS is a simple rating scale for lower extremity trauma, based on: skeletal/soft-tissue damage limb ischemia shock age .

17. Skeletal / Soft-tissue injury Low energy (stab; simple fracture; pistol gunshot wound)……………… 1 Medium energy (open or multiple fractures, dislocation)………… 2 High energy (high speed RTA)……… 3 Very high energy (high speed trauma + gross contamination)……… 4

18. Limb I schemia Pulse reduced or absent but perfusion normal……… 1 Pulseless, paraesthesias , diminished capillary refill……….. 2 Cool, paralysed , insensate, numb……………. 3 Score doubled for ischemia > 6 hours

19. Shock Systolic BP always > 90 mm………….. Hypotensive transiently………… 1 Persistent hypotension..…… 2

20. Age (years) < 30………………………. 30-50 ……………… …… 1 > 50 ……………… ……. 2

21. Preliminary results of the Mangled Extremity Severity Score B oth the prospective and retrospective studies gave evidence that : MESS score of greater than or equal to 7 had a 100% predictable value for amputation

22. MESS validity Retrospective analysis : 26 trauma victims : - 17 limbs ultimately salvaged ( MESS score mean, 4.88 +/- 0.27) - 9 requiring amputation (MESS score mean, 9.11 +/- 0.51) (p less than 0.01). Prospective trial : - 14 salvaged (MESS score mean, 4.00 +/- 0.28) - 12 doomed (MESS score mean, 8.83 +/- 0.53) limbs (p less than 0.01). MESS may be useful in selecting trauma victims whose injured lower extremities warrant primary amputation. Other scoring systems like Limb Salvage Index and NISSA have been used.

23. Salvage procedures Wound care : Wash , debridement … Muscular tissue care : Excision or repair Orthopaedics care : DCO , Ex Fix Vascular surgery care : Repair or grafting Nerve damage care : Repair or grafting

24. Skin coverage surgery Aims : to cover bone & its fixation to cover bone ends at open joint to cover vascular suture or graft to cover nerve suture . Methods : suture , release incisions , split skin grafts, myofascial , myocutaneous flaps.

25. As a result of this In 1987, Hansen series : UP to 2 to 3 years hospital stay Up to 68 surgeries ( debridement , I F , grafting) Many patients lost their jobs, families, savings, and most importantly, their self-image and self-respect EVENTUALLY : Infection, nonunion, and delayed secondary amputation Salvage is not a guarantee of functionality LEAP (lower Extremity Assessment project funded by National Institiute of Health. Outcome: Limb Salvage vs Amputation Mckenzie et.al.

26. Chronicity and outcomes Skin : Ulcerations , raw areas , sinuses , dermatitis. Bone : nonunion , defects , graft failure , infection , osteoporosis . Vascular : chronic ischemia Nerve : lost sensation , painful neuroma Muscles : atrophy ,fibrosis , contracture Joints : deformity , pain ,degeneration& stiffness Secondary amputation

27. DANGER “ Saving Limbs and Ruining Lives ” Life may come back again after amputation and using prosthesis Amputation should not be considered a treatment failure but rather a means of meeting goals of treatment.

28. WHY AMPUTATION ACUTELY ! Amputated limb in the trauma scene Severed sciatic nerve unamenable for repair: - damaged long segment - proximal lesion Irreparable vascular injury Massive skin degloving or loss especially foot

29. If so it is essentially Care of Amputation Stump Wound : Contaminated tissue must undergo debridement & irrigation Fascio -cutaneous flaps fashioning Care of muscle Fashionable bandage Knee & ankle splinting

30. AMPUTATION IS INEVETABLE ( if left it will fall down ) - Non- Reconstructable Vascular Injury - Severe Bone and Soft Tissue Loss RELATIVE ( if left it may survive keeping its troubles ) - Shock and Elderly with Mangled Limb - Massive Muscle Loss associated with Bone Loss - MESS ≥ 7 - No Plantar Sensation Criteria for Amputation

31. Criteria of Good Amputation Stump Good muscle control Full range of related joints Good bone end ( beveled , no spur ) Healthy flaps ( equal , longer side , myoplasty ..)

32. Analysis of Outcomes: Meta-analysis on complex limb salvage or early amputation for severe lower-limb injury shows, No significant differences in functional outcome at least up to 7 years [ 1 ]. A recent meta-analysis evaluating the quality of life (measured with SF-36 and SIP) in post-traumatic amputees (769 patients) in comparison with limb salvage (369 patients) showed that, limb salvage in a mangled extremity yields better psychological outcomes compared to amputation even though the physical outcome was more or less the same [2]. 1. Evidence-Based Orthopaedic Trauma Working Group Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma 2007 2. A meta-analysis of amputation versus limb salvage in mangled lower limb injuries—the patient perspective. Injury. 2011

33. IF YOU ARE IN DOUBT CUT IT OUT or GIVE BENEFIT OF DOUBT ?

34. Common Scenario Doctor : “ I know that it Needs to Come Off, but, we ’ ll Just Keep the Limb on so that we can talk with the patient again, and let him Decide ” “ AT THE SAME TIME ” Patient : “ If it was really that Bad, Why Didn ’ t theyCut it Off initially ”

35. IN CONCLUSION Amputation VS Salvage is a difficult debate Limb salvage gives hope & morale, however the road to salvage is often prolonged Early amputation may shorten the patient’s morbidity associated with salvage Once amputation is decided, obtaining a good useful amputation stump should be the aim of the surgeon Various scoring systems, like MESS (mangled extremity scoring system) can be helpful. Patient counseling is important

36. Case Scenario

37. History 17 year old boy Road traffic accident  pedestrian hit by truck Rushed to A & E after 4 hours of the incident Mangled left upper limb Large gaping wound over left upper chest anteriorly involving the shoulder Open scapula and clavicle fracture, major muscle damage and severed axillary artery

38. Graft repair of Axillary artery Debridement of Non viable soft tissue K-wire temporary fixation of clavicle for support Immediate rush to intensive care for resuscitation and monitoring. Damage Control Procedure PLAN ??