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12 rw principles of mangled extremity management

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12 rw principles of mangled extremity management

  1. 1. Pumsak Thamviriyarak,MD. Orthopaedics Department Khonkaen Hospital
  2. 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. 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. 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. 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
  6. 6.  Vascular Assessment ◦ Hard signs  pulsatile bleeding  rapidly expanding hematoma  classic signs of obvious arterial occlusion  Pulselessness  Pallor  Paresthesia  Pain  Paralysis  Poikilothermia
  7. 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
  8. 8.  Vascular Assessment ◦ Limb deformities + decrease pulse : Reduction and reevaluate ◦ Arterial Pressure Indices(API)  <0.9 suspected vascular inj
  9. 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. 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. 11.  Extend open wound and remove all necrotic tissue in central zone Serial debridement require(zone of marginal stasis)
  12. 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. 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. 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. 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. 16.  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
  17. 17.  To help decision making : amputate vs salvage Many index ◦ MESI ◦ PSI ◦ MESS ◦ LSI ◦ NISSSA
  18. 18.  Amputation threshold ≥7 Only prediction not indication Cautiously decision base on clinical
  19. 19.  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
  20. 20.  Delayed bone healing ◦ Delayed union ◦ Nonunion Infection ◦ Osteomyelitis Flap necrosis
  21. 21.  Imagination is more important than knowledge

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