Mangled extremity and its Management

mangled extremity

1. Mangled Extremity and its Management PRESENTED BY DR. SIDDHARTHA NARU PGT ,MEDICAL COLLEGE DEPT. OF ORTHOPEDICS

2. I ntroduction “Mangled extremity” refers to an injury to an extremity so severe that salvage is often questionable and amputation is a possible outcome. This injury is always a result of high-energy trauma caused by some combination of crush, shear, blast, and bending forces. Component: Soft tissue loss Fracture/bone loss Vascular injury Nerve injury

3. Characteristic features The skin – often degloved with large areas of loss The fascial compartments - incompletely opened by explosion or tear. Muscle tissues - damaged at both local and regional levels by direct as well as indirect injury. Soft tissue planes - extensively disrupted and contaminants infiltrate all of these planes Associated fractures - exhibiting extensive comminution patterns

4. C auses Motor vehicle accident Fall from height Farm/industrial injury Close range shotgun wound Crush injury Explotion injury

5. Life threatening complications Hypovolemic shock Rhabdomyolysis Acute renal failure SIRS MODS Severe sepsis ARDS Arrhythmia Reperfusion injury

6. Initial Evaluation Routine trauma protocols (ATLS) should be followed. Once the patient has been stabilized and the primary and secondary trauma surveys have been completed, a thorough orthopaedic evaluation is mandatory. This should include a -determination of the time and mechanism of injury -presence of any medical comorbidities -a detailed vascular and neurological examination -presence of an associated compartment syndrome -photographs of the extremity -radiographic evaluation

7. Vascular Assessment Arterial injuries usually present with either hard or soft signs suggestive of injury. Hard signs - pulsatile bleeding, presence of a rapidly expanding hematoma, a palpable thrill, or audible bruit, presence of any of the classic signs of obvious arterial occlusion ( pulselessness , pallor, paresthesia , pain, paralysis, poikilothermia )

8. Soft signs – history of arterial bleeding, a nonexpanding hematoma, a pulse deficit without ischemia, a neurological deficit originating in a nerve adjacent to a named artery and the proximity of a penetrating wound, fracture or dislocation near to a named artery The skin color and capillary refilling time of the distal extremity Arterial pressure indices (APIs)-if the API < 0.90 or distal pulses remain absent despite reduction, angiography and/or vascular surgery consultation is indicated.

9. Decision-Making Protocols and Limb Salvage Scores Limb Salvage Decision-Making Variables Patient Variables Age Underlying chronic diseases (e.g., diabetes) Associated Variables Occupational considerations Magnitude of associated injury (Injury Severity Score) Patient and family desires Severity and duration of shock Extremity Variables Warm ischemia time Mechanism of injury (soft tissue injury kinetics) Fracture pattern Arterial/venous injury (location) Neurological (anatomic status) Injury status of ipsilateral foot Intercalary ischemic zone after revascularization

10. Index Domains MESS NISSSA/HFS PSI LSI Ischemia Nerve injury Ischemia Ischemia Bone/tissue Ischemia Bone Bone Shock Soft tissue injury Muscle Muscle Age Skeletal injury Timing Skin Shock Nerve Age Vein

11. Mangled Extremity Syndrome Index(MESI).. Gregory et al . Criterion Score Injury Severity Score <25 1 25-50 2 >50 3 Integument injury Guillotine 1 Crush/burn 2 Avulsion/ degloving 3 Nerve injury Contusion 1 Transection 2 Avulsion 3

12. Bone injury Simple 1 Segmental 2 Segmental comminuted 3 Bone loss <6 cm 4 Articular 5 Articular with bone loss <6 cm 6 Lag time to operation One point is given for each hour over 6 hours … Age (yr) <40 40-50 1 50-60 2 >60 3 Preexisting disease 1 Shock 2 MESSI score >20 amputation

13. Predictive Salvage Index System (PSI) Criterion Score Level of arterial injury Suprapoliteal 1 Popliteal 2 Infrapopliteal 3 Degree of bone injury Mild 1 Moderate 2 Severe 3 Degree of muscle injury Mild 1 Moderate 2 Severe 3 Interval from injury to operating room <6 hr 6-12 hr 2 >12 hr 4 PSI score 8 0r more amputation

14. Mangled Extremity Severity Scoring System(MESS ).. Johansen et al.and Helfet et al Criterion Score Skeletal/soft tissue injury Low energy 1 Medium energy 2 High energy 3 Very high energy 4 Limb ischemia Pulse reduced or absent but normal perfusion 1 * Pulseless, diminished capillary refill 2 * Cool, paralyzed, insensate, numb 3 * * Double value if duration of ischemia exceeds 6 hours

15. Shock SBP always >90 mm Hg SBP transiently <90 mm Hg 1 SBP persistently <90 mm Hg 2 Age ( years) <30 30-50 1 >50 2 In both the prospective and retrospective studies, all salvaged limbs had had scores of 6 or lower and an MESS score of 7 or greater had a 100% positive predictive value for amputation.

16. Limb Salvage Index (LSI)… Russel et al Criterion Score Arterial injury Contusion, intimal tear, partial laceration Occlusion of 2 or more shank vessels, no pedal pulses 1 Occlusion of femoral, popliteal, or three shank vessels 2 Nerve injury Contusion, stretch, minimal clean laceration Partial transection or avulsion of sciatic nerve 1 Complete transection or avulsion of sciatic nerve 2

17. Bone injury Closed fracture or open fracture with minimal comminution Open fracture with comminution or large displacement 1 Bone loss >3 cm; type IIIB or IIIC fracture 2 Skin injury Clean laceration, primary repair, first-degree burn Contamination, avulsion requiring split-thickness skin graft or flap 1 Muscle injury Laceration involving single compartment or tendon Laceration or avulsion of 2 or more tendons 1

18. Deep vein injury Contusion, partial laceration or avulsion Complete laceration or avulsion, or thrombosis 1 Warm ischemia time (hr) <6 6-9 1 9-12 2 12-15 3 >15 4 LSI score of 6 or greater amputation

19. NISSSA Scoring System.. McNamara et al Criterion Score Nerve injury Sensate Loss of dorsal sensation 1 Partial plantar sensation 2 Complete loss of plantar sensation 3 Ischemia None Mild 1 * Moderate 2 * Severe 3 * Soft tissue injury/contamination Low Medium 1 High 2 Severe 3

20. Skeletal injury Low energy Medium energy 1 High energy 2 Very high energy 3 Blood pressure Normotensive Transient hypotension 1 Persistent hypotension 2 Age (yr) <30 30-50 1 >50 2 * Double value if duration of ischemia exceeds 6 hours.

21. Drawback of scoring systems No scoring system is predictive of salvage or amputation. Lower scores has specificity for limb salvage potential, but the low sensitivity of these scoring systems did not validate them as predictors of amputation. Scoring systems are used for documentation and as guides in clinical decision-making, not as absolute indicators for salvage or amputation. Scoring system is not able to predict functional outcome. Injury severity score can not predict functional outcome in patients who underwent limb salvage .

22. Potential scenarios in mangled limb Immediate amputation Successful salvage Attempted salvage with early amputation Unsuccessful salvage with late amputation

23. Limb salvage when to consider Young patients Anatomically intact sciatic /tibial nerve Moderate soft tissue loss/injury Moderate bone loss Can reconstruct vascular supply :proximal injury ,warm ischemia<6hrs Functional ankle ,foot

24. Limb salvage procedure- Operative Debridement In the operating room, “irrigation and débridement ,” the first and most important step. The skin wounds have been extended. All necrotic muscle, fat, fascia, skin, and other nonviable tissue within the central zone of injury should be removed. Muscle should be tested for viability based on its contractility, consistency, color, and capillary bleeding (the four c’s), and if nonviable, it should be debrided, regardless of the expected functional loss. Serial débridements will be required until removal of all nonviable tissue achieved.

25. Skeletal Stabilization Stabilization options – splint immobilization, skeletal traction, External fixation, internal fixation Most limb-threatening injuries present as Gustilo type IIIB or IIIC open fractures and managed with temporizing external fixation.

26. Vascular injury Angiography Once the location of an arterial injury has been identified, attempts at vascular repair. Patient with prolonged ischemia, restoration of arterial inflow should be the highest priority with temporary intraluminal vascular shunting. rapidly restore arterial inflow allow for a more detailed examination to better determine the extent of the injury and whether the limb is indeed salvageable. allow for a more thorough débridement and appropriate stabilization of the bone and soft tissues.

27. V ascular repair can then either proceed immediately or in a delayed fashion if the patient remains in extremis . Fasciotomies should be performed after any revascularization procedure in the mangled extremity .

28. Soft Tissue Coverage Options for coverage- skin grafts, local flaps, or free flaps. Early reconstruction (within 72 hours) -reduces postoperative infection, flap failure, and nonunion rates, development of osteomyelitis. Many authors recommended muscle flap coverage on a more delayed basis (7 to 14 days). Negative pressure wound therapy (NPWT) -very effective tool in the initial soft tissue management of high energy open fractures. Use of NPWT before definitive soft tissue reconstruction had significantly decreased infection rates.

29. Nerve injury Nerve repair Tendon transfer Bracing/aids

30. Hyperbaric Oxygen HBO enhance oxygen delivery to injured tissues affected by vascular disruption, thrombosis, cytogenic and vasogenic edema, and cellular hypoxia as a result of trauma to the extremity. patients breathe 100% oxygen in a chamber under increased barometric pressure supraphysiological arterial oxygen saturation level expanded diffusion for oxygen into tissues increased oxygen delivery at the periphery of wounds.

31. Decision to amputation Indication to primary amputation l0wer limb open # Absolute : a)Complete disruption of post.tibial nerve b)Crush injury with warm ischemia >6hrs,nonrepairable vascular injury Relative : a)Life threatening poly trauma (ISS>20) b)Severe ipsilateral foot trauma c)Prolonged course to provide soft tissue and tibial reconstruction incompatible with personal ,social, and economic consequences of the patient.

32. Risk factors for amputation Gustilo Type IIIC injuries Sciatic/ tibial nerve or two of the three major upper extremity nerves anatomically transected Prolonged ischaemia time/muscle necrosis Crush injury,significant wound contamination Multiple/severely comminuted fractures/segmental bone loss Old age/sever co-morbidity Failed revascularisation

33. Principles of amputation Unless amputation in a damage control situation(guillotine),goal is a functional extremity with residual limb that successfully interacts with patient’s future prosthetic management. Staged amputation-in a patient not adequately resuscitated ,or with significant contamination/ infection,blast or crush mechanism,may improve functional results by preserving length. Incision through soft tissue and bone are at right angle to long axis of the limb Periosteum is reflected proximal to skin incision and bones are transected where periosteum is adherent to bone Suture ligation are preferred to electrocautery for control of transected .

34. Periosteum is reflected proximal to skin incision,and bones are transected where periosteum is adherent to bone Suture ligation are preferred to electrocautery for control of transected . Risk of postoperative neuroma is minimized with simple sharp transection of nerve while maintaining distal traction. Multilayered closure of the incision to ensure soft tissue coverage of bones is essential.drain is recommended. Extremity is spinted and range of motion excerises instituted early

35. Level of transfemoral amputations Level of transtibial amputations

36. Amputation In children Attempts should generally be made to preserve all extremities, even with type IIIC open fractures. Preservation of limb length and physis are important in young children. Mangled extremity severity score (MESS) correlates well with the need for amputation in adults, the correlation is less in children. Bony overgrowth after amputation can be a significant problem, especially due to the need for children to obtain multiple prostheses as they grow .

37. Disarticulate when possible. Disarticulation completely eliminates the problem of terminal overgrowth and subsequent revision surgery. Preserve stump shape- The pediatric amputation stump becomes conical with growth, so preservation of bony architecture such as a short segment of proximal fibula or the distal condyles of the humerus will assist in subsequent rotational control of the prosthesis. The split-thickness skin graft can hypertrophy and become sufficiently strong to withstand the shear forces of prosthesis use .

38. The mangled upper extremity Critical time for reperfusion is longer in the upper (8–10 h) versus the lower extremity (6 h ). A transtibial amputation carries a much better functional prognosis than a transradial amputation . Shortening of the humerus to reduce soft-tissue defects is tolerated well up to 5 cm. Nerve reconstruction in the upper extremity done with reasonable success, whereas major nerve injury is an indication for primary amputation in the lower extremity . The rehabilitation process - more imperative.

39. Limb salvage versus Amputation In limb salvage procedure- Important issues include patient's ability to handle uncertainty, deal with prolonged immobilization, accept social isolation, bear the financial burden, worst-case scenario occurs when a limb must be amputated after the patient has endured multiple operations of an unsuccessful salvage or after years of pain following a “successful” salvage

40. Early amputation and prosthetic fitting associated with decreased morbidity, fewer operations, a shorter hospital course, decreased hospital costs, shorter rehabilitation, earlier return to work. treatment course and outcome are more predictable, Modern prosthetics often provide better function than many “successfully” salvaged limbs.

41. SUMMARY The decision to amputate or salvage a severely injured Extremity is a difficult one. The decision to reconstruct or amputate an extremity cannot depend on limb salvage scores. Results of limb reconstruction are equal to those of amputation following severe lower extremity trauma. The “correct” decisions are based on the patient as a whole, not solely on the extent of the limb injury . Patient with a mangled extremity should be directed to an experienced limb injury center, where strategies to minimize complications, address related posttraumatic stress disorder, improve the patient's self-efficacy, and target early vocational retraining may improve the long-term outcomes.

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