The document discusses mangled extremity injuries, which involve severe soft tissue, bone, vascular and nerve injuries to an extremity. It describes various scoring systems used to evaluate factors like ischemia time, bone/soft tissue damage, and patient characteristics to determine likelihood of successful limb salvage versus requiring amputation. The initial management of a mangled extremity involves stabilization, debridement of non-viable tissue, and restoration of vascular flow. Further treatments may include skeletal stabilization, soft tissue coverage using flaps/grafts, nerve repair, and hyperbaric oxygen to aid healing. Scoring systems guide but do not determine the decision between salvage and amputation.
Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity". Damage Control Orthopaedics (DCO) is a relatively recent concept in orthopaedic practice it means early rapid containment & stabilization of orthopedic injuries without worsening the patient general condition. It is indicated in critically ill polytrauma patient, unfavorable surgical environment, battlefield limb injuries & mass casualties.
Limb Complex Multi system Injury (Mangled Extremity) is one of the most challenging problems in Orthopaedic surgery. Mangled Extremity is a limb with an injury to at least three out of four systems (soft tissue, bone, nerves, and vessels). Decision have to be made either amputation + Prosthesis or limb salvage procedure. The decision of Primary Amputation in the acute setting is difficult for the patient, family, & the treating surgical team. The majority of mangled extremities are potentially salvageable for which, in the acute setting, a treatment plan needs to be made.
POLYTRAUMA AND DAMAGE CONTROL ORTHOPAEDICSDr Slayer
polytrauma is Injury to 2 or more organ systems leading potentially to a life threatening condition
Damage control orthopaedics is an approach to contain and stabilize an orthopaedic injury to improve patient’s physiology which are designed to avoid worsening pt’s condition due to “second hit” phenomenon
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
Vascular Injuries and Principles of ManagementVascular Surgery Workshop 2018
Joel Arudchelvam,MBBS (Col), MD (Sur), MRCS (Eng),Consultant Vascular and Transplant Surgeon Teaching Hospital Anuradhapura.
Causes, Mechanism of injury, Arterial Level injuries, Signs of vessel injury -Hard signs,Soft sign, Principles of management
Surgical Approaches to Acetabulum and PelvisBijay Mehta
Important surgical approaches to acetabulum and pelvis are described.
Ilioinguinal approach, Modified Stoppa Approach, Kocher lagenbeck Approach, Ilifemoral approach and extensile approaches are well illustrated and described.
Damage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity". Damage Control Orthopaedics (DCO) is a relatively recent concept in orthopaedic practice it means early rapid containment & stabilization of orthopedic injuries without worsening the patient general condition. It is indicated in critically ill polytrauma patient, unfavorable surgical environment, battlefield limb injuries & mass casualties.
Limb Complex Multi system Injury (Mangled Extremity) is one of the most challenging problems in Orthopaedic surgery. Mangled Extremity is a limb with an injury to at least three out of four systems (soft tissue, bone, nerves, and vessels). Decision have to be made either amputation + Prosthesis or limb salvage procedure. The decision of Primary Amputation in the acute setting is difficult for the patient, family, & the treating surgical team. The majority of mangled extremities are potentially salvageable for which, in the acute setting, a treatment plan needs to be made.
POLYTRAUMA AND DAMAGE CONTROL ORTHOPAEDICSDr Slayer
polytrauma is Injury to 2 or more organ systems leading potentially to a life threatening condition
Damage control orthopaedics is an approach to contain and stabilize an orthopaedic injury to improve patient’s physiology which are designed to avoid worsening pt’s condition due to “second hit” phenomenon
Hoffa's Fracture: Diagnosis, management & New Classification System by BAGARI...Vaibhav Bagaria
Hoffa's Fracture - coronal split fracture of distal femur, its diagnosis, management strategy, a new classification and tips and tricks of management. First described Hoffa, a new classification system by Bagaria et al helps plan the surgery for these tricky fracture. The most crucial step is not to miss these fractures in ER.
Vascular Injuries and Principles of ManagementVascular Surgery Workshop 2018
Joel Arudchelvam,MBBS (Col), MD (Sur), MRCS (Eng),Consultant Vascular and Transplant Surgeon Teaching Hospital Anuradhapura.
Causes, Mechanism of injury, Arterial Level injuries, Signs of vessel injury -Hard signs,Soft sign, Principles of management
Surgical Approaches to Acetabulum and PelvisBijay Mehta
Important surgical approaches to acetabulum and pelvis are described.
Ilioinguinal approach, Modified Stoppa Approach, Kocher lagenbeck Approach, Ilifemoral approach and extensile approaches are well illustrated and described.
Pinned in a car for two hours, trapped in a building collapse for 12, fallen on the floor for 24. Each of these patients may be experiencing different, but deadly aspects of crush injury, compartment syndrome, and rhabdomyolysis. Why are some victims okay under pressure, but die suddenly when rescued and what, if anything, can EMS do about it? Real-world case-studies bring this presentation to life as it answers these questions and more by bringing you evidence based best practices, protocols and resources that you can use to treat these high-pressure and high-profile patients.
For More Information See:
www.RomDuck.com
www.RescueDigest.com
Learning Objectives: Students will be able to:
- Identify crush injury, compartment syndrome and injuries consistent with rhabdo-myolysis.
- Utilize model pre-hospital protocols for advanced care for crush injury, compart-ment syndrome and rhabdomyolysis patients.
- Integrate with trauma systems of care to provide crush injury, compartment syn-drome and rhabdomyolysis patients with the best chance of outcome.
Spine and extremity injuries are common among people of all ages and can have a significant impact on mobility and quality of life. This PowerPoint presentation provides a comprehensive overview of spine and extremity injuries, including the causes, symptoms, and treatment options.
Through powerful images and personal stories, we showcase the impact of spine and extremity injuries on individuals, families, and communities. We highlight the challenges of accessing healthcare and rehabilitation services, particularly in low-resource settings, and the importance of early intervention and treatment.
The presentation provides detailed information about the various types of spine and extremity injuries, including fractures, dislocations, and soft tissue injuries. We also discuss the diagnostic procedures, including imaging tests and physical exams, and the treatment options, such as surgery, physical therapy, and pain management.
In addition, we explore the efforts being made to prevent and manage spine and extremity injuries. We highlight the importance of safety precautions, such as proper equipment use and ergonomic work practices, and the role of rehabilitation services in promoting recovery and restoring function.
Through this PowerPoint presentation, we aim to raise awareness about spine and extremity injuries and the importance of early diagnosis and treatment. We showcase the latest research and innovations in injury prevention and treatment, and the importance of collaboration and partnership to address the disease.
We urge the audience to take action in the fight against spine and extremity injuries, whether it be through spreading awareness, supporting organizations working on the ground, or advocating for policy change. Let us come together to create a world where everyone has access to the care and support they need to recover from spine and extremity injuries and live healthy, fulfilling lives.
Successful management of Polytrauma must achieve the following goals, 1- Keep someone alive that would be dead without you 2- Prioritize treatment to prevent killing someone 3- Treat extremity injuries to return the patient to a functional life. The Priorities are 1- Life threatening, 2- Limb threatening, 3- Function threatening. The question about the best strategy in the management Polytrauma and the choice between an Early Total Care (ETC) vs. Damage Control Orthopedics (DCO) will be answered in this presentation.
AMPUTATION:
“Surgical removal of limb or part of the limb through a bone or multiple bones”
DISARTICULATION:
“Surgical removal of hole limb or part of the limb through a joint”
MIROS (Minimally Invasive Reduction and Osteosynthesis System®)CHAUDHARY ARPAN
MIROS (Minimally Invasive Reduction and Osteosynthesis System
MIROS consists of four 2.5 mm thick and 50 cm long stainless steel or titanium wires the end
of which is introduced into a metallic clip.
Assumed that the MIROS might provide greater fracture stability and less complications
with respect to traditional percutaneous pinning (TPP).
Similar to Mangled extremity and its Management (20)
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
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Hot Selling Organic intermediates
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
2. Introduction
“Mangled extremity” refers to an injury to an extremity so
severe that salvage is often questionable and amputation is a
possible outcome.
This injury is always a result of high-energy trauma caused by
some combination of crush, shear, blast, and bending forces.
Component:
1. Soft tissue loss
2. Fracture/bone loss
3. Vascular injury
4. Nerve injury
3.
4. Characteristic features
The skin – often degloved with large areas of loss
The fascial compartments - incompletely opened by
explosion or tear.
Muscle tissues - damaged at both local and regional levels by
direct as well as indirect injury.
Soft tissue planes - extensively disrupted and contaminants
infiltrate all of these planes
Associated fractures - exhibiting extensive comminution
patterns
5. Causes
Motor vehicle accident
Fall from height
Farm/industrial injury
Close range shotgun wound
Crush injury
Explotion injury
7. Initial Evaluation
Routine trauma protocols (ATLS) should be followed.
Once the patient has been stabilized and the primary and
secondary trauma surveys have been completed, a thorough
orthopaedic evaluation is mandatory.
This should include a
-determination of the time and mechanism of injury
-presence of any medical comorbidities
-a detailed vascular and neurological examination
-presence of an associated compartment syndrome
-photographs of the extremity
-radiographic evaluation
8. Vascular Assessment
Arterial injuries usually present with either hard or soft signs
suggestive of injury.
Hard signs-
i. pulsatile bleeding,
ii. presence of a rapidly expanding hematoma,
iii. a palpable thrill, or audible bruit,
iv. presence of any of the classic signs of obvious arterial
occlusion (pulselessness, pallor, paresthesia, pain,
paralysis, poikilothermia )
9. Soft signs –
i. history of arterial bleeding,
ii. a nonexpanding hematoma,
iii. a pulse deficit without ischemia,
iv. a neurological deficit originating in a nerve adjacent to a
named artery and the proximity of a penetrating wound,
fracture or dislocation near to a named artery
The skin color and capillary refilling time of the distal
extremity
Arterial pressure indices (APIs)-if the API < 0.90 or distal
pulses remain absent despite reduction, angiography and/or
vascular surgery consultation is indicated.
10. Decision-Making Protocols and Limb
Salvage Scores
Limb Salvage Decision-Making Variables
Patient Variables
Age
Underlying chronic diseases (e.g., diabetes) Associated Variables
Occupational considerations
Magnitude of associated injury (Injury
Severity Score)
Patient and family desires Severity and duration of shock
Extremity Variables Warm ischemia time
Mechanism of injury (soft tissue injury
kinetics)
Fracture pattern
Arterial/venous injury (location)
Neurological (anatomic status)
Injury status of ipsilateral foot
Intercalary ischemic zone after
revascularization
11. Index Domains
MESS NISSSA/HFS PSI LSI
Ischemia Nerve injury Ischemia Ischemia
Bone/tissue Ischemia Bone Bone
Shock Soft tissue injury Muscle Muscle
Age Skeletal injury Timing Skin
Shock Nerve
Age Vein
13. Bone injury
Simple 1
Segmental 2
Segmental comminuted 3
Bone loss <6 cm 4
Articular 5
Articular with bone loss <6 cm 6
Lag time to operation
One point is given for each hour over
6 hours …
Age (yr)
<40 0
40-50 1
50-60 2
>60 3
Preexisting disease 1
Shock 2
MESSI score >20 amputation
14. Predictive Salvage Index System (PSI)
Criterion Score
Level of arterial injury
Suprapoliteal 1
Popliteal 2
Infrapopliteal 3
Degree of bone injury
Mild 1
Moderate 2
Severe 3
Degree of muscle injury
Mild 1
Moderate 2
Severe 3
Interval from injury to operating room
<6 hr 0
6-12 hr 2
>12 hr 4
15. Mangled Extremity Severity Scoring System(MESS)..
Johansen et al.and Helfet et al
Criterion Score
Skeletal/soft tissue injury
Low energy 1
Medium energy 2
High energy 3
Very high energy 4
Limb ischemia
Pulse reduced or absent but
normal perfusion 1*
Pulseless, diminished capillary
refill 2*
Cool, paralyzed, insensate,
numb 3*
*Double value if duration of ischemia exceeds 6 hours
16. Shock
SBP always >90 mm Hg 0
SBP transiently <90 mm Hg 1
SBP persistently <90 mm Hg 2
Age (years)
<30 0
30-50 1
>50 2
In both the prospective and retrospective studies, all salvaged limbs had had scores of 6 or
lower and an MESS score of 7 or greater had a 100% positive predictive value for
amputation.
17. Limb Salvage Index (LSI)…Russel et al
Criterion Score
Arterial injury
Contusion, intimal tear, partial
laceration
0
Occlusion of 2 or more shank
vessels, no pedal pulses
1
Occlusion of femoral,
popliteal, or three shank
vessels
2
Nerve injury
Contusion, stretch, minimal
clean laceration
0
Partial transection or avulsion
of sciatic nerve
1
Complete transection or
avulsion of sciatic nerve
2
18. Bone injury
Closed fracture or open
fracture with minimal
comminution
0
Open fracture with
comminution or large
displacement
1
Bone loss >3 cm; type IIIB or
IIIC fracture
2
Skin injury
Clean laceration, primary
repair, first-degree burn
0
Contamination, avulsion
requiring split-thickness skin
graft or flap
1
Muscle injury
Laceration involving single
compartment or tendon
0
Laceration or avulsion of 2 or
more tendons
1
19. Deep vein injury
Contusion, partial laceration
or avulsion
0
Complete laceration or
avulsion, or thrombosis
1
Warm ischemia time (hr)
<6 0
6-9 1
9-12 2
12-15 3
>15 4
LSI score of 6 or greater amputation
20. NISSSA Scoring System.. McNamara et al
Criterion Score
Nerve injury
Sensate 0
Loss of dorsal sensation 1
Partial plantar sensation 2
Complete loss of plantar
sensation 3
Ischemia
None 0
Mild 1*
Moderate 2*
Severe 3*
Soft tissue injury/contamination
Low 0
Medium 1
High 2
Severe 3
21. Skeletal injury
Low energy 0
Medium energy 1
High energy 2
Very high energy 3
Blood pressure
Normotensive 0
Transient hypotension 1
Persistent hypotension 2
Age (yr)
<30 0
30-50 1
>50 2
* Double value if duration of ischemia exceeds 6 hours.
22. Drawback of scoring systems
No scoring system is predictive of salvage or amputation.
Lower scores has specificity for limb salvage potential, but
the low sensitivity of these scoring systems did not validate
them as predictors of amputation.
Scoring systems are used for documentation and as guides in
clinical decision-making, not as absolute indicators for
salvage or amputation.
Scoring system is not able to predict functional outcome.
Injury severity score can not predict functional outcome in
patients who underwent limb salvage.
23. Potential scenarios in mangled limb
Immediate amputation
Successful salvage
Attempted salvage with early amputation
Unsuccessful salvage with late amputation
24. Limb salvage
when to consider
Young patients
Anatomically intact sciatic /tibial nerve
Moderate soft tissue loss/injury
Moderate bone loss
Can reconstruct vascular supply :proximal injury
,warm ischemia<6hrs
Functional ankle ,foot
25. Limb salvage procedure-
Operative Debridement
In the operating room, “irrigation and débridement,” the first
and most important step.
The skin wounds have been extended.
All necrotic muscle, fat, fascia, skin, and other nonviable
tissue within the central zone of injury should be removed.
Muscle should be tested for viability based on its
contractility, consistency, color, and capillary bleeding (the
four c’s), and if nonviable, it should be debrided, regardless
of the expected functional loss.
Serial débridements will be required until removal of all
nonviable tissue achieved.
26. Skeletal Stabilization
Stabilization options –
i. splint immobilization,
ii. skeletal traction,
iii. External fixation,
iv. internal fixation
Most limb-threatening injuries present as Gustilo typeIIIB or
IIIC open fractures and managed with temporizing external
fixation.
27.
28. Vascular injury
Angiography
Once the location of an arterial injury has been identified,
attempts at vascular repair.
Patient with prolonged ischemia, restoration of arterial
inflow should be the highest priority with temporary
intraluminal vascular shunting.
i. rapidly restore arterial inflow
ii. allow for a more detailed examination to better determine
the extent of the injury and whether the limb is indeed
salvageable.
iii. allow for a more thorough débridement and appropriate
stabilization of the bone and soft tissues.
29. Vascular repair can then either proceed immediately or in a
delayed fashion if the patient remains in extremis.
o Fasciotomies should be performed after any revascularization
procedure in the mangled extremity.
30. Soft Tissue Coverage
Options for coverage-
i. skin grafts,
ii. local flaps, or
iii. free flaps.
Early reconstruction (within 72 hours) -reduces
postoperative infection, flap failure, and nonunion rates,
development of osteomyelitis.
Many authors recommended muscle flap coverage on a more
delayed basis (7 to 14 days).
Negative pressure wound therapy (NPWT) -very effective
tool in the initial soft tissue management of high energy
open fractures.
Use of NPWT before definitive soft tissue reconstruction had
significantly decreased infection rates.
32. Hyperbaric Oxygen
HBO enhance oxygen delivery to injured tissues affected by
vascular disruption, thrombosis, cytogenic and vasogenic
edema, and cellular hypoxia as a result of trauma to the
extremity.
patients breathe 100% oxygen in a chamber under increased
barometric pressure
supraphysiological arterial oxygen saturation level
expanded diffusion for oxygen into tissues
increased oxygen delivery at the periphery of wounds.
33. Decision to amputation
Indication to primary amputation l0wer limb open #
Absolute :
a)Complete disruption of post.tibial nerve
b)Crush injury with warm ischemia >6hrs,nonrepairable
vascular injury
Relative :
a)Life threatening poly trauma (ISS>20)
b)Severe ipsilateral foot trauma
c)Prolonged course to provide soft tissue and tibial
reconstruction incompatible with personal ,social, and
economic consequences of the patient.
34. Risk factors for amputation
• Gustilo Type IIIC injuries
• Sciatic/tibial nerve or two of the three major upper extremity
nerves anatomically transected
• Prolonged ischaemia time/muscle necrosis
• Crush injury,significant wound contamination
• Multiple/severely comminuted fractures/segmental bone
loss
• Old age/sever co-morbidity
• Failed revascularisation
35. Principles of amputation
Unless amputation in a damage control
situation(guillotine),goal is a functional extremity with
residual limb that successfully interacts with patient’s future
prosthetic management.
Staged amputation-in a patient not adequately resuscitated
,or with significant contamination/infection,blast or crush
mechanism,may improve functional results by preserving
length.
Incision through soft tissue and bone are at right angle to
long axis of the limb
Periosteum is reflected proximal to skin incision and bones
are transected where periosteum is adherent to bone
Suture ligation are preferred to electrocautery for control of
transected.
36. Periosteum is reflected proximal to skin incision,and bones
are transected where periosteum is adherent to bone
Suture ligation are preferred to electrocautery for control of
transected.
Risk of postoperative neuroma is minimized with simple
sharp transection of nerve while maintaining distal traction.
Multilayered closure of the incision to ensure soft tissue
coverage of bones is essential.drain is recommended.
Extremity is spinted and range of motion excerises instituted
early
38. Amputation In children
Attempts should generally be made to preserve all
extremities, even with type IIIC open fractures.
Preservation of limb length and physis are important in
young children.
Mangled extremity severity score (MESS) correlates well with
the need for amputation in adults, the correlation is less in
children.
Bony overgrowth after amputation can be a significant
problem, especially due to the need for children to obtain
multiple prostheses as they grow.
39.
40. Disarticulate when possible. Disarticulation completely
eliminates the problem of terminal overgrowth and
subsequent revision surgery.
Preserve stump shape- The pediatric amputation stump becomes
conical with growth, so preservation of bony architecture such as
a short segment of proximal fibula or the distal condyles of the
humerus will assist in subsequent rotational control of the
prosthesis.
The split-thickness skin graft can hypertrophy and become
sufficiently strong to withstand the shear forces of prosthesis use.
41. The mangled upper extremity
Critical time for reperfusion is longer in the upper (8–10 h)
versus the lower extremity (6 h).
A transtibial amputation carries a much better functional
prognosis than a transradial amputation.
Shortening of the humerus to reduce soft-tissue defects is
tolerated well up to 5 cm.
Nerve reconstruction in the upper extremity done with
reasonable success, whereas major nerve injury is an
indication for primary amputation in the lower extremity.
The rehabilitation process -more imperative.
42.
43. Limb salvage versus Amputation
In limb salvage procedure-
Important issues include
i. patient's ability to handle uncertainty,
ii. deal with prolonged immobilization,
iii. accept social isolation,
iv. bear the financial burden,
v. worst-case scenario occurs when a limb must be
amputated after the patient has endured multiple
operations of an unsuccessful salvage or after years of pain
following a “successful” salvage
44. Early amputation and prosthetic fitting associated with
i. decreased morbidity,
ii. fewer operations,
iii. a shorter hospital course,
iv. decreased hospital costs,
v. shorter rehabilitation,
vi. earlier return to work.
vii. treatment course and outcome are more predictable,
viii. Modern prosthetics often provide better function than
many “successfully” salvaged limbs.
45.
46.
47. SUMMARY
The decision to amputate or salvage a severely injured
Extremity is a difficult one.
The decision to reconstruct or amputate an extremity cannot
depend on limb salvage scores.
Results of limb reconstruction are equal to those of
amputation following severe lower extremity trauma.
The “correct” decisions are based on the patient as a whole,
not solely on the extent of the limb injury.
Patient with a mangled extremity should be directed to an
experienced limb injury center, where strategies to minimize
complications, address related posttraumatic stress disorder,
improve the patient's self-efficacy, and target early
vocational retraining may improve the long-term outcomes.