This document discusses the management of mangled extremity injuries. It covers the initial evaluation, assessment of vascular injury, principles of debridement and wound management, considerations for flap coverage vs amputation, and factors that influence functional outcomes. Scoring systems can help guide the decision between amputation and limb salvage, though the final decision requires clinical judgment based on each patient's situation. Complications like infection, non-union, and flap necrosis may still occur despite salvage attempts.
2. 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
3. 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
4. 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
5. 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
7. 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
9. 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
10. 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
11. Extend open wound and remove all necrotic
tissue in central zone
Serial debridement require(zone of marginal
stasis)
12. 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
13. thought to enhance oxygen delivery to
injured tissues affected by vascular disruption
– Improve wound healing
most beneficial in the peripheral zone of
injury
14. 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
15. 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
16.
17. 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
18. To help decision making : amputate vs
salvage
Many index
◦ MESI
◦ PSI
◦ MESS
◦ LSI
◦ NISSSA
19.
20. Amputation threshold ≥7
Only prediction not indication
Cautiously decision base on clinical
21. 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
22. Delayed bone healing
◦ Delayed union
◦ Nonunion
Infection
◦ Osteomyelitis
Flap necrosis
23.
24.
25.
26.
27. Imagination is more
important than
knowledge
Editor's Notes
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