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The Mangled Extremity
The Journal of Emergency Medicine, Vol. 35, No. 4, pp. 437– 444, 2008 Copyright © 2008 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/08 $–see front matter
doi:10.1016/j.jemermed.2007.11.067
Trauma Reports
THE MANGLED EXTREMITY Regina Oakes,
MD,
Amy Urban,
MD,
and Phillip D. Levy,
MD, MPH
Department of Emergency Medicine, Detroit Receiving Hospital-Emergency Medicine Residency, Wayne State University School of Medicine, Detroit, Michigan Reprint Address: Phillip D. Levy, MD, MPH, Department of Emergency Medicine, Detroit Receiving Hospital-Emergency Medicine Residency, Wayne State University School of Medicine, 4201 St. Antoine, 6G, Detroit, MI 48201
e Abstract—The management of patients with severe extremity injuries involves focused efforts at limb salvage and mitigation of potential infectious complications. An indepth understanding of the proper approach to initial management is essential, as it may impact eventual outcome. The use of established scoring systems may predict those at greater risk and enable expeditious utilization of appropriate consultation services. This case-based review highlights critical aspects of patient care and provides a framework for the role of the Emergency Physician. © 2008 Elsevier Inc.
itor, which showed a sinus tachycardia. Fluid resuscitation was initiated with normal saline via two large-bore peripheral intravenous lines while he was placed on high-flow oxygen. On primary survey, the patient was anxious and uncomfortable. His airway was patent and he had normal breath sounds bilaterally. He was grossly intoxicated but able to follow commands, with a Glasgow Coma Scale score of 15. Other than a large wound to his left leg, no other injuries were obvious. Subsequent secondary survey revealed no evidence of external trauma to the rest of the body. The rest of the physical examination was fully unremarkable except for the left leg. A 25 ⫻ 15 cm wound was noted along the medial aspect of the left tibia with an obvious open fracture and significant tissue avulsion. The dorsalis pedis pulse was palpable. There was diminished range of motion, with an inability to plantar flex, dorsiflex, invert, and evert the left foot. In addition, the patient was unable to initiate contraction of the extensor hallucis longus and flexor hallucis longus muscles. Portable chest, lateral cervical spine, and pelvis radiographs were obtained with no abnormalities noted. Radiographic evaluation of the left lower extremity revealed comminuted fractures of the distal tibia and fibula with embedded multiple bullet fragments visible (Figure 1). The patient was given a tetanus vaccination booster as well as intravenous cefazolin and gentamicin. The wound was covered with a sterile dressing and splinted with emergent orthopedic consultation. Upon their eval-
e Keywords—mangled extremity; high-energy extremity injuries; wound management; severity score
CASE PRESENTATION A 44-year-old man was brought in by Emergency Medical Services after sustaining a single gunshot wound to the left leg. The patient reported significant pain with diminished sensation distal to the injury. He denied other injury or symptoms. The patient did not see the weapon used and heard one shot fired. On arrival to the hospital, initial vital signs were: blood pressure 126/79 mm Hg, pulse 113 beats/min, respirations 20 breaths/min, and pulse oximetry 98% on room air. He was immediately placed on a cardiac monTrauma Reports of the Emergency Medicine Residency Program, Wayne State University School of Medicine, Detroit Receiving Hospital.
RECEIVED: 15 June 2007; FINAL ACCEPTED: 7 November 2007
SUBMISSION RECEIVED:
24 October 2007; 437
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Figure 1. Plain radiograph of the left leg showing comminuted fractures of the tibia and fibula with radiopaque bullet fragments. Complete destruction of the distal tibial diaphysis is visible with extensive overlying soft tissue injury.
uation, the patient was taken to the operating room (OR) for planned irrigation, debridement, compartment pressure monitoring, and external fixation.
DISCUSSION “As the energy exerted to an extremity increases, so does the severity of the multiple components of that injury. Although these components must be individually assessed, their sum represents the “personality” of the particular injury . . .” —RJ Brumback (1)
Extremity injuries resulting from high-energy forces are relatively common in today’s modern, industrialized world (2). Often these injuries are complex, with extensive osseous, neurovascular, ligamentous and soft-tissue damage (3–5). In general, the magnitude of destruction is proportional to the kinetic energy and degree of force applied to the limb in relation to the ability to dissipate the impact (1). Many of these injuries involve an open fracture, with a resultant increase in morbidity through wound contamination (3,4). The majority of high-energy extremity injuries are caused by blunt trauma from motor-vehicle collisions, falls, or industrial accidents (Table 1) with crush or avulsion damage to the affected limb (2). Only 2% are due to gunshot wounds (GSW), with the pattern of injury determined largely by the characteristics of the bullet
(caliber, jacketing, shotgun pellets) and the gun used to propel it (velocity, distance to impact). Unlike blunt trauma, however, damage from GSWs can be inflicted by several differing means (6). Crush and laceration injuries are caused by direct contact of the bullet with the soft tissues, and tend to be the only form of damage induced by low-velocity handgun. With higher-velocity projectiles, additional damage results from a shock wave caused by compression of the tissue deep to the site of impact. A temporary cavity, referred to as a “cone of cavitation,” may also be produced by stretch forces imparted on the tissue by the projectile, with significant resulting deformation (6). As this cavity collapses, a pressure differential is created, drawing material in from the bullet entry and exit site. This effect can lead to foreign body retention deep within the extremity, thus creating a nidus with potential for development of an infection. The collapse of this temporary cavity, in addition to the area created by a crush injury, can possibly lead to the formation of a permanent cavity. Due to this, it may be difficult to determine the extent of injury from a GSW based on the surface pattern alone, and even benign-appearing wounds may be associated with severe damage (6). INITIAL RESUSCITATION AND ATLS Patients who present to the Emergency Department (ED) with a high-energy extremity injury (also known as “mangled extremity”) may have other injuries that take priority. Forty to seventy percent will have injuries elsewhere, including intracranial lesions, cardiothoracic or abdominal disruptions, and other fractures or ligamentous damage (2–5). Therefore, the initial management should generally follow the protocols of Advanced Trauma Life Support (ATLS). Although a severely damaged limb can be visually impressive, attention to the ABCs (airway, breathing and circulation) must take precedence, and efforts to salvage the limb should not supersede efforts to attain hemodynamic stability (5,7,8). Prehospital personnel often cover open wounds with sterile dressings and splint obvious fractures. If a de-
Table 1. Causes of High-Energy Extremity Injuries in Civilians* Motorcycle accidents Motor vehicle crash Falls Pedestrian struck Crush injuries Firearms Miscellaneous * Reference (35).
28% 24% 13% 12% 8% 2% 13%
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formed extremity has not already been aligned, reduced, and splinted, this should be performed as soon as it is feasible (4,9). External hemorrhage may be controlled using application of manual pressure or a compressive dressing to blood vessels proximal to the extremity (5). “Modern” pneumatic tourniquet systems designed to minimize potential complications have recently been developed and are widely used during prehospital transport in the military setting as an adjunct to compressive dressings or when direct pressure fails (10 –12). Such tourniquet systems have been used to prevent exsanguination and assist with hemodynamic stabilization, however, knowledge in proper application and utilization is essential to avoid tourniquet-induced ischemiaperfusion-injury (10,11,13). Of particular importance is the total tourniquet application time. Although there has not been a prospective randomized clinical trial of tourniquet application times, a maximal period of 1.5 to 3 h is often targeted intra-operatively (10). A retrospective study by the Israeli military noted an increased prevalence of neurological complications when induced limb hypoperfusion exceeded 150 min (11). There are general recommendations to perform temporary tourniquet release at regular 20-min intervals during long transport times but this alone will not prevent the ischemic effects of prolonged tourniquet application times (10,14). Although similar in principle to limb tourniquets, pneumatic antishock garments are associated with an increase in mortality and their use in routine clinical practice is not recommended. Recombinant factor VII and other clot-promoting bandages are under investigation by the military and are currently in use during aggressive resuscitations to control hemorrhage. However, there is limited evidence regarding their utility and they may not be applicable to civilian circumstances (15).
SOFT TISSUE ASSESSMENT AND RADIOLOGICAL STUDIES Dressings and splints placed by prehospital providers must be fully removed to enable adequate assessment of soft tissue damage and neuromuscular function, but this should not occur repeatedly as the process of undressing and redressing wounds can increase the infection rate three- to fourfold (2). Exploring the wound in the ED is generally not indicated, especially for those in whom immediate operative intervention is planned, as this can further contaminate the wound and precipitate hemorrhage. If there is a delay in transit to the OR, the wound may be gently flushed with 1 or 2 L of sterile normal saline and dressed with sterile saline-soaked gauze pads (4,5,16). Removal of non-viable bony fragments or obvious foreign bodies should be performed under
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sterile conditions, ideally in the OR, in an effort to reduce the frequency of manipulation and the chance for infection (2). Radiographic evaluation is critical to identify the extent of skeletal injury. If the patient has other injuries, standard trauma films (chest, pelvis, and lateral cervical spine) should be obtained before any extremity radiographs. Liberal use of subsequent extremity radiographs is recommended based on observed injury patterns and localized bony pain (4,5,17). In general, the joint above and below the affected limb should be radiographically assessed, with computed tomography preferred if there is joint involvement (4,18). After radiographs have been obtained, many orthopedic surgeons advocate taking Polaroid© or digital photographs of the mangled limb, to document both the extent of the initial injury, and to serve as a record for postoperative progress toward (or away from) a viable extremity. These images can also be used to communicate the injury pattern, potentially obviating the need for repeated inspection (4).
VASCULAR EVALUATION After primary survey and initial resuscitation, the mangled extremity should be thoroughly examined for vascular injury. Injury patterns that are highly associated with vascular disruption include supracondylar fractures in children, posterior knee dislocations, fractures of the distal femur and proximal tibia, and penetrating injuries of the medial or posterior thigh (9,19). Whereas shock and hypotension promote early soft tissue necrosis, limb ischemia is the single most important factor in determining the outcome of an extremity injury with apparent vascular compromise. The goal of the trauma team is to keep the interval between injury and reperfusion of the limb to ⬍ 6 h (17,19,20). Restoration of arterial continuity within this time limit may prevent complications related to soft tissue damage such as compartment syndrome, ischemic contractures, arteriovenous fistula, or loss of the limb (19,21). “Hard signs” of vascular injury such as pulsatile bleeding, a palpable arterial thrill or audible bruit, signs of distal ischemia, or a visible expanding hematoma mandate further diagnostic evaluation or immediate operative intervention (8,13). These physical findings, however, are present in only 30% of those with vascular injury and it is important to maintain a high degree of suspicion even when such signs are absent. Contrast arteriography is the diagnostic modality of choice for identification of suspected vascular disruption and early use may prevent unnecessary surgical exploration (9).
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“Soft signs” of vascular injury including non-pulsatile hematoma, a history of “possible” arterial hemorrhage (i.e., a report of pulsatile bleeding by initial providers when no such bleeding is visible at the time of ED examination), delayed capillary filling, paresthesias, or a temperature gradient between limbs have also been proposed, but are less likely to be of importance in the truly mangled extremity. For less severe injuries, however, these findings should prompt close observation, a precise and well-documented physical examination, and interval reassessment of extremity perfusion (19). Further vascular evaluation using angiography or Doppler ultrasound, however, is not routinely indicated and should be reserved for those patients with clinical deterioration (13,18). The ankle to brachial index (ABI) enables rapid assessment of extremity vascular flow and may be a particularly useful adjunct for this group. The ABI is obtained by using a blood pressure cuff to measure the systolic pressure at the largest point of the ankle and dividing it by the systolic pressure of either arm. If the ABI is ⬎ 0.9, observation is recommended; if ⬍ 0.9, further evaluation is warranted with contrast arteriography in a stable patient and operative exploration in a hemodynamically unstable or hemorrhaging patient (13,18).
DESCRIPTION AND CLASSIFICATION OF ORTHOPEDIC INJURY Emergency Physicians should be prepared to recognize and describe the fracture pattern to orthopedic consultants. A systematic approach using the acronym NOLARD may be useful for this purpose. NOLARD stands for the following: neurovascular status of the extremity (N), open vs. closed (O), location (L), angulation/alignment/articular involvement (A), rotation (R), and displacement (D). Other components that should be addressed for accurate description include mechanism of injury, muscle crush or loss, and degree of contamination. The Gustilo classification of open fractures (Table 2) provides objective
terminology that may assist Emergency Physicians with their ability to describe the potential for wound contamination through clarification of the size of the soft tissue defect, presence or absence of contusion, the complexity of the bony lesion, and the degree of fracture comminution (16,22). There may be significant inter-observer variability in assignment of the class of injury, however, especially when applied by individuals who are not widely familiar with its components (23). Care must be taken, therefore, to avoid definitive prognostication based on a single assessment alone.
FRACTURE STABILIZATION When managing a severely deformed extremity injury, stabilization is a critical component. Although definitive management is ultimately achieved through the use of internal or external orthopedic fixation, splinting may be a life- or limb-saving temporizing measure. A reduced and splinted fracture can ease patient transportation and provide a measure of comfort. Early realignment may improve apparent neurovascular compromise, reducing further ischemia and diminishing the potential for development of compartment syndrome. Additionally, when optimal blood flow is available to a mangled limb, the rate of infection is decreased and wound healing is enhanced (2,5). Operative fixation of unstable fractures of the pelvis, femur, and tibia using internal or external implants should be performed within the first 24 h if medically possible (4,5,16). This allows for early joint motion and mobilization, decreased musculoskeletal morbidity, and decreased hospital stay (5).
TETANUS PROPHYLAXIS AND ANTIBIOTIC THERAPY Mangled extremity wounds are considered to be highly tetanus prone, and prophylaxis with tetanus toxoid
Table 2. The Gustillo Classification of Open Fractures* I II III IIIA IIIB IIIC
A fracture with a clean cutaneous wound ⬍ 1 cm in length usually from inside to outside; minimal muscle contusion. Simple transverse or short oblique fractures A fracture with laceration ⬎ 1 cm in length without severe soft tissue damage; minimal to moderate crushing component. Simple transverse or short oblique fractures with minimal comminution A fracture with significant soft tissue loss; extensive soft tissue damage including muscles, skin, and neurovascular structures. Often a high energy injury with severe crushing component A fracture with adequate soft tissue coverage, despite extensive cutaneous lacerations or flaps. High energy trauma regardless of wound size; segmental fracture, gunshot wound, minimal periosteal stripping. Extensive injury of the soft tissue; periosteal stripping and soft tissue gaps, bone exposure requiring soft tissue flap closure. Usually associated with massive contamination Any open fracture with arterial injury which requires repair, regardless of degree of soft tissue destruction.
* References (24,25).
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Table 3. Mangled Extremity Severity Score* Components of Score Skeletal/soft tissue injury Low energy (stab, simple fracture, “civilian” GSW Medium energy (open or multiple fractures, dislocation) High energy (close-range shotgun, “military” GSW, crush injury) Very high energy (above ⫹ gross contamination, soft-tissue avulsion) Limb ischemia Pulse reduced or absent but normal perfusion Pulseless, parasthesias, diminished capillary refill Cool, paralyzed, insensate limb Shock Systolic blood pressure always ⬎ 90 mm Hg Hypotensive transiently Persistent hypotension Age (years) ⬍30 30–50 ⬎50
Points 1 2 3 4 1† 2† 3† 0 1 2 0 1 2
* Reference (26). † Score doubled for ischemia ⬎ 6 h.
should be administered to those patients with uncertain or deficient immunization status. Tetanus immunoglobulin should also be considered for those with no history of prior immunization. In addition, these injuries are at high risk for bacterial contamination, with reported rates of close to 65% (2,4,16). As such, early initiation of antibiotic prophylaxis should be considered in virtually all cases. Although GSWs were long considered to be sterile, recent data have shown that they are exceedingly susceptible to contamination from the bullet or shotgun wading itself, imbedded clothing fragments, and other foreign materials (24). There is an increased risk of infectious complications with advanced age and comorbid conditions such as diabetes mellitus, peripheral vascular disease, or immunosuppression (2). The beneficial role of antibiotics for open fractures has been clearly demonstrated in prospective randomized trials, and parenteral administration should be initiated as soon as possible after arrival at the ED (optimal time ⬍ 3 h from onset of injury) (25,26). Whereas selection of appropriate systemic antibiotics depends on the severity of soft tissue injury and existence of potential contaminating agents, etiology itself is not an important discriminating factor. Skin flora such as Staphylococcus epidermidis, Proprionobacterium acnes, Corynebacterium spp., and Micrococcus spp. have long been considered the most common causative organisms of wound infection, and initial therapy should be directed toward them (26,27). Recent studies have noted the emergence of nosocomial organisms such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus, espe-
cially in patients who have undergone debridement and operative intervention underscoring the need for early, routine antibiotic administration (4,16). Wound cultures may assist with organism identification but there is little evidence to show that they actually impact eventual management (16). Despite demonstration of clinical effectiveness, there is a paucity of evidence regarding the optimal antibiotic regimen for treatment of mangled extremity injuries. Current recommendations advocate monotherapy with a first-generation cephalosporin that provides adequate Gram-positive coverage (i.e., cefazolin) for all Gustilo type I (and some Gustilo type II) open fractures and closed fractures with significant soft tissue destruction (4,16). An aminoglycoside (usually gentamicin) should be added for type Gustilo II and III open fractures for better Gram-negative coverage. If the injury occurred on farmland with agricultural equipment or the wound has heavy soil contamination, penicillin (or clindamycin, if penicillin allergic) should be added to the antibiotic regimen to cover Clostridium spp. Patients with diabetes mellitus and those with wounds contaminated by bowel contents may also be at risk for clostridial infections (4,16). Antibiotic therapy should continue for 48 –72 h post-injury and again for 48 –72 h each time a further procedure is performed. Restrictive antibiotic utilization in this fashion will help prevent the emergence of resistant organisms (2). Use of antibiotic impregnated beads may diminish protracted infectious complications, but this is an operative decision outside of the realm of ED management (4,16).
THE MANGLED EXTREMITY SEVERITY SCORE The Mangled Extremity Severity Score (MESS) was developed to be a clinically applicable scoring system to predict limb salvage in the mangled lower extremity (Table 3). Although generally used by orthopedic and
Table 4. Evidence-Based Pearls Initial management Avoid temptation to focus solely on extremity injury Avoid wound exploration or debridement Obtain radiographs of joint above and below apparent injury Assess for vascular injury Look for “hard” and “soft” signs Use ankle-brachial index and angiography judiciously Outcome improved by Early splinting Temporization of hemorrhage and restoration of limb perfusion Antibiotic therapy within 3 hours of presentation Rapid initiation of operative care
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vascular surgeons, this simple system can be practical in the ED as well. The MESS score incorporates four major clinical variables, all generally available at the initial ED evaluation: skeletal/soft tissue injury, limb ischemia, shock, and patient age. The MESS system was based on a retrospective case review of 26 mangled lower extremities and then validated with a prospective trial of 26 patients at a separate trauma center (28). In both trials, a MESS score of ⬍ 7 was able to predict limb salvage with 100% accuracy (28,29). Further trials have attempted to validate these findings, with variable results (15,30).
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Other lower extremity injury scoring systems have been devised, but are less widely used. These include the Limb Salvage Index, the Predictive Salvage Index, the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score, and the Hannover Fracture Scale-97 for ischemic and non-ischemic limbs (22,30,31). As a general rule, lower scores correlate with increasing limb-salvage potential. Overall, however, none are considered to be sufficiently predictive to enable derivation of an amputation threshold (30). Of further note, these scoring systems have limited applicabil-
Figure 2. Algorithm for evaluation and management of blunt abdominal trauma.
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ity for upper extremity injuries and should be used cautiously in the pediatric population (32,33).
OTHER CONSIDERATIONS In addition to infection, malunion, and limb loss, other potential complications of long bone fractures may need to be addressed after immediate resuscitation. These include fat embolism, deep venous thrombosis and pulmonary embolism, bleeding disorders (i.e., disseminated intravascular coagulopathy), Acute Respiratory Distress Syndrome, myositis ossificans, post-traumatic osteoarthritis, and reflex sympathetic dystrophy (5).
AUTHOR’S RECOMMENDATIONS The revascularization or reimplantation of a mangled extremity is now the preferred alternative to amputation in patients with a moderate or better chance of limb salvation (2,34). To facilitate this objective, an Emergency Physician must be able to properly stabilize the patient, provide an appropriate assessment, and initiate the optimal preliminary care (Table 4). Although the limb injury may be particularly distracting due to its dramatic presentation, hemodynamic stability must take initial precedence in the resuscitative effort (1,4,5,8,14). Once established, complete and thorough evaluation of the musculoskeletal, neurologic, and vascular status of the extremity will allow for classification and guidance of treatment (1,2,4,5,8,14). Calculation of the MESS (or other injury severity score) may be helpful for the determination of potential limb viability, but is not sufficiently predictive for definitive decision-making (30). A clean wound is the ultimate goal, and this is best achieved through aggressive irrigation and debridement in the OR (1,5). Avoid the temptation to explore the wound and remove debris in the ED. Treat soft tissue damage conservatively through application of a salinesoaked gauze dressing. All fractures should then be reduced or splinted (5). Early prophylaxis against infectious complication is essential due to the high rate of associated morbidity (1,3,4). Antibiotics should be administered as soon as possible. Tetanus immunoglobulin and toxoid should be administered if indicated. Expeditious management in this fashion may prevent compartment syndrome, limit the extent of neuromuscular damage, and enhance the likelihood of successful recovery. An open fracture should always be considered a surgical emergency. Any delay at the scene of injury or in the ED may jeopardize limb survival. Simultaneous execution of multiple tasks is thus essential to the rapid achievement of definitive treatment (4,5,8). Surgical in-
Figure 3. Plain radiograph displaying external fixator device applied for stabilization of the patient’s injury.
tervention within 4 – 8 h has been suggested as an appropriate target, so early consultation with an orthopedic surgeon is vital (26). Depending on the extent of injury, a vascular surgeon may need to be involved in the case as well (1,20). If the capability for this level of care is not available at your institution, transfer the patient as soon as possible to the closest trauma center. An algorithmic approach to the patient with a mangled extremity is outlined in Figure 2.
CASE CONCLUSION In the OR, the patient underwent irrigation, debridement, and placement of external fixator with insertion of antibiotic beads. Compartment pressures were within normal limits (diastolic blood pressure ⫺ compartment pressure ⬎ 20 mm Hg) and fasciotomy was avoided. Numerous operative revisions were ultimately required with skin grafting and latissimus dorsi free flap placement. To promote bone regeneration and lengthening, an Ilizarov external-fixation device with distractors was applied (Figure 3). The patient eventually required an autologous bone graft from his iliac crest to enable more complete healing. He was eventually discharged to an in-patient rehabilitation facility and, on follow-up, has been doing fairly well.
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444 2. Behrens F. Fractures with soft tissue injuries. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd edn. Philadelphia, PA: WB Saunders; 1992:391– 418. 3. Norris BL, Kellam JF. Soft tissue injury associated with high energy extremity trauma: principles of management. J Am Acad Orthop Surg 1997;5:37– 46. 4. Zalavaras CG, Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop Surg 2003;11:212–9. 5. Turen CH, Dube MA, LeCroy MC. Approach to the polytraumatized patient with musculoskeletal injuries. J Am Acad Orthop Surg 1999;7:154 – 65. 6. Wiss DA, Gelman H, Moldawer T. Gunshot wounds to the musculoskeletal system. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, eds. Skeletal trauma: fractures, dislocations, ligamentous injuries, 2nd edn. Philadelphia, PA: WB Saunders; 1992: 449 – 69. 7. Hoogendoorn JM, van der Werken C. The mangled leg: decision making based on scoring systems and outcome. Eur J Trauma 2002;28:1–10. 8. Patzakis MJ. Management of open fracture wounds. Instr Course Lect 1987;36:367–9. 9. O’Sullivan S, Hehir DJ. Diagnosis and management of vascular injury. Irish Med J 1998;91:126 – 8. 10. Wakai A, Winter DC, Street JT, Redmond PH. Pneumatic tourniquets in extremity surgery. J Am Acad Orthop Surg 2001;9: 345–51. 11. Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience. J Trauma 2003;54(5 Suppl):S221–5. 12. Chambers LW, Green DJ, Sample K, et al. Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during Operation Iraqi Freedom: one unit’s experience. J Trauma 2006;61:824 –30. 13. Bjerke HS. Extremity vascular trauma. October 23, 2003. Available at. http://www.emedicine.com/med/topic2812.htm. Accessed October 23, 2007. 14. Behrens F. Basic concepts and applications in open tibial fractures. Instr Course Lect 1984;33:124 –30. 15. Rush RM Jr, Kjorstad R, Starnes BW, Arrington E, Devine JD, Andersen CA. Application of the Mangled Extremity Severity Score in a combat setting. Mil Med 2007;172:777– 81. 16. Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am 2006;88: 2739 – 48. 17. Schwartz RJ, Jacobs LM, Gabram SG, Bennett-Jacobs B. Continuous quality improvement applied to a scientific assembly: the history of the Eastern Association for the Surgery of Trauma. J Trauma 1993;35:544 –9. 18. Arrigalla A, Bynoe R, Frykberg ER, Nagy K. Practice management guidelines for penetrating trauma to the lower extremity. Paper
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doi:10.1016/j.jemermed.2007.11.067
Trauma Reports
THE MANGLED EXTREMITY Regina Oakes,
MD,
Amy Urban,
MD,
and Phillip D. Levy,
MD, MPH
Department of Emergency Medicine, Detroit Receiving Hospital-Emergency Medicine Residency, Wayne State University School of Medicine, Detroit, Michigan Reprint Address: Phillip D. Levy, MD, MPH, Department of Emergency Medicine, Detroit Receiving Hospital-Emergency Medicine Residency, Wayne State University School of Medicine, 4201 St. Antoine, 6G, Detroit, MI 48201
e Abstract—The management of patients with severe extremity injuries involves focused efforts at limb salvage and mitigation of potential infectious complications. An indepth understanding of the proper approach to initial management is essential, as it may impact eventual outcome. The use of established scoring systems may predict those at greater risk and enable expeditious utilization of appropriate consultation services. This case-based review highlights critical aspects of patient care and provides a framework for the role of the Emergency Physician. © 2008 Elsevier Inc.
itor, which showed a sinus tachycardia. Fluid resuscitation was initiated with normal saline via two large-bore peripheral intravenous lines while he was placed on high-flow oxygen. On primary survey, the patient was anxious and uncomfortable. His airway was patent and he had normal breath sounds bilaterally. He was grossly intoxicated but able to follow commands, with a Glasgow Coma Scale score of 15. Other than a large wound to his left leg, no other injuries were obvious. Subsequent secondary survey revealed no evidence of external trauma to the rest of the body. The rest of the physical examination was fully unremarkable except for the left leg. A 25 ⫻ 15 cm wound was noted along the medial aspect of the left tibia with an obvious open fracture and significant tissue avulsion. The dorsalis pedis pulse was palpable. There was diminished range of motion, with an inability to plantar flex, dorsiflex, invert, and evert the left foot. In addition, the patient was unable to initiate contraction of the extensor hallucis longus and flexor hallucis longus muscles. Portable chest, lateral cervical spine, and pelvis radiographs were obtained with no abnormalities noted. Radiographic evaluation of the left lower extremity revealed comminuted fractures of the distal tibia and fibula with embedded multiple bullet fragments visible (Figure 1). The patient was given a tetanus vaccination booster as well as intravenous cefazolin and gentamicin. The wound was covered with a sterile dressing and splinted with emergent orthopedic consultation. Upon their eval-
e Keywords—mangled extremity; high-energy extremity injuries; wound management; severity score
CASE PRESENTATION A 44-year-old man was brought in by Emergency Medical Services after sustaining a single gunshot wound to the left leg. The patient reported significant pain with diminished sensation distal to the injury. He denied other injury or symptoms. The patient did not see the weapon used and heard one shot fired. On arrival to the hospital, initial vital signs were: blood pressure 126/79 mm Hg, pulse 113 beats/min, respirations 20 breaths/min, and pulse oximetry 98% on room air. He was immediately placed on a cardiac monTrauma Reports of the Emergency Medicine Residency Program, Wayne State University School of Medicine, Detroit Receiving Hospital.
RECEIVED: 15 June 2007; FINAL ACCEPTED: 7 November 2007
SUBMISSION RECEIVED:
24 October 2007; 437
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Figure 1. Plain radiograph of the left leg showing comminuted fractures of the tibia and fibula with radiopaque bullet fragments. Complete destruction of the distal tibial diaphysis is visible with extensive overlying soft tissue injury.
uation, the patient was taken to the operating room (OR) for planned irrigation, debridement, compartment pressure monitoring, and external fixation.
DISCUSSION “As the energy exerted to an extremity increases, so does the severity of the multiple components of that injury. Although these components must be individually assessed, their sum represents the “personality” of the particular injury . . .” —RJ Brumback (1)
Extremity injuries resulting from high-energy forces are relatively common in today’s modern, industrialized world (2). Often these injuries are complex, with extensive osseous, neurovascular, ligamentous and soft-tissue damage (3–5). In general, the magnitude of destruction is proportional to the kinetic energy and degree of force applied to the limb in relation to the ability to dissipate the impact (1). Many of these injuries involve an open fracture, with a resultant increase in morbidity through wound contamination (3,4). The majority of high-energy extremity injuries are caused by blunt trauma from motor-vehicle collisions, falls, or industrial accidents (Table 1) with crush or avulsion damage to the affected limb (2). Only 2% are due to gunshot wounds (GSW), with the pattern of injury determined largely by the characteristics of the bullet
(caliber, jacketing, shotgun pellets) and the gun used to propel it (velocity, distance to impact). Unlike blunt trauma, however, damage from GSWs can be inflicted by several differing means (6). Crush and laceration injuries are caused by direct contact of the bullet with the soft tissues, and tend to be the only form of damage induced by low-velocity handgun. With higher-velocity projectiles, additional damage results from a shock wave caused by compression of the tissue deep to the site of impact. A temporary cavity, referred to as a “cone of cavitation,” may also be produced by stretch forces imparted on the tissue by the projectile, with significant resulting deformation (6). As this cavity collapses, a pressure differential is created, drawing material in from the bullet entry and exit site. This effect can lead to foreign body retention deep within the extremity, thus creating a nidus with potential for development of an infection. The collapse of this temporary cavity, in addition to the area created by a crush injury, can possibly lead to the formation of a permanent cavity. Due to this, it may be difficult to determine the extent of injury from a GSW based on the surface pattern alone, and even benign-appearing wounds may be associated with severe damage (6). INITIAL RESUSCITATION AND ATLS Patients who present to the Emergency Department (ED) with a high-energy extremity injury (also known as “mangled extremity”) may have other injuries that take priority. Forty to seventy percent will have injuries elsewhere, including intracranial lesions, cardiothoracic or abdominal disruptions, and other fractures or ligamentous damage (2–5). Therefore, the initial management should generally follow the protocols of Advanced Trauma Life Support (ATLS). Although a severely damaged limb can be visually impressive, attention to the ABCs (airway, breathing and circulation) must take precedence, and efforts to salvage the limb should not supersede efforts to attain hemodynamic stability (5,7,8). Prehospital personnel often cover open wounds with sterile dressings and splint obvious fractures. If a de-
Table 1. Causes of High-Energy Extremity Injuries in Civilians* Motorcycle accidents Motor vehicle crash Falls Pedestrian struck Crush injuries Firearms Miscellaneous * Reference (35).
28% 24% 13% 12% 8% 2% 13%
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formed extremity has not already been aligned, reduced, and splinted, this should be performed as soon as it is feasible (4,9). External hemorrhage may be controlled using application of manual pressure or a compressive dressing to blood vessels proximal to the extremity (5). “Modern” pneumatic tourniquet systems designed to minimize potential complications have recently been developed and are widely used during prehospital transport in the military setting as an adjunct to compressive dressings or when direct pressure fails (10 –12). Such tourniquet systems have been used to prevent exsanguination and assist with hemodynamic stabilization, however, knowledge in proper application and utilization is essential to avoid tourniquet-induced ischemiaperfusion-injury (10,11,13). Of particular importance is the total tourniquet application time. Although there has not been a prospective randomized clinical trial of tourniquet application times, a maximal period of 1.5 to 3 h is often targeted intra-operatively (10). A retrospective study by the Israeli military noted an increased prevalence of neurological complications when induced limb hypoperfusion exceeded 150 min (11). There are general recommendations to perform temporary tourniquet release at regular 20-min intervals during long transport times but this alone will not prevent the ischemic effects of prolonged tourniquet application times (10,14). Although similar in principle to limb tourniquets, pneumatic antishock garments are associated with an increase in mortality and their use in routine clinical practice is not recommended. Recombinant factor VII and other clot-promoting bandages are under investigation by the military and are currently in use during aggressive resuscitations to control hemorrhage. However, there is limited evidence regarding their utility and they may not be applicable to civilian circumstances (15).
SOFT TISSUE ASSESSMENT AND RADIOLOGICAL STUDIES Dressings and splints placed by prehospital providers must be fully removed to enable adequate assessment of soft tissue damage and neuromuscular function, but this should not occur repeatedly as the process of undressing and redressing wounds can increase the infection rate three- to fourfold (2). Exploring the wound in the ED is generally not indicated, especially for those in whom immediate operative intervention is planned, as this can further contaminate the wound and precipitate hemorrhage. If there is a delay in transit to the OR, the wound may be gently flushed with 1 or 2 L of sterile normal saline and dressed with sterile saline-soaked gauze pads (4,5,16). Removal of non-viable bony fragments or obvious foreign bodies should be performed under
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sterile conditions, ideally in the OR, in an effort to reduce the frequency of manipulation and the chance for infection (2). Radiographic evaluation is critical to identify the extent of skeletal injury. If the patient has other injuries, standard trauma films (chest, pelvis, and lateral cervical spine) should be obtained before any extremity radiographs. Liberal use of subsequent extremity radiographs is recommended based on observed injury patterns and localized bony pain (4,5,17). In general, the joint above and below the affected limb should be radiographically assessed, with computed tomography preferred if there is joint involvement (4,18). After radiographs have been obtained, many orthopedic surgeons advocate taking Polaroid© or digital photographs of the mangled limb, to document both the extent of the initial injury, and to serve as a record for postoperative progress toward (or away from) a viable extremity. These images can also be used to communicate the injury pattern, potentially obviating the need for repeated inspection (4).
VASCULAR EVALUATION After primary survey and initial resuscitation, the mangled extremity should be thoroughly examined for vascular injury. Injury patterns that are highly associated with vascular disruption include supracondylar fractures in children, posterior knee dislocations, fractures of the distal femur and proximal tibia, and penetrating injuries of the medial or posterior thigh (9,19). Whereas shock and hypotension promote early soft tissue necrosis, limb ischemia is the single most important factor in determining the outcome of an extremity injury with apparent vascular compromise. The goal of the trauma team is to keep the interval between injury and reperfusion of the limb to ⬍ 6 h (17,19,20). Restoration of arterial continuity within this time limit may prevent complications related to soft tissue damage such as compartment syndrome, ischemic contractures, arteriovenous fistula, or loss of the limb (19,21). “Hard signs” of vascular injury such as pulsatile bleeding, a palpable arterial thrill or audible bruit, signs of distal ischemia, or a visible expanding hematoma mandate further diagnostic evaluation or immediate operative intervention (8,13). These physical findings, however, are present in only 30% of those with vascular injury and it is important to maintain a high degree of suspicion even when such signs are absent. Contrast arteriography is the diagnostic modality of choice for identification of suspected vascular disruption and early use may prevent unnecessary surgical exploration (9).
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“Soft signs” of vascular injury including non-pulsatile hematoma, a history of “possible” arterial hemorrhage (i.e., a report of pulsatile bleeding by initial providers when no such bleeding is visible at the time of ED examination), delayed capillary filling, paresthesias, or a temperature gradient between limbs have also been proposed, but are less likely to be of importance in the truly mangled extremity. For less severe injuries, however, these findings should prompt close observation, a precise and well-documented physical examination, and interval reassessment of extremity perfusion (19). Further vascular evaluation using angiography or Doppler ultrasound, however, is not routinely indicated and should be reserved for those patients with clinical deterioration (13,18). The ankle to brachial index (ABI) enables rapid assessment of extremity vascular flow and may be a particularly useful adjunct for this group. The ABI is obtained by using a blood pressure cuff to measure the systolic pressure at the largest point of the ankle and dividing it by the systolic pressure of either arm. If the ABI is ⬎ 0.9, observation is recommended; if ⬍ 0.9, further evaluation is warranted with contrast arteriography in a stable patient and operative exploration in a hemodynamically unstable or hemorrhaging patient (13,18).
DESCRIPTION AND CLASSIFICATION OF ORTHOPEDIC INJURY Emergency Physicians should be prepared to recognize and describe the fracture pattern to orthopedic consultants. A systematic approach using the acronym NOLARD may be useful for this purpose. NOLARD stands for the following: neurovascular status of the extremity (N), open vs. closed (O), location (L), angulation/alignment/articular involvement (A), rotation (R), and displacement (D). Other components that should be addressed for accurate description include mechanism of injury, muscle crush or loss, and degree of contamination. The Gustilo classification of open fractures (Table 2) provides objective
terminology that may assist Emergency Physicians with their ability to describe the potential for wound contamination through clarification of the size of the soft tissue defect, presence or absence of contusion, the complexity of the bony lesion, and the degree of fracture comminution (16,22). There may be significant inter-observer variability in assignment of the class of injury, however, especially when applied by individuals who are not widely familiar with its components (23). Care must be taken, therefore, to avoid definitive prognostication based on a single assessment alone.
FRACTURE STABILIZATION When managing a severely deformed extremity injury, stabilization is a critical component. Although definitive management is ultimately achieved through the use of internal or external orthopedic fixation, splinting may be a life- or limb-saving temporizing measure. A reduced and splinted fracture can ease patient transportation and provide a measure of comfort. Early realignment may improve apparent neurovascular compromise, reducing further ischemia and diminishing the potential for development of compartment syndrome. Additionally, when optimal blood flow is available to a mangled limb, the rate of infection is decreased and wound healing is enhanced (2,5). Operative fixation of unstable fractures of the pelvis, femur, and tibia using internal or external implants should be performed within the first 24 h if medically possible (4,5,16). This allows for early joint motion and mobilization, decreased musculoskeletal morbidity, and decreased hospital stay (5).
TETANUS PROPHYLAXIS AND ANTIBIOTIC THERAPY Mangled extremity wounds are considered to be highly tetanus prone, and prophylaxis with tetanus toxoid
Table 2. The Gustillo Classification of Open Fractures* I II III IIIA IIIB IIIC
A fracture with a clean cutaneous wound ⬍ 1 cm in length usually from inside to outside; minimal muscle contusion. Simple transverse or short oblique fractures A fracture with laceration ⬎ 1 cm in length without severe soft tissue damage; minimal to moderate crushing component. Simple transverse or short oblique fractures with minimal comminution A fracture with significant soft tissue loss; extensive soft tissue damage including muscles, skin, and neurovascular structures. Often a high energy injury with severe crushing component A fracture with adequate soft tissue coverage, despite extensive cutaneous lacerations or flaps. High energy trauma regardless of wound size; segmental fracture, gunshot wound, minimal periosteal stripping. Extensive injury of the soft tissue; periosteal stripping and soft tissue gaps, bone exposure requiring soft tissue flap closure. Usually associated with massive contamination Any open fracture with arterial injury which requires repair, regardless of degree of soft tissue destruction.
* References (24,25).
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Table 3. Mangled Extremity Severity Score* Components of Score Skeletal/soft tissue injury Low energy (stab, simple fracture, “civilian” GSW Medium energy (open or multiple fractures, dislocation) High energy (close-range shotgun, “military” GSW, crush injury) Very high energy (above ⫹ gross contamination, soft-tissue avulsion) Limb ischemia Pulse reduced or absent but normal perfusion Pulseless, parasthesias, diminished capillary refill Cool, paralyzed, insensate limb Shock Systolic blood pressure always ⬎ 90 mm Hg Hypotensive transiently Persistent hypotension Age (years) ⬍30 30–50 ⬎50
Points 1 2 3 4 1† 2† 3† 0 1 2 0 1 2
* Reference (26). † Score doubled for ischemia ⬎ 6 h.
should be administered to those patients with uncertain or deficient immunization status. Tetanus immunoglobulin should also be considered for those with no history of prior immunization. In addition, these injuries are at high risk for bacterial contamination, with reported rates of close to 65% (2,4,16). As such, early initiation of antibiotic prophylaxis should be considered in virtually all cases. Although GSWs were long considered to be sterile, recent data have shown that they are exceedingly susceptible to contamination from the bullet or shotgun wading itself, imbedded clothing fragments, and other foreign materials (24). There is an increased risk of infectious complications with advanced age and comorbid conditions such as diabetes mellitus, peripheral vascular disease, or immunosuppression (2). The beneficial role of antibiotics for open fractures has been clearly demonstrated in prospective randomized trials, and parenteral administration should be initiated as soon as possible after arrival at the ED (optimal time ⬍ 3 h from onset of injury) (25,26). Whereas selection of appropriate systemic antibiotics depends on the severity of soft tissue injury and existence of potential contaminating agents, etiology itself is not an important discriminating factor. Skin flora such as Staphylococcus epidermidis, Proprionobacterium acnes, Corynebacterium spp., and Micrococcus spp. have long been considered the most common causative organisms of wound infection, and initial therapy should be directed toward them (26,27). Recent studies have noted the emergence of nosocomial organisms such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus, espe-
cially in patients who have undergone debridement and operative intervention underscoring the need for early, routine antibiotic administration (4,16). Wound cultures may assist with organism identification but there is little evidence to show that they actually impact eventual management (16). Despite demonstration of clinical effectiveness, there is a paucity of evidence regarding the optimal antibiotic regimen for treatment of mangled extremity injuries. Current recommendations advocate monotherapy with a first-generation cephalosporin that provides adequate Gram-positive coverage (i.e., cefazolin) for all Gustilo type I (and some Gustilo type II) open fractures and closed fractures with significant soft tissue destruction (4,16). An aminoglycoside (usually gentamicin) should be added for type Gustilo II and III open fractures for better Gram-negative coverage. If the injury occurred on farmland with agricultural equipment or the wound has heavy soil contamination, penicillin (or clindamycin, if penicillin allergic) should be added to the antibiotic regimen to cover Clostridium spp. Patients with diabetes mellitus and those with wounds contaminated by bowel contents may also be at risk for clostridial infections (4,16). Antibiotic therapy should continue for 48 –72 h post-injury and again for 48 –72 h each time a further procedure is performed. Restrictive antibiotic utilization in this fashion will help prevent the emergence of resistant organisms (2). Use of antibiotic impregnated beads may diminish protracted infectious complications, but this is an operative decision outside of the realm of ED management (4,16).
THE MANGLED EXTREMITY SEVERITY SCORE The Mangled Extremity Severity Score (MESS) was developed to be a clinically applicable scoring system to predict limb salvage in the mangled lower extremity (Table 3). Although generally used by orthopedic and
Table 4. Evidence-Based Pearls Initial management Avoid temptation to focus solely on extremity injury Avoid wound exploration or debridement Obtain radiographs of joint above and below apparent injury Assess for vascular injury Look for “hard” and “soft” signs Use ankle-brachial index and angiography judiciously Outcome improved by Early splinting Temporization of hemorrhage and restoration of limb perfusion Antibiotic therapy within 3 hours of presentation Rapid initiation of operative care
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vascular surgeons, this simple system can be practical in the ED as well. The MESS score incorporates four major clinical variables, all generally available at the initial ED evaluation: skeletal/soft tissue injury, limb ischemia, shock, and patient age. The MESS system was based on a retrospective case review of 26 mangled lower extremities and then validated with a prospective trial of 26 patients at a separate trauma center (28). In both trials, a MESS score of ⬍ 7 was able to predict limb salvage with 100% accuracy (28,29). Further trials have attempted to validate these findings, with variable results (15,30).
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Other lower extremity injury scoring systems have been devised, but are less widely used. These include the Limb Salvage Index, the Predictive Salvage Index, the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score, and the Hannover Fracture Scale-97 for ischemic and non-ischemic limbs (22,30,31). As a general rule, lower scores correlate with increasing limb-salvage potential. Overall, however, none are considered to be sufficiently predictive to enable derivation of an amputation threshold (30). Of further note, these scoring systems have limited applicabil-
Figure 2. Algorithm for evaluation and management of blunt abdominal trauma.
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ity for upper extremity injuries and should be used cautiously in the pediatric population (32,33).
OTHER CONSIDERATIONS In addition to infection, malunion, and limb loss, other potential complications of long bone fractures may need to be addressed after immediate resuscitation. These include fat embolism, deep venous thrombosis and pulmonary embolism, bleeding disorders (i.e., disseminated intravascular coagulopathy), Acute Respiratory Distress Syndrome, myositis ossificans, post-traumatic osteoarthritis, and reflex sympathetic dystrophy (5).
AUTHOR’S RECOMMENDATIONS The revascularization or reimplantation of a mangled extremity is now the preferred alternative to amputation in patients with a moderate or better chance of limb salvation (2,34). To facilitate this objective, an Emergency Physician must be able to properly stabilize the patient, provide an appropriate assessment, and initiate the optimal preliminary care (Table 4). Although the limb injury may be particularly distracting due to its dramatic presentation, hemodynamic stability must take initial precedence in the resuscitative effort (1,4,5,8,14). Once established, complete and thorough evaluation of the musculoskeletal, neurologic, and vascular status of the extremity will allow for classification and guidance of treatment (1,2,4,5,8,14). Calculation of the MESS (or other injury severity score) may be helpful for the determination of potential limb viability, but is not sufficiently predictive for definitive decision-making (30). A clean wound is the ultimate goal, and this is best achieved through aggressive irrigation and debridement in the OR (1,5). Avoid the temptation to explore the wound and remove debris in the ED. Treat soft tissue damage conservatively through application of a salinesoaked gauze dressing. All fractures should then be reduced or splinted (5). Early prophylaxis against infectious complication is essential due to the high rate of associated morbidity (1,3,4). Antibiotics should be administered as soon as possible. Tetanus immunoglobulin and toxoid should be administered if indicated. Expeditious management in this fashion may prevent compartment syndrome, limit the extent of neuromuscular damage, and enhance the likelihood of successful recovery. An open fracture should always be considered a surgical emergency. Any delay at the scene of injury or in the ED may jeopardize limb survival. Simultaneous execution of multiple tasks is thus essential to the rapid achievement of definitive treatment (4,5,8). Surgical in-
Figure 3. Plain radiograph displaying external fixator device applied for stabilization of the patient’s injury.
tervention within 4 – 8 h has been suggested as an appropriate target, so early consultation with an orthopedic surgeon is vital (26). Depending on the extent of injury, a vascular surgeon may need to be involved in the case as well (1,20). If the capability for this level of care is not available at your institution, transfer the patient as soon as possible to the closest trauma center. An algorithmic approach to the patient with a mangled extremity is outlined in Figure 2.
CASE CONCLUSION In the OR, the patient underwent irrigation, debridement, and placement of external fixator with insertion of antibiotic beads. Compartment pressures were within normal limits (diastolic blood pressure ⫺ compartment pressure ⬎ 20 mm Hg) and fasciotomy was avoided. Numerous operative revisions were ultimately required with skin grafting and latissimus dorsi free flap placement. To promote bone regeneration and lengthening, an Ilizarov external-fixation device with distractors was applied (Figure 3). The patient eventually required an autologous bone graft from his iliac crest to enable more complete healing. He was eventually discharged to an in-patient rehabilitation facility and, on follow-up, has been doing fairly well.
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