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.

1. Pumsak Thamviriyarak,MD.
Orthopaedics Department
Khonkaen Hospital

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

6.  Vascular Assessment
◦ Hard signs
 pulsatile bleeding
 rapidly expanding hematoma
 classic signs of obvious arterial occlusion
 Pulselessness
 Pallor
 Paresthesia
 Pain
 Paralysis
 Poikilothermia

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.  Vascular Assessment
◦ Limb deformities + decrease pulse : Reduction and
reevaluate
◦ Arterial Pressure Indices(API)
 <0.9 suspected vascular inj

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

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

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

27.  Imagination is more
important than
knowledge