Mangled extremity

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Management of mangled Extremities, MESS, Principles for Limb Salvage

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Mangled extremity

  1. 1. Department of Orthopaedics MH Kirkee SEMINAR MANGLED EXTREMITY Maj Rohit Vikas Resident
  2. 2. MANGLED EXTREMITY INTRODUCTION
  3. 3. COMPONENTS•Soft tissue loss•Fracture/bone loss•Vascular injury•Nerve injury
  4. 4. RESUSCITATIONPlace in context of ATLS protocolABCFluid and Blood ReplacementExaminationIV antibioticsTetanusGross debridement and wound washSterile dressingSplint limb
  5. 5. LIFE THREATENING COMPLICATIONSHYPOVOLEMIC SHOCKRHABDOMYOLYSISACUTE RENAL FAILURESIRSSEVERE SEPSISARDSMODSREPERFUSION INJURYARYHTHMIAS
  6. 6. ASSESSMENTSOFT TISSUEHow 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.)?VASCULARPalpable pulses? Asymmetry?Doppler pulses? Asymmetry? Wave form?Color, temperature of limbCompartmentsExpanding hematoma, pulsatile bleedingNEUROLOGICALSciatic --> Tibial + PeronealFemoral --> Saphenous
  7. 7. DECISION TO AMPUTATE1. Is the limb salvagable?2. If salvaged, will afunctional limb result?POTENTIAL SCENARIOSImmediate amputationAttempted salvage with early amputationSuccessful salvageUnsuccessful salvage with late amputation
  8. 8. MANGLED EXTREMITY SCORESHow we decide on salvage versus amputation? Predictive Salvage Index (PSI) Mangled Extremity Severity Score (MESS) Limb Salvage Index (LSI) Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age (NISSSA) Score Hannover Fracture Scale-97 (HFS-97) Trauma Scores: Do not correlate well with final limb function
  9. 9. MESS <= 6 – Limb salvageable
  10. 10. LIMB SALVAGE When to consider salvage?Anatomically intact sciatic/tibial nerveCan reconstruct vascular supply: proximal injury, warm ischemia < 6 hrsModerate soft tissue injury or lossModerate bone lossFunctional ankle, foot and kneeYounger patients
  11. 11. MANGLED EXTREMITY PRIMARY AMPUTATION
  12. 12. Amputation: Replantation Mangled and Crushed – Poor Candidate
  13. 13. DECISION TO AMPUTATEIndications for Primary Amputation in Lower Extremity Open Fractures*Absolute:a. complete disruption of the posterior tibial nerve in an adultb. crush injury with warm ischemia >6H or nonreparable vascular injuryRelative:a. life threatening polytrauma (ISS > 20)b. severe ipsilateral foot traumac. prolonged course to provide soft tissue and tibial reconstruction incompatiblewith personal,sociologic and economic consequences for the patient*civilian world
  14. 14. RISK FACTORS FOR AMPUTATIONGustilo III-C injuries � comminuted,Open tib-fib fractures with vascular disruption.Sciatic or tibial nerve, or two of the three major upper extremity nerves,anatomically transectedProlonged ischemia (>4-6 hours)/muscle necrosisCrush or destructive soft tissue injurySignificant wound contaminationMultiple/severely comminuted fractures/segmental bone lossOld age/severe co-morbidityLower vs. upper extremityApparent futility of revascularization/failed revascularization
  15. 15. HARD SIGNS OF VASCULAR INJURYActive hemorrhageLarge, expanding or pulsatile hematomaBruit or thrill over the wound(s)Absent palpable pulses distallyDistal ischemic manifestations(pain, pallor, paralysis, paresthesias, poikilothermy,or coolness)
  16. 16. PRINCIPLES OF AMPUTATIONPrinciples:o Unless amputation is in a damage control situation (“guillotine”), the goal is a functionalextremity with a residual limb that successfully interacts with the patient’s futureprosthetic mgt.oStaged amputation - In a patient not been adequately resuscitated, or with significantContamination/ infection, blast or crush mechanism, may improve functional results bypreserving length.o Incisions through soft tissue and bone are at right angles to the longitudinal axisof limb with few exceptions. Do not bevel the incision as this may create ischemic flaps.o The periosteum is reflected proximal to skin incisions, and bones are transectedwhere the periosteum is adherent to the bone to decrease the chance for an avascularsequestrum. Bone edges are filed after transection.o Suture ligatures are preferred to electrocautery for control of transected vessels.
  17. 17. PRINCIPLES OF AMPUTATIONPrinciples:o Risk of postoperative neuroma is minimized with simple sharp transection of nerveswhile maintaining distal traction. Judicious use of sutures to control bleeding andminimizing the use of clamps also decrease neuroma formation.o Multilayered closure of the incisions to ensure soft tissue coverage of bones is essential.Drains are recommended for larger amputations.o Skin grafts should be used to preserve limb length and joints as long as adequate musclecoverage is present to cover bone.o Extremities are splinted to prevent contractures during healing and range of motionexercises instituted early
  18. 18. IRRIGATION DEBRIDEMENTWith the exception of tendon and nerve, if it does not bleed it is dead.If it is dead, get rid of it.If you cannot get rid of it, think amputation.Serial debridements and washouts are desirableAssess viability in OT – Color/ contractility/ bleedingDebridement AmputationWhen life over limb is the issue or in certain extremity injuries where there is nomeans of limb salvage
  19. 19. guillotine-style transfemoral amputation
  20. 20. myodesis to the anteriordistalaspect of the tibia
  21. 21. myodesis to the anteriordistalaspect of the tibia
  22. 22. a sciatic nerve that had been included in theamputation myoplasty.The resulting neuroma was symptomatic andprecluded prosthetic wear and walking
  23. 23. MANGLED EXTREMITY LIMB SALVAGE
  24. 24. DEBRIDEMENTWith the exception of tendon and nerve,if it does not bleed it is dead.If it is dead, get rid of it.If you cannot get rid of it, thinkamputation.Serial debridements and washouts aredesirableAssess viability in OT – Color/contractility/ bleeding
  25. 25. INVESTIGATIONSDOPPLER No signal = no perfusion Signal ≠ normal arteries
  26. 26. FASCIOTOMY
  27. 27. DAMAGE CONTROLHemodynamic instability,Coagulopathy,Acidosis,Hypothermia of the patientUnstable skeletonMajor wound contamination/infection or soft tissue deficits precluding woundcoverageRequirement for any definitive repair more complex than lateral suture or endto end anastomosis (i.e. extra-anatomic bypass, interposition graft)Austere environment with no resources for definitive managementOther life threatening injuries requiring urgent management
  28. 28. DEFINITIVE REPAIRDefinitive repair should be performed provided: Hemodynamic and physiologic stability of patient Stable skeleton Clean wound with adequate viable soft tissue Availability of necessary time and resources No other injuries requiring more urgent management
  29. 29. VASCULAR SHUNTS Angiography In theatre Diagnostic Therapeutic Covered stent Embolisation Open exploration Repair Bypass
  30. 30. SKELETAL STABILIZATIONUniplanar fixatorCircular fixatorDelayed ORIF
  31. 31. EXCLUDE ANY CLINICALLY SIGNIFICANT VASCULAR INJURY
  32. 32. WOUND MANAGEMENTTIMING FOR WOUND CLOSUREALL MAJOR STUDIES HAVE SHOWN EARLY FLAP CLOSURE WITHIN 7 DAYS LEADS TOLOWEST COMPLICATION RATESBOTTOM LINE: IF YOU ARE INVOLVED IN MANGLED EXTREMITY CARE ACOMMITMENT MUST BE MADE TO ACHIEVE COVERAGE WITHIN A WEEK WITHHEALTHY VASCULARIZED TISSUEVAC USE DOES NOT CHANGE THIS DICTUM Soft Tissue Coverage Primary closure Skin grafts Local or free flaps
  33. 33. NERVE INJURYNerve Injury Nerve repair Tendon transfers Bracing/aids
  34. 34. TISSUE ENGINEERINGIssues that can be addressed with tissue engineeringMissing or injured nerveNeuromas in-continuityMissing bone, enhanced bone healingWound vascularityDelayed wound healing
  35. 35. TISSUE ENGINEERINGTISSUE ENGINEERING CONSIDERATIONSBioabsorbable nerve guides supplemented by growth factorsBone matrix to replace need for microsurgical transplantationAngiogenic factorsAcellular tissue matrix to enhance wound healing
  36. 36. MANGLED EXTREMITYSECONDARY AMPUTATION
  37. 37. SECONDARY AMPUTATION“Life over Limb” Metabolic burden Reassess, reassess, reassess Continuous dialogue w/ patient and family Septic source (esp. osteo) Use Psych, pastoral care, clergy Extensive tissue necrosis/ skin loss Assess home environmental & personal factors Associated MODS 2nd Opinion – Ortho, Plastics, Vascular, Neuro, Rehab, Intensivist Profound neurologic impairment Earlier the better Extensive functional impairment
  38. 38. MANGLED EXTREMITY CLINICAL EXAMPLES
  39. 39. Rectus abdominus flapWith skin mesh over the flap
  40. 40. MANAGEMENT OF AMPUTEE• Preparation PROSTHETICS• Good Surgical Technique• Rehabilitation • Passive• Early Prosthetic Fitting – Cosmetic• Team Approach • Body Powered• Vocational and Activity – Harnesses and cables Rehabilitation • Myoelectric – Surface EMG – Activation delay • Neuroprosthetics – Investigational
  41. 41. MANGLED EXTREMITY CONCLUSION
  42. 42. 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
  43. 43. World record for the 100m sprint - 9.58 sec
  44. 44. World Record for 100m sprint for an amputee - 10.91 sec Oscar Pistorius
  45. 45. Record for a limb salvage patient?

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