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Official reprint from UpToDate www.uptodate.com ©2014 UpToDate

AuthorsJeremy W Cannon, MD, FACSTodd E Rasmussen, MD, FACS

Section EditorsHeidi L Frankel, MD, FACSJohn F Eidt, MDJoseph L Mills, Sr, MD

Deputy EditorKathryn A Collins, MD, PhD, FACS

Severe extremity injury in the adult patient

Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Dec 2013. | This topic last updated: oct 22, 2013.

INTRODUCTION — Trauma to the extremities represents one of the most common injury patterns seen in

emergency medical and surgical practice. As extremity injuries are evaluated, each of four functional

components (nerves, vessels, bones, and soft tissues) must be considered individually and together. If three of

these four elements are injured, the patient has a “mangled extremity” [1]. Achieving the best outcome in

patients with severe extremity injuries requires a multidisciplinary approach with oversight by the general or

trauma surgeon and commitment from other specialists including orthopedic, vascular, and plastic surgeons, as

well as rehabilitation specialists. In most instances, limb salvage can be attempted even if the patient has a

mangled extremity. However, at times, the injury to the extremity is so severe that primary amputation at the

initial operation is required to save the patient’s life.

The initial management of severe extremity injury will be reviewed here. The management of minor extremity

injuries, including isolated fracture management, is discussed elsewhere. (See "General principles of fracture

management: Bone healing and fracture description" and "General principles of fracture management: Early and

late complications" and "General principles of acute fracture management" and "General principles of definitive

fracture management".)

ETIOLOGY — The etiology of extremity injuries ranges widely from falls and motor vehicle collisions to blast

and fragmentation injuries. The nature and severity of extremity injuries differs between the military and civilian

setting. Military extremity injuries are primarily due to penetrating or combined mechanisms, which are

associated with high rates of open fracture and vascular injury [2]. In contrast, most severe extremity injuries in

civilians are due to blunt trauma, but about 12 percent of civilian extremity injures occur as a result of

penetrating or combined mechanisms.

Civilian — Civilian extremity injuries occur most often due to falls (representing 50 to 60 percent of lower

extremity injuries and 30 percent of upper extremity injuries), industrial or work-related accidents (up to 20

percent of upper extremity injuries), and motor vehicle crashes [3]. Most upper extremity injuries occur as a

result of using machinery or tools.

In civilians with nonfatal trauma, upper and lower extremity injuries are the most common reason for

hospitalization, with more than one-third of those hospitalized having serious or limb-threatening injuries [3-5].

Military — About 50 percent of the injuries recorded in the Joint Theater Trauma Registry involve the extremities

[6,7]. Many soldiers with extremity injuries also have other serious life-threatening injuries which complicate

limb salvage [8]. In one series, 25 percent had an extremity injury associated with another serious non-

extremity injury [2].

Most extremity wounds during combat have a penetrating component, typically resulting from explosions (81

percent) or gunshot wounds (17 percent). Only 2 percent of extremity injuries during combat are due to isolated

blunt trauma [6]. Because of the predominantly penetrating mechanism and war environment, many of these

injuries involve multiple functional components (bone, nerve, vessel and soft-tissue damage), resulting in a high

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rate of mangled extremities.

INCIDENCE — In 2012, 278,100 lower extremity injuries and 223,650 upper extremity injuries were entered into

the civilian National Trauma Data Bank (NTDB) [4]. Traumatic injury in civilians results in an estimated 3700

major amputations annually [3,9]. The contemporary incidence of extremity injuries during combat is lower than

in previous recorded conflicts representing about 50 percent of injuries, compared with about 59 percent during

World War II, 60.2 percent during the Korean War, and 61.1 percent in the Vietnam War [7].

The presence of an open fracture significantly increases the risk of osteomyelitis and, ultimately, limb loss

depending upon the severity of injury to the associated soft tissues. Open fractures occur in approximately 3

percent of long bone fractures for an annual incidence of between 11.5 and 13 per 100,000 [10,11]. The long

bone that is most commonly involved in open fracture is the tibia. In one study, 24 percent of tibial fractures

were open [12]. High-energy motor vehicle collisions were responsible for 58 percent of these injuries [11].

Associated vascular injuries occur in <1 percent of all civilian fractures (0.4 percent in one series) [13]. The risk

of vascular injury increases with increasing injury severity. In retrospective reviews, the incidence of vascular

injury was cited at 5 percent for severe fractures [10], and 6.6 percent for penetrating extremity injuries [14].

Among patients with arterial injury, bony injuries were present in 43 percent of patients, in a five-year

retrospective review [15]. Venous injuries occurred in 20 percent of the patients studied.

The presence of a vascular injury also increases the risk for limb loss. In a contemporary combat review (2002

to 2009), 1570 patients with vascular injuries were identified out of 13,076 casualties (12 percent). Of these, 79

percent involved the upper and lower extremities. Isolated extremity arterial injuries were documented in 63

percent, isolated extremity venous injuries in 15 percent, and combined arterial and venous injuries in 22

percent. Rates of vascular injury in prior conflicts ranged from 1 percent in World War II to 2 to 3 percent in

Korea and Vietnam [16].

EXTREMITY ANATOMY — Knowledge of extremity anatomy and functional physiology is important for proper

preoperative and postoperative extremity assessment. The anatomy of the upper and lower extremity is reviewed

elsewhere. (See "Surgical management of severe extremity injury", section on 'Extremity anatomy'.)

INITIAL EVALUATION AND MANAGEMENT — We perform initial resuscitation, diagnostic evaluation, and

management of the trauma patient with blunt or penetrating trauma based upon protocols from the Advanced

Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma

[17]. The initial resuscitation and evaluation of the patient with blunt or penetrating head, thoracic, or abdominal

trauma is discussed in detail elsewhere. Resuscitation and management of these life-threatening injuries takes

precedence over the extremity injury. (See "Initial evaluation and management of blunt thoracic trauma in adults"

and "Initial evaluation and management of penetrating thoracic trauma in adults".)

Control of hemorrhage — External bleeding from the extremity, and particularly bleeding from the junctional

segment of the extremity vasculature (ie, axillary artery, common femoral artery), is life-threatening and should

be controlled as soon as possible.

Bleeding from extremity vascular injury can usually be controlled using direct pressure. However, because

prolonged application of direct pressure, particularly bleeding from junctional vessels, is not practical during

transport in the prehospital or tactical environment, other approaches have been used including topical agents,

external compression clamps, and endovascular occlusion devices. These methods are not widely accepted in

mainstream civilian clinical practice and have not been endorsed by the American College of Surgeons in the

current version of the Advanced Trauma Life Support (ATLS) curriculum [17]. (See "Prehospital care of the adult

trauma patient", section on 'Hemorrhage control'.)

Bleeding can also be controlled using a tourniquet [18,19], or direct clamping of visible vessels. Clamping

vessels that cannot be clearly identified should not be performed. Pneumatic tourniquets are commonly used to

lessen bleeding during the course of upper and lower extremity surgery. There is renewed interest in the civilian

community in the use of tourniquets for control of extremity hemorrhage. The current version of Advanced

Trauma Life Support (ATLS) endorses the judicious use of a tourniquet for major extremity arterial hemorrhage,

and several civilian guidelines now include tourniquet application as a temporary adjunct to control extremity

hemorrhage when direct pressure is unsuccessful [20,21], or during tactical civilian events, which are situations

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where ballistic or explosive wounds are possible (eg, an active shooter standoff) [22]. (See "Prehospital care of

the adult trauma patient", section on 'Hemorrhage control'.)

A variety of tourniquets have been developed to manage combat-related extremity hemorrhage with a low risk of

ischemia and neurologic complications [23,24]. The Combat Application Tourniquet (CAT), Emergency and

Medical Tourniquet (EMT), and Special Operations Forces Tactical Tourniquet (SOFTT) meet the effectiveness

standard of the United States military and occlude distal flow in >80 percent of subjects [23,24]. The relative

effectiveness of these tourniquets has been evaluated in human volunteers with each shown to attenuate the

distal arterial pulse in upper and lower extremities [25]. The benefits of tourniquet application are illustrated in

the following studies in combat casualty populations:

Extremity radiography — Patients with any of the following findings on primary trauma survey should undergo

plain radiographs. Radiographic assessment should focus on the area of abnormality to include a joint above

and below the potential injury, and the study should be performed with two projections (eg, anterior-posterior and

lateral).

Bony injuries, particularly comminuted fractures, increase the risk of concomitant arterial injury (table 1) and

include fractures of the proximal humerus, humeral shaft (image 1), distal radius or ulna, mid-femur (image 2),

and mid- or distal tibia-fibula fractures (image 3). The presence of these fractures on radiographic survey should

prompt full vascular assessment. (See 'Vascular assessment' below.)

Antibiotics — Systemic antibiotics should be started at the time of the diagnosis of open fracture. The open

fracture site should be cleaned of any foreign debris and dressed with a moist sterile dressing. (See "Treatment

and prevention of osteomyelitis following trauma".)

Tetanus prophylaxis — Tetanus prophylaxis should be given according to the Centers for Disease Control

(CDC) guidelines [26]. (See "Tetanus-diphtheria toxoid vaccination in adults", section on 'Immunization for

patients with injuries'.)

Special situations — Two clinical scenarios involving extremity injury require specific management: traumatic

amputation and electrical injury.

Traumatic amputation — Traumatic amputation refers to limb loss that occurs in the field at the time of

the initial trauma and is a special form of the mangled extremity. It is distinguished from primary amputation,

which is removal of the limb during initial operative management, and secondary amputation, which is removal of

the limb following attempted limb salvage. (See "Surgical management of severe extremity injury", section on

'Limb salvage versus amputation' and "Lower extremity amputation".)

Upper or lower limb replantation may be possible if the distal detached extremity is relatively uninjured [27-29].

Replantation is performed more commonly for traumatic upper extremity amputations. In the lower extremity, a

prosthesis provides a good functional outcome that, in some cases, may be superior to that achieved with

replantation.

In a study that evaluated 165 patients, 67 of whom had a prehospital tourniquet applied, control of bleeding

was significantly improved with tourniquet application versus no tourniquet (83.3 versus 60.7 percent), and

there were no differences in secondary amputation rates [23].

●

A prospective study of 232 combat casualties found a significantly improved survival rate (77 percent

versus 0 percent) when using a tourniquet (prehospital or emergency department) versus no tourniquet

[24]. In this study, no amputations were required due to tourniquet use, but four transient nerve palsies

were reported.

●

Extremity deformity●

Point tenderness●

Ecchymosis ●

Laceration deep to the muscle fascia●

Laceration in proximity to a joint●

Joint laxity●

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Warm ischemia time should be limited by wrapping the amputated body part in saline-soaked gauze or by

indirect cooling (placing the body part in a container and then placing the container on ice). The extremity

should not be exposed directly to ice.

A multidisciplinary decision for replantation is made at the receiving facility with input from the trauma surgeon

overseeing the patient’s care, taking into consideration the patient’s other injuries, and with input from

subspecialists in orthopedic, plastic, and vascular surgery regarding feasibility of replantation and likely

projected outcomes.

Extremity electrical injury — The upper extremity is commonly involved in electrical injuries which can

result in significant soft tissue damage. These injuries are stratified into two groups based upon the voltage

involved: low voltage (ie, <1000 volts) and high voltage (≥1000 volts). The epidemiology, diagnosis, and general

issues of the treatment of electrical injuries are discussed in detail elsewhere. (See "Environmental electrical

injuries".)

Soft tissue damage occurring between the entrance and exit wounds can be substantial with high-voltage

injuries. Amputation is necessary in up to 40 percent of these cases, which is not surprising given the large

volume of soft tissue loss [30]. The involved soft tissues should closely monitored for necrosis and vascular

thrombosis [31]. Reconstruction can be undertaken once the full extent of soft tissue injury has manifested.

Compartment syndrome should be anticipated with high voltage injuries and early fasciotomy should be

performed as indicated. (See "Lower extremity fasciotomy techniques" and "Patient management following

extremity fasciotomy".)

EXTREMITY EVALUATION — A brief extremity exam is performed during the initial trauma assessment

(primary survey) but should be repeated in more detail once life-threatening injuries have been addressed and

any active external bleeding is controlled. The extremity evaluation should proceed in an orderly fashion using

the four functional elements of the extremity as a framework, which includes assessment of the nerves, vessels,

bones, and soft tissues.

Peripheral nerve assessment — The neurologic exam in alert, cooperative patients should easily identify

associated motor or sensory deficits. In the unconscious or uncooperative patient, gross deficits should be

noted, such as a lack of movement in all or part of an extremity, or asymmetric movements. Detailed ongoing

extremity evaluation should be performed as the patient’s neurologic status improves to identify specific deficits

referable to peripheral nerve injury.

In the lower extremity, function of the femoral, sciatic, tibial, and peroneal nerves should be assessed since

these nerves are more likely to be directly injured or affected by ischemia.

Although lack of plantar sensation has historically been taught as determining that a lower extremity is

nonviable, subsequent data have found that this is not a reliable physical finding because patients with an

insensate foot on initial exam can subsequently regain function [32]. (See "Surgical management of severe

extremity injury", section on 'Lower extremity anatomy'.)

In the upper extremity, the axillary nerve, radial nerve, and median nerve are all vulnerable to injury given their

anatomic course. The game of “rock, paper, scissors” is a quick way to assess the motor function of the

median, radial, and ulnar nerves, respectively [33]. (See "Surgical management of severe extremity injury",

section on 'Upper extremity anatomy'.)

Injury to the sciatic nerve results in decreased sensation on the medial thigh and weakness of hip flexion.●

Injury to the femoral nerve causes decreased sensation in the lateral thigh and leg, weakness of hip

extension, and loss of motor function of the leg and foot.

●

Deep peroneal nerve injury causes decreased sensation in the first dorsal webspace and causes foot drop.●

Injury to the tibial nerve results in loss of sensation to the heel, inability to plantar flex the foot, and cavus

deformity of the foot.

●

Injury to the axillary nerve (proximal humerus fractures) results in loss of arm abduction and an area of●

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Vascular assessment — A detailed vascular assessment of the injured extremity begins with a complete pulse

examination (common femoral, popliteal, dorsalis pedis and posterior tibial arteries, axillary, brachial, radial,

ulnar arteries) to identify asymmetry of pulses or the absence of palpable pulses. Auscultation over the injury

site may reveal a bruit that may be indicative of a partially thrombosed or compressed vessel. (See "Surgical

management of severe extremity injury", section on 'Lower extremity anatomy' and "Surgical management of

severe extremity injury", section on 'Upper extremity anatomy'.)

In the setting of a shock or the presence of joint dislocation or angulated fracture, the pulse assessment should

be repeated after resuscitation and/or reduction of the abnormality. In a study of combat injuries, 74 percent of

patients who had no pulses on initial examination had reestablished blood flow to the foot following resuscitation

and limb stabilization [34].

Hard signs of arterial injury — Hard signs of vascular injury include the following [4]:

In a large observation study of penetrating extremity trauma, the presence of a hard sign of arterial injury was

nearly 100 percent predictive of a vascular injury warranting surgical repair [14]. These patients should be taken

directly to the operating room where the injury can be surgically explored. If arteriography is needed to clarify

arterial anatomy, it can be performed intraoperatively.

With blunt trauma, hard signs are less reliable and false positives are common. Repeat physical examination

after resuscitation, warming, and reduction of any orthopedic injuries should be performed. If a diminished pulse

or other signs of vascular injury persist in the hemodynamically stable patient with blunt extremity injury,

angiography should be performed to further delineate the location and nature of the injury. (See 'Arteriography'

below.)

Injured extremity index — The injured extremity index (IEI) or arterial pressure index (API) is analogous to

the ankle-brachial index (ABI) and should be performed in any patient who does not have hard signs of vascular

injury. The term “injured extremity index” is a trauma-specific term that is broader and can be applied to the

upper or lower extremity. (See "Noninvasive diagnosis of arterial disease", section on 'Ankle-brachial index'.)

The IEI is the ratio of the highest systolic occlusion pressure in the injured extremity at the level of the dorsalis

pedis/posterior tibial (or radial/ulnar arteries) divided by the systolic pressure in a proximal vessel in an uninjured

extremity (most often the brachial artery). As an example, for an injured upper extremity, the higher value of the

radial or ulnar occlusion pressure in the injured extremity would be divided by the occlusion pressure of the

contralateral brachial artery.

numbness or paresthesia along the lateral aspect of the upper arm.

Radial nerve injury leads to loss of sensation on the dorsum of the hand and weakness of the wrist and

finger extensors.

●

Injury to the median nerve leads to decreased sensation on the palmar aspect of the first three digits and

weakness of the thenar musculature.

●

Injury to the ulnar nerve leads to decreased sensation on the palmar aspect of the fourth and fifth digits

and weakness of the flexors of these digits.

●

Active hemorrhage●

Expanding or pulsatile hematoma●

Bruit or thrill over wound●

Absent distal pulses●

Extremity ischemia (pain, pallor, paralysis, cool to touch)●

A normal IEI (ie, >0.9) has a high negative predictive value for vascular injury, allowing the patient to be

observed or managed without immediate vascular imaging [35,36].

●

An IEI that is abnormal (ie, ≤0.9) may indicate an occult vascular injury. For patients who are hypothermic

or hypotensive during the initial assessment, the IEI should be repeated 10 to 15 minutes after

resuscitation and warming. An IEI that is persistently below 0.9 is predictive of vascular injury that requires

●

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The diagnostic approach for patients with an IEI ≤0.9 should be within the context of the patient’s overall clinical

status and other associated injuries. In patients with multiple injuries who require head, torso, and abdominal

computed tomography (CT), adding extremity CT angiography is a rational choice. The information obtained with

respect to the extremity (positive or negative) assists the trauma surgeon in determining which injuries to

manage first.

For isolated extremity injuries or injuries with less complex associated injuries, the approach should be more

individualized. Some patients may benefit from immediate surgical exploration and others from digital

subtraction arteriography (DSA) rather than CT angiography. Every effort should be made to avoid an algorithm

that exposes the patient to excessive radiation and intravenous contrast load such as CT angiography followed

by DSA, which usually occurs in the context of seeking to better define subtle irregularities [37]. Consultation

with a vascular surgeon can help aid with decision-making.

Arteriography — Arteriography, which can be accomplished using computed tomographic (CT) or

conventional digital subtraction angiography (DSA), may be necessary to exclude vascular injury in

hemodynamically stable patients with clinical signs consistent with potential vascular injury, such as an

equivocal pulse examination, persistently diminished injured extremity index (IEI) in spite of resuscitation, and

posterior knee dislocation. (See 'Injured extremity index' above.)

The need for vascular repair (open or endovascular) should be determined in the context of clinical findings in

conjunction with an arteriographic study that shows a vascular injury. The clinical findings also establish the

timing or urgency of the operation. In the context of a clinical examination, the following findings on

arteriography (CT or DSA) strongly indicate the need for exploration and vascular repair. (See "Surgical

management of severe extremity injury", section on 'Revascularization'.)

The high sensitivity and speed of modern CT makes it attractive as a noninvasive study to identify and

characterize suspected vascular injury. To obtain optimal images, contrast injection should be performed remote

from the extremity of interest. In upper extremity exams, the arms should be raised above the head [38]. The

sensitivity of helical CT angiography with three-dimensional reconstruction ranges from 90 to 100 percent, with

specificities >99 percent [39-41]. Interobserver agreement is about 90 percent. Newer generation multidetector

scanners (16- or 64-slice) have sensitivity and specificity approaching 100 percent for clinically significant

injuries [42,43]. In one study, multidetector CT angiography adequately imaged the extremity vasculature in

spite of the artifact caused by orthopedic hardware and retained fragments [44]. Three-dimensional

reconstruction is not an absolute requirement with higher slice scanners. We use a 64-slice scanner without

reconstruction, but consider it ideal to have the trauma or vascular surgeon review the cross-sectional images

together with the radiologist.

CT angiography is often preferred in patients with multiple trauma because it is less invasive than conventional

arteriography and can be performed at the same time as head, chest, or abdominal CT, which are frequently

needed in trauma patients. As a single study, computed tomographic (CT) angiography is less expensive than

conventional arteriography [43]. However, the cost of additional studies to sort out nondiagnostic findings on CT

angiography and the cost of unnecessary surgical explorations or other interventions based upon the results of

CT angiography need to be taken into account. As an example, in a study of 132 patients with penetrating

trauma, 59 patients underwent CT angiography of which 28 were performed as a completion of a

head/chest/abdominal series, and 31 were for isolated extremity injury [37]. Ten percent of the studies were

indeterminate with two of these patients requiring exploration. There was no difference in the rate of

indeterminate studies between whole body studies and those done for isolated extremity injury.

additional vascular evaluation [35,36].

Extravasation of contrast or pseudoaneurysm●

Arteriovenous fistula●

Flow-limiting intimal flap (flow-limiting based upon clinical exam). If the injured extremity index is normal,

any observed flap is not considered to be flow-limiting.

●

Occlusion of axial extremity arteries●

Distal embolism (may occur even in the presence of a relatively minor proximal injury)●

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Conventional digital subtraction arteriography (DSA) may be preferred initially in some patients, and can be

performed in a dedicated interventional suite or in the operating room. Arteriography in the operating room has

the advantage of eliminating unnecessary patient transport. A hybrid operating room (operating suite with

interventional capabilities) is ideal but not necessary. Intraoperative arteriography can be performed using a

portable power injector and portable digital subtraction arteriography, which are generally available in the

operating room at civilian and military hospitals [45].

Assessing soft tissue and bone — The soft tissue envelope of muscle, subcutaneous fat, and skin should be

evaluated for signs that indicate a potential underlying fracture, and to assess the severity of soft tissue

damage, which is important for determining the potential risk of limb loss.

The soft tissue injury should identify areas of missile entry and exit, soft tissue avulsion, skin or muscle flap

formation, and evidence of contamination. In penetrating injuries, such as high velocity gunshot wounds or

fragmentation injuries, the external wound may be relatively small; however, underlying soft tissue destruction

can be significant. Severe or extensive muscle tissue damage can lead to rhabdomyolysis, independent of other

risk factors such as ischemia-reperfusion or acute compartment syndrome. The diagnosis and management of

rhabdomyolysis is reviewed elsewhere. (See "Surgical management of severe extremity injury", section on

'Rhabdomyolysis and myoglobinuria'.)

Lacerations should be assessed for proximity to fracture sites and joint spaces. Extremity injuries with

suspected joint space involvement (traumatic arthrotomy) can be further evaluated by injecting the joint with

saline. During the injection, the joint should be assessed to identify any distension, and the associated wound

or laceration evaluated for fluid extravasation. Available studies indicate that between 155 and 194 mL of saline

needs to be injected to achieve 95 percent sensitivity for identifying traumatic arthrotomy of the knee [46,47].

(See "Joint aspiration or injection in adults: Technique and indications".)

The muscle compartments of the affected extremity should also be evaluated on initial exam. Soft tissue injury

and swelling can result in compartment syndrome. The lower extremity is more prone to compartment

syndrome compared with the upper extremity because of its greater muscle mass and possibly because of its

dependent position. The diagnosis and management of compartment syndrome are discussed elsewhere. (See

"Acute compartment syndrome of the extremities" and "Lower extremity fasciotomy techniques" and "Patient

management following extremity fasciotomy".)

Extremity deformity, point tenderness, ecchymosis, laceration deep to the muscle fascia, laceration near a

joint, and joint laxity are signs of a potential fracture. Plain radiography should be performed to establish a

diagnosis. (See 'Extremity radiography' above.)

Detailed discussions of specific fractures are found in separate topic reviews:

An open fracture is defined as a bony fracture and soft tissue laceration that are in communication with each

other (picture 1). In civilians series, open fractures occur in up to 24 percent of tibia fractures [11,12]. In a review

of 1281 soldiers with extremity injuries, 915 fractures were identified of which 82 percent were open [48]. Open

fracture significantly increases the risk of osteomyelitis and ultimately limb loss depending upon the severity of

the associated soft tissue injury. (See 'Open fracture grading' below and "Surgical management of severe

extremity injury", section on 'Wound complications'.)

Following the initial assessment, the affected bone(s) should be aligned as well as possible and stabilized with

a splint or traction to minimize soft tissue injury and to optimize distal perfusion. Open wounds should be

irrigated with saline to eliminate gross contamination prior to the application of temporary gauze dressings. The

patient can then undergo further diagnostic workup for associated injuries. Techniques for splinting

Hip and thigh – (See "Hip fractures in adults" and "Midshaft femur fractures in adults".)●

Leg and ankle – (See "Proximal tibial fractures in adults" and "Tibial shaft fractures in adults" and

"Overview of ankle fractures in adults".)

●

Arm – (See "Proximal humeral fractures in adults" and "Midshaft humeral fractures in adults".)●

Forearm – (See "Radial head and neck fractures in adults" and "Distal radius fractures in adults".)●

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musculoskeletal injuries are discussed in elsewhere. (See "Splinting of musculoskeletal injuries".)

Posterior knee dislocation is associated with popliteal artery injury, and a careful vascular examination should

be performed when this injury is identified. Following reduction of the dislocation, the vascular examination

should be repeated and, if normal, the patient should continue to be observed. If the pulses remain abnormal,

vascular imaging is indicated (arteriography) and management depends upon the findings (algorithm 1). (See

"Knee (tibiofemoral) dislocation and reduction".)

INJURY SEVERITY SCORING — Following examination of the extremity, overall injury severity should be

assessed to determine whether a primary amputation should be performed, of if the limb is potentially

salvageable. The utility of using injury severity scores in predicting the success of limb salvage is discussed

elsewhere. (See 'Predicting limb loss' below.)

Various extremity injury severity scores are described, including the Mangled Extremity Severity Score (MESS);

the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury,

Skeletal Injury, Shock, and Age of Patient Score (NISSSA); the Hannover Fracture Scale-97 (HFS-97) and the

Gustilo-Anderson open fracture grading system [1,49-53].

MESS — The Mangled Extremity Severity Score (MESS) is the most widely applied scoring system to

categorize the degree of extremity injury [1]. The term “mangled” refers to a limb in which at least three of the

four functional components (bone, vessels, nerves, and soft tissue) are injured.

The MESS is calculated by scoring each of the areas listed below (calculator 1). Component scores are then

added to yield the MESS which ranges from 2 to 14. “Severity and duration of ischemia” scores are doubled if

perfusion has not been restored within six hours of injury.

Open fracture grading — Open fractures should be graded using the Gustilo-Anderson system, which is

usually performed intraoperatively; however, the severity of the orthopedic injury can generally be estimated

during the initial extremity evaluation. An increasing grade of open fracture has been correlated to an increased

risk of infection and increased rate of amputation [49,50]. A disadvantage of this scoring system is the low

interobserver agreement of 60 percent [51,52].

The Orthopaedic Trauma Association has recently proposed a framework for developing a new classification

scheme for open fractures [53]. Over time, this descriptive framework may replace the Gustillo-Anderson

system, but it has yet to be validated and correlated with complications and outcomes.

Predicting limb loss — The likelihood that extremity injury will result in limb loss can be estimated based

upon clinical findings with the aid of scoring systems. No injury severity scoring system has been found to be

sufficiently sensitive for determining whether efforts at limb salvage will fail; however, determining the factors that

may influence outcomes may be helpful when counseling the patient (or family members) about options for

treatment, and may guide a decision for primary amputation. (See "Surgical management of severe extremity

injury", section on 'Limb salvage versus amputation'.)

Clinical predictors — Some injuries are associated with high amputation rates in spite of best efforts at

limb salvage. The risk of limb loss is the greatest for injuries with combined bony instability, vascular injury

Severity of skeletal and/or soft tissue injury●

Severity and duration of limb ischemia●

Severity of shock●

Patient age●

Type I – Wound <1 cm; minimal contamination, comminution, or soft tissue damage●

Type II – Wound >1cm; moderate soft tissue damage; minimal periosteal stripping●

Type IIIA – Severe soft tissue damage and substantial contamination; soft tissue coverage adequate●

Type IIIB – Severe soft tissue damage and substantial contamination; soft tissue coverage inadequate●

Type IIIC – Open fracture with an associated arterial injury requiring repair●

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(particularly combined arterial and venous injury), and soft tissue injury. One example is posterior dislocation of

the knee, which can present with severe ligamentous instability and injury to the popliteal artery and vein [54].

High-energy and penetrating injuries can also lead to combined bony, vascular, and soft tissue injury [16].

Guidelines for the management of complex extremity injuries prepared by the American College of Surgeons

Committee on Trauma ad hoc Committee on Outcomes [55], supplemented by the Eastern Association for the

Surgery of Trauma (EAST) [56], cite the following as factors that increase the risk for limb loss:

Scoring systems — Injury severity scoring systems are widely applied but are not highly sensitive for

predicting the need for amputation following extremity injury. (See 'Injury severity scoring' above.)

The mangled extremity severity score (MESS) (calculator 1) is a commonly cited tool that provides a frame of

reference for comparing extremity injuries; however, it is limited in its ability to predict need for amputation. The

MESS is best used alongside clinical exam and patient comorbidities to help in the decision for or against limb

salvage. A low score suggests limb salvage potential; however, a high score does not reliably predict the need

for eventual amputation.

The Lower Extremity Assessment Program (LEAP) investigators evaluated 556 patients with lower extremity

injuries using five injury severity scoring systems, including MESS [57]. Each of the scoring systems were

highly specific (0.84 to 0.98) but not sensitive (0.37 to 0.67) for predicting limb loss. Specifically, regarding the

MESS, these authors found that a MESS of 7 had a sensitivity of 0.45 but a specificity of 0.93 for predicting

amputation.

MANAGEMENT APPROACH — Once a severe extremity injury has been identified, a management plan should

be developed taking into consideration the patient’s other injuries. In multiply injured trauma patients, the

management plan should be made by one lead surgeon in collaboration with the orthopedic, vascular, and

neurosurgery services, as needed. The priority of each injury, and timing and approach to each injury, should be

determined in advance.

Hemodynamically unstable — Based upon ATLS principles, the hemodynamically unstable trauma patient

with indications for surgery (eg, positive Focused Assessment with Sonography for Trauma [FAST], hard signs

of vascular injury) should be taken to the operating room to identify and control bleeding. Life-threatening injuries

to the head, neck, chest, or abdomen take precedence over the extremity injury. A damage control or staged

approach to the injured extremity is warranted once external bleeding from the extremity is controlled. In some

cases, the severity of the extremity injury or time constraints due to the need to manage life-threatening injuries

will preclude meaningful attempts at limb salvage and primary amputation may be the best option. If the

extremity is the primary (or only) injury, a more definitive approach to repair can be taken at the outset. (See

'Hard signs of arterial injury' above and "Surgical management of severe extremity injury", section on 'Damage

control surgery'.)

Hemodynamically stable with vascular injury — For hemodynamically stable patients, the timing of the

management of extremity injury when vascular injury is present depends upon the degree and duration of

ischemia. Patients with hard signs of vascular injury should be taken immediately to the operating room for

evaluation and management. Patients with clinical signs of arterial injury, including an injured extremity index

(IEI) <0.9, should be evaluated using computed tomographic (CT) angiography or conventional arteriography

depending upon institutional resources. In the presence of bony instability, arterial revascularization is fraught

Delay in revascularization●

Blunt trauma●

High-velocity penetrating trauma●

Lower extremity versus upper extremity vascular involvement (especially popliteal artery)●

Associated injuries●

Older age and older physiologic health●

Shock and obvious limb ischemia●

Forward combat zone●

Resource-limited environment●

Multi-casualty event●

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with difficulties. Under these circumstances, arterial shunting, if needed, and fracture stabilization followed by

definitive vascular repair once the bones have been stabilized may be the most appropriate sequence of care.

(See "Surgical management of severe extremity injury", section on 'Revascularization' and "Surgical

management of severe extremity injury", section on 'Fracture management'.)

Hemodynamically stable without vascular injury — The timing and management of extremity injury when

no vascular injury is present depends upon the severity of fracture and the degree of soft tissue loss. Open

fracture debridement and fracture stabilization should be performed as soon as feasible depending upon the

nature and extent of nonextremity injuries. Multiple debridement procedures are frequently required before

definitive fracture fixation and soft tissue coverage can be achieved. (See "Surgical management of severe

extremity injury", section on 'Soft tissue debridement/coverage' and "Surgical management of severe extremity

injury", section on 'Fracture management'.)

MORBIDITY AND MORTALITY — Patients with severe lower extremity injuries have a high incidence of

complication, including wound complications (infection, necrosis, nonunion, osteomyelitis), venous

thromboembolism, rhabdomyolysis, and late complications including amputation and heterotopic ossification in

residual limbs. Most of these complications require or prolong hospitalization, or require additional operative

treatment [58]. These complications are discussed elsewhere. (See "Surgical management of severe extremity

injury", section on 'Complications'.)

In blunt civilian extremity injury, mortality ranges from 5 to 10 percent and is greater with blunt compared with

penetrating injuries [15,59]. Mortality correlates to the volume of blood lost as a result of the extremity injury,

which can be significant with involving the junctional vasculature [18]. Higher mortality rates reflect more severe

extremity injury, coexistent injury, and development of complications (eg, venous thromboembolism). Mortality

rates are lowest for isolated extremity injuries.

SUMMARY AND RECOMMENDATIONS

Trauma to the extremities represents one of the most common injury patterns seen in emergency

practice. Civilian extremity injuries are most commonly due to blunt mechanisms, whereas combat injuries

are predominantly due to penetrating or mixed mechanisms. In combat, extremity injuries are present in

half of all casualties. (See 'Introduction' above and 'Incidence' above and 'Etiology' above.)

●

A brief extremity exam is performed during the initial trauma assessment (primary survey), but should be

repeated once life-threatening injuries have been addressed. The extremity evaluation should be structured

to assess the four functional components of the extremity (nerves, vessels, bones, soft tissues). Injury to

three of these four elements constitutes a “mangled extremity.” Patients with extremity deformity, point

tenderness, ecchymosis, deep laceration, laceration near a joint, or joint laxity should undergo plain

radiographs to evaluate for extremity fracture. (See 'Initial evaluation and management' above.)

●

Patients with hard signs of a vascular injury (eg, pulsatile bleeding, an expanding hematoma, distal

ischemia) should be taken directly to the operating room for further examination and management. Direct

pressure is usually effective in controlling extremity hemorrhage. For extremity hemorrhage that is not

adequately controlled with direct pressure, we suggest placement of an extremity tourniquet (Grade 2C).

Although not widely used for civilian injuries, military experience with prehospital and emergency

department tourniquet application has shown that tourniquets save lives with a low rate of complications.

(See 'Control of hemorrhage' above and "Prehospital care of the adult trauma patient", section on

'Hemorrhage control'.)

●

For patients without hard signs of vascular injury, an injured extremity index (IEI) should be performed,

which is analogous to the ankle-brachial index (ABI). An abnormal IEI (<0.9) suggests the presence of a

vascular injury. Hemodynamically stable patients with an abnormal IEI should undergo further imaging to

exclude vascular injury. Arteriography is often performed using computed tomographic (CT) angiography,

because it is less invasive than conventional arteriography; has high sensitivity and specificity; and can be

performed at the same time as head, chest, or abdominal CT, which are frequently needed. Where an

appropriately sensitive CT scanner is not immediately available, conventional arteriography can be

performed to exclude vascular injury either in a dedicated interventional suite or in the operating room.

(See 'Injured extremity index' above and 'Arteriography' above.)

●

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●

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Topic 15150 Version 6.0

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GRAPHICS

Artery and nerve injuries associated with specific fractures

Fracture Artery Nerves

Upper extremity Proximal humerus Axillary

Brachial

Axillary

Suprascapular

Humerus shaft Brachial Radial

Median

Ulnar

Supracondylar (humerus) Brachial Median

Radial

Ulnar

Radius/ulna Brachial

Axillary

Ulnar

Median

Ulnar

Lower extremity Femur Femoral Femoral

Tibia Popliteal

Anterior tibial

Posterior tibial

Tibial

Superficial peroneal

Deep peroneal

Data from: Schlickewei W, Kuner EH, Mullaji AB, et al. Upper and lower limb fractures with

concomitant arterial injury. J Bone Joint Surg Br 1992; 74:181.

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Humerus fracture

Radiograph of a comminuted humerus fracture.

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Comminuted femoral shaft fracture

Courtesy of Klane White, MD.

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Tib-fib fracture

Radiograph of a tib-fib fracture.

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Open fracture of the lower extremity

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Management of knee (tibiofemoral) dislocation