Western Trauma Mangled Extremity Guidelines (J Trauma 2012;72(1):86)
INITIAL CARE OF THE MANGLED LOWER EXTREMITY
Following initial ATLS protocols the next priority for the traumatised lower limb is the diagnosis of the
absolute or relative ischemia of its parts (Keally, 1983, McCabe, 1983) it should only be delayed if
systemic hypotension causes peripheral ischemia.
While wound exposure (for preoperative planning and wound culture) should be done between the
accident scene and the operating room for most open fractures (Rojczyk, 1982) this early culture usually
grows multiple organisms and if a wound infection subsequently occurs , the infecting bacteria will be
among those cultures initially 70% of the time (Patsakis, 1974). After the culture is prepared antibiotics
should be started intravenously. Usually a first generation ca——— ——— and an amino glycoside.
Penicillin should be added if claus—- is likely to be among the flora of the wound. Tetanus prophylaxis
should be given according to the most recent recommendations. A thorough neurological examination
should be conducted with special attention to the posterior tibial nerve. Documentation of this nerve
function is especially important. However, even if its function is lost, its anatomic condition must be
known before a ———- prognosis can be determined. Lang et al as previously mentioned used the
condition of this nerve as a major deciding factor between salvage and amputation.
If the posterior tibial nerve is disrupted, the chances of salvaging a functional limb in adults with the
usual low cut to crush ratio of blunt trauma are poor due to atrophic ulcers on the foot. However, in
cases involving patients younger than 20 years of age and or having a high cut to crush ratio
revascularisation or replantation should be considered. It has been reported that this technique has been
accomplished with a salvage rate of 66% in The Peoples Republic of China (Chen, 1987) after at least a
2 year follow up none of the salvaged feet in that study had atrophic ulcers.
X-rays taken during this primary period must be inclusive for assessment of limb injury severity and
preoperative planning for bony reduction and fixation.
McAndrew and Lantz have stated that angiography is indicated in almost all massively traumatized
Table 1. Indications for Angiography
Terminal segment (pulseless foot)
Intercalary segment (i.e., single-vessel leg)
Fractures (severely displaced)
Page THE MANGLED LOWER EXTREMITY e 7 of 9
Knee instability (probable dislocation)
Impaired neurologic function
A normal Doppler exam does not eliminate need for angiography
Limbs with terminal segment ischemia need to be evaluated to establish the correct level at which the
vascular anatomy is disrupted. A more recent recognised indication for early angiography is interval or
intercalary segment ischemia in the leg. These terms describe a leg in which one or two the three vessels
are injured but the foot remains viable. However, as reported when vascular repair was not
accomplished, delayed healing of soft tissues and bone as well as limb loss was observed especially in
blunt trauma (Rich, 1978, Shah, 1988). This association between hypoxia and delayed union or
nonunion of fractures has been further confirmed by transcutaneous oxsimitry in humans (Kwong, 1988)
and by experimentally derived fractures surrounded by iatrogenic ischemic muscle (Holden, 1972). The
angiogram should be done rapidly, preferably in the operating room, unfortunately, the first incision
point between amputation and limb salvage is often based on warm ischemic time. The time that it is
reported vary from 2-12 hours (Burger 1984, Chen 1987, Howe 1987, Lang 1985, Rich 1978). The wide
variation is explained by differences in the cut to crush ratios, accompanying bony injury, collateral flow
and anatomic level of arterial injury.
Johansen in 1982 described the use of temporary interluminal shunt as a resolution of the management
dilemma in complex vascular injuries. The use of a temporary arterial shunt allowed urgent limb
revascularisation following which bony stabilisation and other soft tissue procedures could be performed
before a formal arterial repair was under taken (Johansen , 1982).
Compartment Syndrome occurs in a significant number of massively traumatised lower limbs and must
be considered a cause of limb ischemia. Few complications have been reported by Physicians who
prophylactically released the four leg compartments in patients who are difficult to follow clinically (i.e.
patients with head injury, on mechanical ventilation and or on medications) (Blick 1986, Boss 1984).
More recently Court Brown has described the use of continual compartment pressure monitoring if the
difference between the anterior compartment pressure and diastolic blood pressure became less than
30mm of mercury a four compartment sasiotomy was performed with a 0% complication rate from
Compartment Syndrome in their series (need exact figures). An open injury does not relieve the
compartment of the leg, and open tibial fractures have been accompanied by limb threatening
compartment pressures in between 5 and 9% of cases in 2 series of open tibial fractures (Blick 1986,
Delee 1981) prophylactic releases following most revascularisations, especially after blunt trauma are
Page THE MANGLED LOWER EXTREMITY e 8 of 9
Most limbs requiring major soft tissue and bony reconstruction or revascularisation are those with an
open wound (Howe 1987, Johansen 1982, Keely 1983). However, Tscherne has reported the need to
treat severely contused limbs with in tact skin and fractures in a similar fashion to those with open
wounds. In either case, the prevention of infection depends most on the completeness of the initial
debridement (Schweter 1940). To initiate the debridement, wounds are extended along lines of described
surgical exposures to allow for complete visualisation of tissues in the zone of trauma. The definitions of
viability for both skin and muscles are based on gross observation. Skin should have colour compatible
to the skin of the uninjured limbs, and the edges of viable dermis and subcutaneous fat should bleed.
The muscle must meet both of these criteria, plus have contactuity and its usual consistency when
palpated. (Saunders 1981, Scheweter 1940, Tscherne 1984) All in tact segmental muscular vascular
branches must be preserved to allow for maximal preservation of viable muscle. When the borders have
been defined, all non viable skin and muscle should be removed sharply. Pressure or pulsed lavage have
been demonstrated to be more effective than syringe irrigation for cleansing the wound (Gross 1972,
Haver 1975, Rodeheaver 1975). Physiological fluids such as ring solution are best for the lavarge.
Iodine and soap containing agents should not be used because of their cytotoxicity (Faddis 1977, Spar
1981). Bone debridement requires the removal of all bone without soft tissue attachments.
(This is a discussion, I am not sure if I should get in to, although it seems reasonable to discuss some of
the pros and cons of external fixation, versus intramedullary fixation in the lower limb, with regards to
expediency and subsequent soft tissue and bony procedures. I wonder if you have thoughts on this
Post operatively, the patients metabolic condition must be observed closely. Potential renal toxicity
caused by a marginal limb must be determined immediately. (Bondurant 1988, Brotman 1982)
Secondly, the patients caloric intake must be measured to prevent malnutrition. An intake of less than 40
kc or one gram of protein per kilogram of body weight per day will lead to slow wound and fracture
healing and an impaired immune response. (Smith 1987)
Eval of the Scores (J Bone and Joint Surg 2001;83A(1):3)
Pillgram-Larsen J. COMPRESSION BANDAGE, NOT TOURNIQUET. EXPERIENCE IN 68 PATIENTS WITH TRAUMATIC AMPUTATION AFTER MINE INJURIES. PAPER NBR 04 – 2 MP-HFM-109 . ATACCC august 2004. Mellesmo S, Pillgram-Larsen J. Primary care of amputation injuries. JEUR 1995; 8: 131-35. Husum H, Gilbert M, Wisborg T, Pillgram-Larsen J. Prehospital tourniquets: There should be no controversy. J Trauma 2004;56:214-5. Pillgram-Larsen J, Mellesmo S, Peck R. Injuries from mines. Tidsskr Nor Lægeforen 1992; 112: 2183- 7. [In Norwegian with English abstract] Pillgram-Larsen J, Mellesmo S. Not tourniquet, but a compressive bandage. Experience in 68 patients with amputation after mine injuries. Tidsskr Nor Lægeforen 1992; 112: 2188-90. [In Norwegian with English abstract]
Combined Arterial and Skeletal Extremity Trauma
Eric R. Frykberg, MD. FACS
Professor of Surgery
University of Florida
Complex extremity trauma involving both arterial and skeletal injuries remains challenging. This combination of injuries is rare, comprising only 0.2% of all military and civilian trauma, and only 0.5%-1.7% of all extremity fractures and dislocations. Vascular and trauma surgeons are more likely than orthopedic surgeons to encounter these injuries, as 10%-70% of all extremity arterial injuries are associated with skeletal trauma. In past years, the great majority of complex extremity injuries in the civilian sector have been caused by blunt trauma, although in some recent series penetrating trauma has caused a majority of these injuries. Combat injuries of this type from military series usually are due to high velocity penetrating trauma.
Combined arterial and skeletal extremity trauma imparts a substantially higher risk of limb loss and limb morbidity than do isolated skeletal and arterial injuries. Debakey and Simeone documented this in WWII battle casualties, in which all injured arteries were ligated, reporting amputation in 60% of all combined injuries and 42% in isolated arterial injuries. Although McNamara and coworkers(65) reported a substantial improvement in limb salvage from isolated arterial injuries in the Vietnam War, combined injuries still had a 10-fold greater rate of limb loss(23% vs 2.5%). These authors also documented a higher incidence of failed vascular repair among combined extremity injuries (33%) than among isolated extremity arterial injuries(5%). Romanoff and coworkers reported more than a 3-fold increase in limb loss in combined combat extremity trauma compared to isolated arterial injuries (36% vs 11%) in the hostilities in Israel. This trend has continued into recent years in the civilian sector, even in the most experienced trauma centers, where amputation rates approaching 70% still are reported from combined arterial and skeletal extremity trauma, while less than 5% of limbs currently are lost following isolated arterial or skeletal trauma. Limb loss most commonly is attributed to delay in diagnosis and revascularization in most published series of this unique trauma. Major nerve damage, extensive soft tissue injury which disrupts collaterals and prevents adequate vessel coverage, infection, and compartment syndrome are other reasons for such a high rate of loss of these severely compromised limbs.
Prompt diagnosis is essential if rapid treatment and optimal limb salvage is to be achieved in these complex extremity injuries. This requires that a high index of suspicion of arterial trauma be applied to every injured extremity by noting whether any hard signs are present (i.e. active hemorrhage, large, expanding or pulsatile hamatoma, bruit or thrill over wound, absent distal pulses, and signs of distal ischemiathe 5 Ps: pain, pallor, paralysis, paresthesias, poikilothermy, or coolness). The presence of hard signs in any blunt or complex extremity trauma requires immediate arteriography due to the relatively low incidence of surgically significant arterial injury in this setting. This is best done by the surgeon as a percutaneous hand-injected study in the trauma center, or on the operating table, to minimize time delay while achieving excellent accuracy. The absence of hard signs excludes major arterial injury with sufficient accuracy to allow further diagnostic workup to be avoided. Since most complex extremity trauma does not manifest hard signs, avoiding the considerable expense of arteriography in this population has substantial economic advantages.
This principle holds true even for the especially high risk injury of posterior knee dislocation, in which setting routine arteriography has been advocated in all cases, due to a substantial risk of popliteal artery disruption and its associated high rate of limb loss. However, those published studies that compare the clinical manifestations of patients with posterior knee dislocation with outcome show no surgically significant arterial injuries in that majority of patients who have no hard signs(Table 1), confirmed by follow-ups of up to 2 years. Again, most cases present without hard signs, allowing major resource savings at no harm to the patient by using only physical findings to exclude arterial injury. Arteriography is indicated only in that minority of patients with knee dislocation presenting with hard signs, to exclude the need for surgery in those 30% of patients who do not have an arterial injury. Immediate surgery without imaging may be undertaken if the clinical picture clearly indicates vascular injury(i.e. absent pulse, cold ischemic foot).
There is no clear role for noninvasive testing in the initial evaluation of complex extremity injuries (Doppler pressures or signals, duplex U/S), due to a paucity of studies of their use in this category of trauma, and uncertainty over its accuracy in the presence of severe tissue disruption and large bulky dressings. Further study is necessary to clarify this. Again, the physical exam quite clearly answers all questions of management in this setting, as absent pulses mandates ruling out vascular injury, and present pulses in the absence of other hard signs reliably excludes vascular injury as well as any imaging modality. Noninvasives add nothing and may lead the examiner astray, as Doppler flow signals may be transmitted by collaterals around a completely occluded or transected vessel, while a pulse can not. Thus, Doppler flow signals DO NOT exclude a vascular injury. The presence or absence of a pulse is all that is necessary to decide on the next step in diagnosis.
Appropriate prioritization of the management of the vascular and skeletal injuries is a major determinant of limb salvage. Initial fracture stabilization and fixation has been advocated in past years, due to concerns that an established vascular repair will be disrupted by subsequent orthopedic manipulation, as long as there is no overt ischemia. However, published evidence has refuted such concerns, showing minimal disruption of initial vascular repairs, and no adverse impact of prompt revascularization on outcome. Also, substantial tissue damage still can occur in the absence of clinical signs of ischemia, as our understanding of compartment syndrome has made clear. Further, clinical studies have shown a substantially higher rate of limb salvage among combined vascular and skeletal extremity injuries in which revascularization is performed first, compared with those in which it is delayed until the skeleton is addressed.
In fact, definitive vascular repair should be delayed in cases of unstable or severely comminuted fractures or dislocations, segmental bone loss, or severe soft tissue destruction and contamination, due to the risk of undue tension or slack on the repaired vessel when the limb is fixed at its proper length, and to the possibility of disruption from skeletal manipulation. But this should not ever delay immediate restoration of perfusion to the extremity, which can be accomplished rapidly by temporary intraluminal shunting until skeletal stabilization and soft tissue debridement has been completed. Alternatively, immediate definitive vascular repair should be the means of initial revascularization in the setting of uncomplicated and stable skeletal injuries in which minimal subsequent manipulation and length discrepancy is anticipated.
External fixation of the skeleton is preferred when rapid stabilization is necessary, in open, comminuted and unstable fractures, or in the presence of severe soft tissue disruption and contamination. Internal fixation has been used successfully in this setting, and is preferred if the patients condition permits.
The consensus of authorities now favors limb revascularization as the first priority in all combined extremity trauma. How the revascularization is accomplished(i.e. definitive repair or temporary shunting) is a matter of judgement based on the nature of the skeletal and soft tissue injuries and the condition of the patient. Only with a cooperative multidisciplinary effort, with close communication between the trauma, orthopedic and plastic surgeons, can the outcome of these injuries be optimized.
In addition to prompt diagnosis with on-table arteriography, liberal use of a number of surgical adjuncts has improved limb salvage following combined arterial and skeletal extremity trauma. Intra-operative completion arteriography is important to document patency of the repair, as any technical errors could easily result in limb loss in these severely compromised limbs. Four compartment fasciotomy should be applied liberally and prophylactically in this setting due to the high risk of compartment syndrome following reperfusion. Extra-anatomic bypass, and pedicled or free-tissue flap coverage should be considered in the setting of severe contamination and soft tissue injury or loss to protect the vascular repair. Careful attention to all of these considerations, as well as to avoiding unnecessary surgery for nonocclusive arterial lesions, and meticulous postoperative surveillance, has led to dramatic improvements in limb salvage, with amputation rates even in this challenging setting falling below 10% in a small number of recent studies.
The decision for amputation
Among the most difficult challenges in the management of complex extremity trauma is the decision as to whether and when amputation is indicated. Recent advances in the ability to salvage limbs have led to prolonged and aggressive reconstruction efforts following injuries which would have undergone amputation in the past. Such heroic efforts actually may harm patients in terms of prolonging hospitalization and time lost from work, as well as increasing sepsis, operative procedures, and even mortality. These outcomes are especially undesirable if amputation or severe limb dysfunction ultimately occur anyway.
Although it is often difficult to predict soon after injury which extremities will require amputation, there are injuries of such destruction and severity that a decision for immediate, or primary, amputation can be made easily. These are injuries in which it is obvious that attempts at revascularization are futile due to the extent of soft tissue and skeletal trauma, major nerves are transected, or other life-threatening injuries are present which prevent any attention to the limbs. Gustilo III-C injuries (comminuted open tibial-fibular fractures with arterial injury) are an example of limb trauma generally mandating immediate amputation.
However, most complex extremity injuries are not that clear cut. In these cases, immediate revascularization should be performed, along with important surgical adjuncts such as shunts, fasciotomy, or extra-anatomic bypass, the skeleton should be stabilized promptly by either traction or external fixation, and then the extremity should be observed over the next 24-48 hours to determine what level of function and tissue viability returns. Nerve transection never should be assumed, but only determined by direct visualization, as vascular insufficiency or muscle damage alone may cause profound deficits that can be confused with nerve damage. If revascularization fails, tissue loss is severe or worsens, systemic sepsis or crush syndrome develops, or profound neurologic or functional deficits persist, amputation then should be performed. If improvement occurs, limb salvage may proceed, but should be assessed just as critically at each successive stage to minimize unnecessarily prolonged, costly and futile efforts.
A number of scoring systems have been developed to objectify this difficult decision that is so often clouded by subjective and wishful thinking, often at the patients expense. Although none have been found to be prospectively useful in predicting amputation or the degree of functional impairment, they do focus attention on those factors which most closely correlate with outcome, and which must be a part of the treatment decision (Table 2). Another major consideration in this decision is whether the injury is in the upper or lower extremity, as the former is less likely to require amputation, being more tolerant of deficits in protective sensation, motor function, weight-bearing concerns, and length discrepancy, and prostheses tend to be less satisfactory.
This decision must be a matter of clinical judgement based on each individual case, and it must always involve a consensus of the entire health care team, including the trauma, orthopedic, vascular and plastic surgeons, rehabilitation specialist, psychologist, nursing, and most importantly the patient and family. The sophistication of limb prostheses, prompt return to work, short hospitalizations and lower costs and morbidity following early amputation are often preferable to salvage efforts which may take months or years and still fail. The ultimate goal is to return the patient to a comfortable, self-sufficient and productive life as quickly as possible.
Table 1: Relation of Physical Findings of Vascular Injury to Outcome Following Knee Dislocation
Hard Signs Present
No. (%) a # Surgery(%)b
Hard Signs Absent
No. (%) a # Surgery (%)
Kaufman et al
4 (21) 4 (100)
15 (79) 0
Treiman et al
29 (25) 22 (75)
86 (75) 0
Dennis et al
2 (13) 2 (100)
36 (87) 0
Kendall et al
6 (16) 6 (100)
31 (84) 0
Miranda et al
8 (25) 6 (75)
24 (75) 0
Martinez et al
11 (48) 2 (18)
12 (52) 0
60 (23) 42 (70)
204 (77) 0
aPercentage of all knee dislocations.
bPercentage of all patients with hard signs.
KD = Knee dislocation
Table 2: High-Risk Factors for Ultimate Limb Loss or Severe Dysfunction Following Combined Vascular and Skeletal Extremity Trauma
Gustilo III – C skeletal injuries
Transected tibial or sciatic nerve
Transection of 2 of 3 upper extremity nerves
Prolonged ischemia (> 6-12 hours)
Shock and life-threatening associated injuries
Below-knee arterial injury
Extensive soft tissue loss
Elderly with medical comorbidity
1. Howe HR, Poole GV, Hansen KJ, et al: Salvage of lower extremities following combined orthopedic and vascular trauma: A predictive salvage index. Am Surg 53:205,1987.
2. McNamara JJ, Brief DK, Stremple JF et al: Management of fractures with associated arterial injury in combat casualties. J Trauma 13:17,1973.
3. Applebaum R. Yellin AE, Weaver FA et al: Role of routine arteriography in blunt lower extremity trauma. Am J Surg 160:221,1990.
4. Norman J, Gahtan V, Franz M et al: Occult vascular injuries following gunshot wounds resulting in long bone fractures of the extremities. Am Surg 61:146,1995.
5. Miranda FE, Dennis JW, Veldenz HC et al: Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for popliteal artery injury: A prospective study. J Trauma 49:375,2000.
6. Feliciano DV, Mattox KL, Graham JM et al: Five-year experience with PTFE grafts in vascular wounds. J Trauma 25:71,1985.
7. Feliciano DV, Accola KD, Burch JM et al: Extraanatomic bypass for peripheral arterial injuries. Am J Surg 158:506,1989.
8. Khalil IM, Livingston DH: Intravascular shunts in complex lower limb trauma. J Vasc Surg 4:582,1986.
9. Mubarak SJ, Hargens AR: Acute compartment syndromes. Surg Clinic North Am 63:539,1983.
10. Feliciano DV, Cruse PA, Spjut-Patrinely V et al: Fasciotomy after trauma to the extremities. Am J Surg 156:533,1988.
11. Attebery LR, Dennis JW, Russo-Alesi F et al: Changing patterns of arterial injuries associated with fractures and dislocations. J Am Coll Surg 183:377,1996.
12. Bishara RA, Pasch AR, Lim LT et al: Improved results in the treatment of civilian vascular injuries associated with fractures and dislocations. J Vasc Surg 3:707,1986.
13. Johansen K, Daines M, Howey T et al: Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 30:568,1990.
14. Palazzo JC, Ristow AB, Cury JM et al: Traumatic vascular lesions associated with fractures and dislocations. J Cardiovasc Surg 27:688,1986.
15. Romanoff H, Goldberger S: Combined severe vascular and skeletal trauma: management and results. J Cardiovasc Surg 20:493,1979.
16. Kaufman SL, Martin LG: Arterial injuries associated with complete dislocation of the knee. Radiology 184:153,1992.
17. Treiman GS, Yellin AE, Weaver FA et al: Examination of the patient with a knee dislocation: the case for selective arteriography. Arch Surg 127:1056,1992
18. Dennis JW, Jagger C, Butcher JL et al: Reassessing the role of arteriograms in the management of posterior knee dislocations. J Trauma 35:692,1993.
19. Kendall RW, Taylor DC, Salvian AJ et al: The role of arteriography in assessing vascular injuries associated with dislocations of the knee. J Trauma 35:875,1993.
20. Martinez D, Sweatman K, Thompson EC: Popliteal artery injury associated with knee dislocations. Am Surg 67:165,2001.
21. Durham RM, Mistry BM, Mazuski JE et al: Outcome and utility of scoring systems in the management of the mangled extremity. Am J Surg 172:569,1996.
22. Bosse MJ, MacKenzie EJ, Kellam JF, et al: An analysis of outcomes of reconstruction or amputation of leg-threatening injuries. N Engl J Med 2002;347:1924-31.
23. Stannard JP, Sheils TM, Lopez-Ben RR, et al: Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg 2004;86A:910-915.
- Understand the clinical manifestations of vascular injury and the diagnostic approaches to confirm or exclude vascular injury in complex extremity trauma.
2. Know the appropriate prioritization of management of vascular injury, skeletal injury, and soft tissue and nerve and tendon injury in complex extremity trauma
3. Be familiar with the criteria for early amputation in complex extremity trauma.
Mangled Extremity Scoring System (MESS Score)
There are four components to MESS: limb ischemia, patient age, presence of shock, and mechanism of injury. Each component is assigned an integer value depending on severity. The possible values range from 1 to 14. Here’s the breakdown of each component:
- +1 Reduced pulse but normal perfusion
- +2 Pulseless, paresthetic, reduced capillary refill
- +3 Cool, paralyzed, insensate
- Add 3 points if limb ischemia has been present more than 6 hours
- +0 <30 years
- +1 30-50 years
- +2 >50 years
- +0 SBP >90 consistently
- +1 Transient hypotension
- +2 Persistent hypotension
Mechanism (kinetic energy)
- +1 Low (stab, gunshot, simple fracture)
- +2 Medium (dislocation, open or multiple fractures)
- +3 High (high speed MVC, rifle)
- +4 Very high (high energy trauma with gross contamination)
Per the original study, values of 7 or greater predict low salvageability. However, with advancing technology, drugs, and operative techniques, the threshold has been creeping higher. But not that much higher, probably 8 or so.