limb salvage in severe trauma

DR. Fathi NeanaChief of Orthopaedics

DR. Fakhry and Alrajhy HospitalSaudi Arabia

November17, 2016

LIMB SALVAGEIN

SEVERE TRAUMA

Mangled Extremity

Skin/Soft tissue loss

Fracture/bone loss

Vascular injury

Nerve injury

Limb Complex Multisystem Injury(Mangled Extremity)

A limb with an injury to at least three out of four systems (soft tissue, bone, nerves, and vessels)

Limb Complex Multisystem Injury (Mangled Extremity)High Energy Trauma

1 -Blunt trauma

2 -Motor vehicle crashes

3 -Industrial/Farm accidents

4 -Falls from a height

5 -High-velocity gunshots

6a- Explosion injuries

6b- Specific subgroup

Blast injuries in the Middle East

Blast Injury

DIME (Dense Inert Metal Explosives)

White Phosphorus

BONE DEFECT (BONE LOSS)

ETIOLOGY OF BONE LOSS(BONE DEFECT)

Traumatic (Open Fractures) Blast injuries

Segmental FracturesPost debridement

Non Traumatic Resection of swelling

InfectionOsteonecrosis

INJURY EVALUATIONWhat we are dealing with


1- FRACTURE CLASSIFICATION

2- SKIN INJURYClosed fractures (IC ) 5 GRADESOpen fractures (IO ) 5 GRADES

3- NEUROVASCULAR INJURY(NV) 5 GRADES

4- MUSCLE/TENDON INJURY(MT) 5 GRADES

FRACTURE CLASSIFICATION

AO soft-tissue classification: closed skin lesions (IC).

IC 1No skin lesionIC 2No skin laceration, but contusionIC 3Circumscribed deglovingIC 4Extensive, closed deglovingIC5Necrosis from contusion

AO soft-tissue classification: open skin lesions (IO).IO 1Skin breakage from inside outIO 2Skin breakage from outside in < 5 cm, contused edgesIO 3Skin breakage from outside in > 5 cm, increased contusion,

devitalized edgesIO 4Considerable, full-thickness contusion, abrasion, extensive

open degloving, skin lossIO5Extensive degloving

SKIN INJURY

CLOSED SKIN LESIONS (IC) 5 GRADES

OPEN SKIN LESIONS IO 5 GRADES

NEUROVASCULAR INJURYNV 5 GRADES

MUSCLE/TENDON INJURYMT 5 GRADES

Skeletal /42-C3 Soft Tissues /IO4-MT4-NV5


PERSONALITY OF THE INJURYGlobal vs Key hole vision

(The Injured limb) Soft tissue envelope

Infection Joint contracture and range of motion

Nerve function : sensation, motor Vasculature : perfusion, angiogram ?

Location and size of the defect

(The Patient) General health of the Host

(The Hospital) Hardware , Equipments & Medical staff

(The Resources) Psychosocial & Economic

A DECISION HAVE TO BE MADE

Amputation + Prosthesisvs.

Limb salvage procedure

AMPUTATION VS. SALVAGEPotential Scenarios

Immediate amputation

Attempted salvage with early amputation

Successful salvage

Unsuccessful salvage with late amputation

1- Personality of injury

The injured limb

The patient

The health care environment

Psycho Social Resources

2- Scoring system !

AMPUTATION VS. SALVAGEGUIDELINES – OUTCOME

AMPUTATION VS. SALVAGEGUIDELINES

SCORING SYSTEM ! MANGLED EXTREMITY

SEVERITY SCORE(MESS)

AMPUTATION COSIDERED IN TOTAL SCORE > 7

BONE & SOFT TISSUE GROUPLOW ENERGY 1MEDIUM ENERGY 2HIGH ENERGY 3MASSIVE CRUSH 4

SHOCK GROUPNORMOTENSIVE 0TRANSIENT HYPOTENSION 1PROLONGED HYPOTENSION 2ADVANCED 3

ISCHAEMIA GROUPNONE 0MILD 1MODERATE 2ADVANCED 3

AGE GROUP < 30 Y. 030-50 Y. 1> 50 Y. 2

Nowadays Advances in evacuation, resuscitation, wound care, free tissue transfer, and internal fixation make it nowadays

possible to salvage limbs that would have been amputated in the past

HistoricallyMangled extremities

have been associated withvery high amputation rates

LIMB AMPUTATION

Mangled Extremity Severity Score(MESS) > 7

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

Amputation is indicated in

1- Patients with complete traumatic irreparable disruption

2- Prolonged limb ischemia

3- Severe soft-tissue loss that cannot be reconstructed

4- Concurrent life-threatening injuries in an unstable polytrauma patient

The alternative is prolonged unsuccessful attempts at limb

salvage

Subjecting the patient to great physical, psychological, financial, and social

suffering

LIMB SALVAGE

Mangled Extremity Severity Score(MESS) < 7

1- 1- Prolonged hospital stay

2- Multiple operations

3- Complication rate

4- Delayed amputation level

5- Psychological attachment

6- Economic disability

7- Medico legal problems

8- May be useless limb

Please remember A failed limb salvage or a

salvaged useless limb can be Devastating to the patient functionally,

economically & psychologically

LIMB SALVAGE PROBLEMS

LIMB SALVAGE TREATMENT PHILSOPHY

1-Stop the Injury (ABC)

2. Stop the Pathogens (Debridment,Irrigation,Antibiotics)

3. Do not harm (Surgical Trauma)(live, clean, manageable tissues)

4. Low risk procedures (DCO Principals)(Spanning frames,Unreamed nails, Open wounds)

5. Define Objectives (Union,Alingment,Function)

LIMB SALVAGE Management Priorities (6R)

Resuscitate

Restore blood supply

Remove dead & infected tissue

Restore soft tissue envelope

Restore skeletal stability

Rehabilitation

LIMB SALVAGE PROCEDURE

Irrigation & Debridement

External fixation

Antibiotic bead spacers

Soft tissue coverage

Restore Skeletal Stability (Salvage of Bone Defect)

limb salvage in severe trauma

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