In Brief

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Mangled limbs, or injured extremities in which amputation is a possible outcome, represent a truly difficult problem faced by general surgeons and traumatologists throughout the world. This is due to the prevalence of extremity injuries; wide variations in the mechanism and presentation of injuries; and markedly different practice patterns among treating surgeons due to differences in expertise, available resources, and patient populations. Because of these differences, treatment outcomes are difficult to compare and thus recommendations can vary, just as well as the definition of a successful outcome can vary. The first goal, as with any injury, is a live patient. The second goal is a functional patient who is able to contribute to society after recovery. Embarking on a course of limb salvage may be inappropriate in a patient who initially presents in extremis and is circling in the lethal triad of death, since this may hasten their demise. Limb salvage may be similarly inappropriate for those patients who do not possess the will or socioeconomic capability to undergo repeated operations and deal with multiple complications and the vigorous rehabilitation necessary to return to a productive life. Although the scope of describing the entirety of the management options in treating extremity injuries is not the purpose of this monograph, we do present some initial guidance that can be used by the trauma team, independent rural surgeon, and military surgeon.

We would caution looking at any historical data in a vacuum, since the development of other areas in the management of the injured patient have advanced as well as those that specifically improve our ability to save a mangled extremity and influence what surgeons can now do for this complex problem. Assuring vital organ function while preventing ongoing external hemorrhage is the most important goal of prehospital and initial emergency department management of the injured. The advent of Prehospital Trauma Life Support (PHTLS), Advanced Trauma Life Support (ATLS), the Combat Lifesaver Course (AMEDD Center and School, Fort Sam Houston, TX), and other point-of-injury programs provide a universal framework for treating victims of severe trauma. Initially, adjuncts to save a severely injured extremity are aimed at saving the patient's life—primarily by ensuring that the patient has a patent airway, is able to oxygenate, and by preventing exsanguination—especially in the case of obvious external hemorrhage. Extremity bleeding can be managed by manual pressure, an appropriately placed tourniquet, and/or the application of a hemostatic dressing. Tourniquets can and do save lives and are found to increase the potential for successful limb salvage in some of the larger series of extremity injuries now coming from current battlefield data. As with all treatment methods, the key is appropriate placement and education in their usage.

Revascularization and fracture stabilization of the extremity must be accomplished quickly and are primary treatment priorities. Once in the trauma resuscitation bay or operating room, the use of pneumatic tourniquets, tying off bleeding arteries and veins, temporary intraluminal shunts, splints, external fixation devices, and prophylactic fasciotomies are damage control techniques that can be performed quickly in the setting of a cold, bleeding patient to minimize operative time and add to the patient's total damage control resuscitation plan. Tried and true therapies of any contaminated, open wound involve the complete debridement of devitalized soft tissue and irrigation of that which remains. Nerves, vessels, and bone should be kept at the longest length possible, since these structures can be vital in later reconstructive efforts. Definitive fracture management and soft tissue coverage are not always possible at the outset and some patients benefit from being taken back to the operating room for second and third look operations to ensure complete debridement of nonviable soft tissue and sometimes bone, as well as conversion of temporary external fixation of the skeleton to internal fixation or more definitive external fixator. External fixation is sometimes more appropriate when a large amount of soft tissue and skin destruction has occurred adjacent to the fracture site. Skin grafts, local rotational flaps, and free tissue transfers are available to provide definitive coverage of open fracture sites, exposed vascular grafts, and in areas of large soft tissue defects that do not close secondarily.

Primary or immediate amputation is necessary in certain instances and can be a lifesaving procedure. A well-performed amputation at the outset can sometimes serve a patient better than repeated operations performed over months to years in attempting to salvage a severely mangled and dysfunctional limb. Due to marked advancements in limb salvage techniques, 2 surgeons should evaluate the injury and agree with amputation as an appropriate course of action. The keys to performing amputations are: 1) complete closure of the amputation stump is not necessary at the first operation when the amputation is performed, especially in the case of grossly contaminated wounds, and 2) the most important consideration when performing an amputation is an adequate soft tissue envelope in which to form the definitive stump. This is very important for a prosthesis fitting after healing. Alternatively, secondary or late amputation is sometimes necessary during the course of attempted limb salvage and can be thought of by the patient as a psychological failure leading to depression and further loss of work and function. It is important for the treating surgeon to understand that wound complications still occur even for expertly performed amputations in the best of situations. Most patients with amputations are forced to take time off from work each year for skin ulcerations, prosthesis refitting, the treatment of superficial infections, and stump revisions.

Scoring systems for mangled extremities that attempt to assist surgeons in making the decision of whether or not to amputate or salvage have been proposed. All lack reproducibility. However, scoring systems do provide a common language in which to describe complex extremity injuries so that surgeons can more easily communicate the extent of injury present so that appropriate initial treatment options can be initiated at the outset. The presence of an initial pulse and the quality of the soft tissue, or mainly muscle, with respect to predicted ultimate function of the limb are very important factors in determining future viability and usefulness of the limb. Additionally, the patient's psychological support system and financial well-being should be taken into consideration. Some do not possess the will or means to undergo the vigorous rehabilitation necessary to embark on a sometimes long course of limb salvage. Regardless, the experience of the treating team is a very important factor in determining the appropriateness of amputation or salvage.

Special situations or problems may arise in patients with mangled extremities. The development of compartment syndrome must be anticipated and treated expeditiously. Crush injuries, prolonged ischemia with reperfusion, electrical injuries, and direct tissue trauma are primary causes. When suspected, fasciotomy is the treatment of choice and must be performed expeditiously. The lower leg and forearm represent the most common areas where compartment syndrome of the extremity develops and it is important to release all compartments in these areas for successful treatment. Prophylactic or preventive fasciotomy is useful in situations where the likelihood of compartment syndrome is high and the ability to provide close serial evaluations of the extremity is not possible, such as in prolonged evacuation systems and mass casualties. In crush and electrical injuries, myoglobinuria must be anticipated and treated to prevent renal failure. Heterotopic ossification, or bone growth in soft tissue areas outside of the axial skeleton, can occur and is difficult to treat. Radiation therapy in wounds caused by high energy mechanisms can sometimes minimize its development if delivered in the first 48 hours. Otherwise, surgical excision of symptomatic areas that occur months to years after the injury is the primary treatment.

The mangled upper limb requires additional efforts in salvage due to its markedly different function from the leg. Although some scoring systems have been applied to the mangled upper extremity, even a dysfunctional upper limb can offer prehension and an element of balance while ambulating. Additionally, upper limbs should be saved at relatively all costs due to the lack of functional prostheses available for patients with amputated upper limbs. Replantation is a viable option in certain cases when the resources are present and the wounding mechanism causes a “cleaner” cut, especially in the hands and fingers. Advances in microsurgery, leech therapy, and further anatomic delineations for free and rotational flaps have made this a possibility.

Mangled extremities occurring in the military environment offer special challenges. The wounding mechanisms are mostly penetrating and result from high energy munitions. The development of the improvised explosive device has produced an array of injuries due to its multimechanistic nature: blast, fragments, and flames cause high energy penetrating wounds, burns, and blunt trauma resulting from vehicles overturning or crashing into other objects. The complexity of these injuries is enormous, but yet the ratio of amputations to extremity injuries is low. Interestingly, several reviews of the latest combat casualty data demonstrate an even greater shift toward extremity injuries, to a prevalence of over 70%. Having upgraded body armor, as well as commanders enforcing its use, allows more injured soldiers to withstand blast injuries and protect their torso from the lethality of gunshot wounds but only to survive to sustain severely injured extremities and amputations. This situation has caused the Department of Defense to escalate its funding and support of programs designed to assist these injured soldiers and their families by developing improved battlefield resuscitative strategies, upgraded and highly functional prostheses for amputees, entire centers dedicated to the rehabilitation of the intrepid and the research resources necessary to continue to make positive changes.