Mangled Extremity and Treatment

- review of the literature -

Dr. Seti Aji Hadinoto

Dr. Darmawan Ismail Sp.BTKV

Mangled Extremity
Term : injury to an extremity so severe that salvage is often
questionable and amputation is a possible outcome
(Rockwood, 2010)
Crush Injury :
A crush injury occurs when a compressive type of force is
applied to the tissues. At the site of injury the tissues experience
several forces simultaneously, including shearing, contusion, and
stretching in addition to pressure (Practical Plastic Surgery,
2010)
 MESS was originally created by Johansen et al, 1990 for
predict amputation following lower extremity trauma
Vascular assesment : (Rockwood, 2010)
Hard Sign
Soft Sign
 Soft Sign : Small Hematome, Injury to adjacent nerve,
unexplained hypotension, history of hemmorhage, proximity
of wound to major vessel
(The Trauma Manual 3ed, 2008)
Scoring System Available
Why we use MESS?
Johansen et al : 100% Sensitivity
Easy to use
Fast
Decision Making
Why MESS is inappropriate for Upper
Extremity
When to make definitive classification?
Make in the operating room, during first debridemant, full
exploration of the extend of wound and soft tissue injury
(AADO, 2009)
Muscle viability : 4 Cs (Apley, 2010)
Color
Contractility
Consistency
Capacity to Bleed
Damage Control Surgery
Operating beyond the physiologic response of the patients
Containment of bleeding and contamination
Prevent the triangle of death
3 stage :
Initial exploratory laparotomy : control hemmorhage &
contamination
Physiologic stabilization in ICU
Reoperation for removal of intraabdominal packing
(The Trauma Manual 3ed, 2008. Manual of DSTC, 2007)
American College of Surgeons,
Commite on Trauma, 2005
El Shaarawy, 2005
 Between Dec 2000 August 2003
Using MESS and MESSI
62 patients arterial exploration
Result :
MESS (< 7, 100% vs > 7, 91%; p = .22)
MESI (< 20, 100% vs > 20, 90.5%; p = .154)
(upper limb 100% vs lower limb 89%; p = .08%)
Recommend that all injuries, whatever their score, should be
surgically explored before treatment decisions are made.
Bose, et al 2001
Sensitivity & Specificity of MESS
Behdad et al 2012 : Sensitivity : 73%, Specifity 54%
Kumar et al 2007 : Sensitivity 91%, Specificity 98%
Mashali et al 2006 : Sensitivity 58%, Specificity 63%
Bose et al, 2001 : Sensitifity 95%, Specificity 45%
If the.. (Rockwood, 2010)
Location identified ortho and vascular therapy
Fracture stable immediate vascular repair precedes
skeletal stabilization
Fracture excessively comminuted quick stabilization
followed by vascular repair
Prolonged ischemia vascular shunting
Result
Three patient died :
Massive pulmonary embolism, 40 y.o female, 5 days post op,
severe OF tibia with Gustillo IIIC + Ruptured popliteal artery
above trifurcation
Crush syndrome. 48 hours post op, crush injury + OF Distal
femur Gustillo IIIC + kontralateral tibial traumatic amputation
Severe sepsis, 2 weeks post op, after attempting salvage in OF
tibia with Gustillo IIIC
 All the remaining patients require secondary amputation
within 15 days due to :
Extensive muscular necrosis
Severe extremity sepsis positive tissue and blood culture
discussion
Unfortunately, "salvage" of a mangled extremity is no guarantee of
functionality or employability.
In most of the patients, sepsis and other infection complications
may be so severe and persistent that ultimately secondary
amputation is required
 (Georgiadis,1993) studied the long-term outcomes and
quality of life in patients with open tibial shaft fractures and
severe soft tissue loss. Compared to amputees, limb salvage
patients took longer to achieve full weight bearing status,
were less willing or able to work
(Fairhurst, 1994) demonstrated that early amputees had
higher functional scores, fewer operations and returned
to work and sporting activities within six months. They
concluded that early amputation was better when confronted
with a borderline salvageable tibial injury
American College of Surgeons,
Commite on Trauma, 2005
 (The Trauma Manual 3ed, 2008. Manual of DSTC,
2007)

The presence of hard sign mandates immediate vascular

evaluation by arteriography
Most hard sign are not due to vascular injury in the setting of
blunt trauma
Arteriography minimize the risk of negative exploration
Arteriography remain the Gold Standard for diagnosis of
arterial injury
Conclusion
Semua sistem skoring yang tersedia tidak dapat dijadikan
satu- satunya pijakan untuk mengamputasi atau
mempertahankan ekstremitas
MESS lebih dipilih karena : simple, cepat, sensitivitas tinggi
Tindakan memperbaiki vaskularisasi harus dilakukan pada
kasus emergency vascular injury, dengan pertimbangan
tertentu.
Harus mempertimbangkan nyawa, harapan pasien, ekonomi,
fungsi, kemampuan institusi dan operator