12 rw principles of mangled extremity management
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Principles of Mangled Extremity Management
Pumsak Thamviriyarak,MD.Orthopaedics Department
Khonkaen Hospital
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
Introduction
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
Historical Background
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
Historical Background
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
PRINCIPLES OF MANAGEMENT
Vascular Assessment◦ Hard signs
pulsatile bleeding rapidly expanding hematoma classic signs of obvious arterial occlusion
Pulselessness Pallor Paresthesia Pain Paralysis Poikilothermia
PRINCIPLES OF MANAGEMENT
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
PRINCIPLES OF MANAGEMENT
Vascular Assessment◦ Limb deformities + decrease pulse : Reduction
and reevaluate◦ Arterial Pressure Indices(API)
<0.9 suspected vascular inj
PRINCIPLES OF MANAGEMENT
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
PRINCIPLES OF MANAGEMENT
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
Operative Debridement
Extend open wound and remove all necrotic tissue in central zone
Serial debridement require(zone of marginal stasis)
Operative Debridement
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
Skeletal Stabilization
thought to enhance oxygen delivery to injured tissues affected by vascular disruption – Improve wound healing
most beneficial in the peripheral zone of injury
Hyperbaric Oxygen
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
Soft Tissue Coverage
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
PATIENT ASSESSMENT AND DECISION MAKING
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
PATIENT ASSESSMENT AND DECISION MAKING
To help decision making : amputate vs salvage
Many index◦ MESI◦ PSI◦ MESS◦ LSI◦ NISSSA
Limb Salvage Scores
Amputation threshold ≥7 Only prediction not indication Cautiously decision base on clinical
MESS
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
Foot and ankle injuries
Delayed bone healing◦ Delayed union◦ Nonunion
Infection◦ Osteomyelitis
Flap necrosis
Smoking
Outcomes
References
Imagination is more important than knowledge
Thank you