Principles of Mangled Extremity Management

Pumsak Thamviriyarak,MD.Orthopaedics Department

Khonkaen Hospital

Mangled extremity◦ An injury to an extremity so severe that salvage is

often questionable and amputation is a possible outcome

High energy force◦ Degloved skin◦ Soft tissue disrupted◦ Extensive comminuted fracture

Motor vehicle accident

Introduction

Hippocrates (400BC)◦ Amputation◦ Very high mortality rate

Celsus (25 BC) ◦ wound management with removal of FB and

hemostasis Ambroise Pare (1540)

◦ Basic principles of amputation◦ Phantom pain◦ Stump revision

Historical Background

Pierre-Joseph Desault (1770) ◦ coined “debridement”

Incidence of post treatment osteomyelitis 80% WWI 1914 25% WW II 1939 (ATB / aseptic technique)

Korean War 1950 ◦ 62% amputation artery repair 13%

Nowaday◦ Multiple complex reconstruction technique◦ Development of ATB◦ Microsurgery

Historical Background

Initial Evaluation◦ ATLS principle◦ Evaluate perfusion of injured limb◦ ATB and Tetanus prophylaxis◦ Removed gross contamination◦ Reduction of Fracture and Joint+Splint

Check distal neurovascular before and after◦ Look for Compartment syndrome◦ Plain film: 2 orthogonal views

PRINCIPLES OF MANAGEMENT

Vascular Assessment◦ Hard signs

pulsatile bleeding rapidly expanding hematoma classic signs of obvious arterial occlusion

Pulselessness Pallor Paresthesia Pain Paralysis Poikilothermia

PRINCIPLES OF MANAGEMENT

Vascular Assessment◦ Soft signs

history of arterial bleeding nonexpanding hematoma a pulse deficit without ischemia neurological deficit originating in a nerve adjacent to

a named artery the proximity of a penetrating wound, fracture, or

dislocation near to a named artery

PRINCIPLES OF MANAGEMENT

Vascular Assessment◦ Limb deformities + decrease pulse : Reduction

and reevaluate◦ Arterial Pressure Indices(API)

<0.9 suspected vascular inj

PRINCIPLES OF MANAGEMENT

patient with a pulseless but perfused limb◦ Stable Fracture

Vascular repair before EF◦ Unstable Fracture

EF before vascular repair Ischemic limb

◦ Temporary intraluminal vascular shunting first◦ Debridement+EF◦ Vascular repair

Fasciotomy in all pts prevent compartment syndrome

PRINCIPLES OF MANAGEMENT

Placed Tourniquet but not inflate (Inflate when bloody field)-prevent further ischemic injury

irrigation and debridement -most important step

Zone of injuries◦ central zone of necrotic tissue-non viable tissue◦ zone of marginal stasis+/-viable tissue◦ the periphery zone of the injury

Operative Debridement

Extend open wound and remove all necrotic tissue in central zone

Serial debridement require(zone of marginal stasis)

Operative Debridement

Prevents ongoing soft tissue damage Promotes wound healing Thought to protect against infection Most managed with temporizing external

fixation◦ applied relatively quickly◦ without the use of fluoroscopy◦ providing excellent stability and alignment◦ allows for redisplacement of the fracture fragments

for a more thorough evaluation and débridement of the soft tissues during any repeat procedures

Skeletal Stabilization

thought to enhance oxygen delivery to injured tissues affected by vascular disruption – Improve wound healing

most beneficial in the peripheral zone of injury

Hyperbaric Oxygen

Principle◦ Type of Flap coverage

Local rotational flap : beware for flap necrosis from initial trauma(may be in zone of injury)

Free flap◦ Timing :controversial

>7d increase infection rate

Soft Tissue Coverage

Variables◦ Patient Variables◦ Extremities Variables◦ Associated Variables

Survivability : Amputation when severely injured extremity with an irreparable vascular

injury prolonged warm ischemia (longer than 6 hours) critically injured with significant hemodynamic instability

PATIENT ASSESSMENT AND DECISION MAKING

Plantar sensation◦ Before 1980, believed that absent plantar

sensation was a reason to amputate a limb Chronic complications

◦ Now , the study concluded that plantar sensation should not be included as a factor in the decision making for limb salvage in lower extremity trauma

PATIENT ASSESSMENT AND DECISION MAKING

To help decision making : amputate vs salvage

Many index◦ MESI◦ PSI◦ MESS◦ LSI◦ NISSSA

Limb Salvage Scores

Amputation threshold ≥7 Only prediction not indication Cautiously decision base on clinical

MESS

Functional outcome of the patients with foot injuries was significantly worse than that of the patients without foot injuries

amputation may indeed be a better long-term option

Foot and ankle injuries

Delayed bone healing◦ Delayed union◦ Nonunion

Infection◦ Osteomyelitis

Flap necrosis

Smoking

Outcomes

References

Imagination is more important than knowledge

Thank you