Download - Limb salvage in severe trauma
DR. Fathi NeanaChief of Orthopaedics
DR. Fakhry and Alrajhy HospitalSaudi Arabia
November17, 2016
LIMB SALVAGEIN
SEVERE TRAUMA
Mangled Extremity
Skin/Soft tissue loss
Fracture/bone loss
Vascular injury
Nerve injury
Limb Complex Multisystem Injury(Mangled Extremity)
A limb with an injury to at least three out of four systems (soft tissue, bone, nerves, and vessels)
Limb Complex Multisystem Injury (Mangled Extremity)High Energy Trauma
1 -Blunt trauma
2 -Motor vehicle crashes
3 -Industrial/Farm accidents
4 -Falls from a height
5 -High-velocity gunshots
6a- Explosion injuries
6b- Specific subgroup
Blast injuries in the Middle East
Blast Injury
Blast Injury
DIME (Dense Inert Metal Explosives)
White Phosphorus
BONE DEFECT (BONE LOSS)
ETIOLOGY OF BONE LOSS(BONE DEFECT)
Traumatic (Open Fractures) Blast injuries
Segmental FracturesPost debridement
Non Traumatic Resection of swelling
InfectionOsteonecrosis
INJURY EVALUATIONWhat we are dealing with
INJURY EVALUATIONWhat we are dealing with
1- FRACTURE CLASSIFICATION
2- SKIN INJURYClosed fractures (IC ) 5 GRADESOpen fractures (IO ) 5 GRADES
3- NEUROVASCULAR INJURY(NV) 5 GRADES
4- MUSCLE/TENDON INJURY(MT) 5 GRADES
FRACTURE CLASSIFICATION
AO soft-tissue classification: closed skin lesions (IC).
IC 1No skin lesionIC 2No skin laceration, but contusionIC 3Circumscribed deglovingIC 4Extensive, closed deglovingIC5Necrosis from contusion
AO soft-tissue classification: open skin lesions (IO).IO 1Skin breakage from inside outIO 2Skin breakage from outside in < 5 cm, contused edgesIO 3Skin breakage from outside in > 5 cm, increased contusion,
devitalized edgesIO 4Considerable, full-thickness contusion, abrasion, extensive
open degloving, skin lossIO5Extensive degloving
SKIN INJURY
CLOSED SKIN LESIONS (IC) 5 GRADES
OPEN SKIN LESIONS IO 5 GRADES
NEUROVASCULAR INJURYNV 5 GRADES
MUSCLE/TENDON INJURYMT 5 GRADES
Skeletal /42-C3 Soft Tissues /IO4-MT4-NV5
INJURY EVALUATIONWhat we are dealing with
PERSONALITY OF THE INJURYGlobal vs Key hole vision
(The Injured limb) Soft tissue envelope
Infection Joint contracture and range of motion
Nerve function : sensation, motor Vasculature : perfusion, angiogram ?
Location and size of the defect
(The Patient) General health of the Host
(The Hospital) Hardware , Equipments & Medical staff
(The Resources) Psychosocial & Economic
A DECISION HAVE TO BE MADE
Amputation + Prosthesisvs.
Limb salvage procedure
AMPUTATION VS. SALVAGEPotential Scenarios
Immediate amputation
Attempted salvage with early amputation
Successful salvage
Unsuccessful salvage with late amputation
1- Personality of injury
The injured limb
The patient
The health care environment
Psycho Social Resources
2- Scoring system !
AMPUTATION VS. SALVAGEGUIDELINES – OUTCOME
AMPUTATION VS. SALVAGEGUIDELINES
SCORING SYSTEM ! MANGLED EXTREMITY
SEVERITY SCORE(MESS)
AMPUTATION COSIDERED IN TOTAL SCORE > 7
BONE & SOFT TISSUE GROUPLOW ENERGY 1MEDIUM ENERGY 2HIGH ENERGY 3MASSIVE CRUSH 4
SHOCK GROUPNORMOTENSIVE 0TRANSIENT HYPOTENSION 1PROLONGED HYPOTENSION 2ADVANCED 3
ISCHAEMIA GROUPNONE 0MILD 1MODERATE 2ADVANCED 3
AGE GROUP < 30 Y. 030-50 Y. 1> 50 Y. 2
Nowadays Advances in evacuation, resuscitation, wound care, free tissue transfer, and internal fixation make it nowadays
possible to salvage limbs that would have been amputated in the past
HistoricallyMangled extremities
have been associated withvery high amputation rates
LIMB AMPUTATION
Mangled Extremity Severity Score(MESS) > 7
The decision of Primary Amputation in the acute setting is difficult for the patient, family, & the treating surgical team
The majority of mangled extremities are potentially salvageable for which, in the acute setting, a treatment plan needs to be made
Amputation is indicated in
1- Patients with complete traumatic irreparable disruption
2- Prolonged limb ischemia
3- Severe soft-tissue loss that cannot be reconstructed
4- Concurrent life-threatening injuries in an unstable polytrauma patient
The alternative is prolonged unsuccessful attempts at limb
salvage
Subjecting the patient to great physical, psychological, financial, and social
suffering
LIMB SALVAGE
Mangled Extremity Severity Score(MESS) < 7
1- 1- Prolonged hospital stay
2- Multiple operations
3- Complication rate
4- Delayed amputation level
5- Psychological attachment
6- Economic disability
7- Medico legal problems
8- May be useless limb
Please remember A failed limb salvage or a
salvaged useless limb can be Devastating to the patient functionally,
economically & psychologically
LIMB SALVAGE PROBLEMS
LIMB SALVAGE TREATMENT PHILSOPHY
1-Stop the Injury (ABC)
2. Stop the Pathogens (Debridment,Irrigation,Antibiotics)
3. Do not harm (Surgical Trauma)(live, clean, manageable tissues)
4. Low risk procedures (DCO Principals)(Spanning frames,Unreamed nails, Open wounds)
5. Define Objectives (Union,Alingment,Function)
LIMB SALVAGE Management Priorities (6R)
Resuscitate
Restore blood supply
Remove dead & infected tissue
Restore soft tissue envelope
Restore skeletal stability
Rehabilitation
LIMB SALVAGE PROCEDURE
Irrigation & Debridement
External fixation
Antibiotic bead spacers
Soft tissue coverage
Restore Skeletal Stability (Salvage of Bone Defect)
LIMB SALVAGE PROCEDURE
Irrigation & Debridement
External fixation
Antibiotic bead spacers
Soft tissue coverage
Restore Skeletal Stability (Salvage of Bone Defect)
LIMB SALVAGE PROCEDURE
Irrigation & Debridement
External fixation
Antibiotic bead spacers
Soft tissue coverage
Restore Skeletal Stability (Salvage of Bone Defect)
LIMB SALVAGE PROCEDURE
Irrigation & Debridement
External fixation
Antibiotic bead spacers
Soft tissue coverage
Restore Skeletal Stability (Salvage of Bone Defect)
LIMB SALVAGE PROCEDURE
Irrigation & Debridement
External fixation
Antibiotic bead spacers
Soft tissue coverage
Restore Skeletal Stability (Salvage of Bone Defect)