12 rw principles of mangled extremity management
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Principles of Mangled Extremity Management
Pumsak Thamviriyarak,MD.Orthopaedics Department
Khonkaen Hospital
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Mangled extremity◦ An injury to an extremity so severe that salvage is
often questionable and amputation is a possible outcome
High energy force◦ Degloved skin◦ Soft tissue disrupted◦ Extensive comminuted fracture
Motor vehicle accident
Introduction
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Hippocrates (400BC)◦ Amputation◦ Very high mortality rate
Celsus (25 BC) ◦ wound management with removal of FB and
hemostasis Ambroise Pare (1540)
◦ Basic principles of amputation◦ Phantom pain◦ Stump revision
Historical Background
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Pierre-Joseph Desault (1770) ◦ coined “debridement”
Incidence of post treatment osteomyelitis 80% WWI 1914 25% WW II 1939 (ATB / aseptic technique)
Korean War 1950 ◦ 62% amputation artery repair 13%
Nowaday◦ Multiple complex reconstruction technique◦ Development of ATB◦ Microsurgery
Historical Background
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Initial Evaluation◦ ATLS principle◦ Evaluate perfusion of injured limb◦ ATB and Tetanus prophylaxis◦ Removed gross contamination◦ Reduction of Fracture and Joint+Splint
Check distal neurovascular before and after◦ Look for Compartment syndrome◦ Plain film: 2 orthogonal views
PRINCIPLES OF MANAGEMENT
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Vascular Assessment◦ Hard signs
pulsatile bleeding rapidly expanding hematoma classic signs of obvious arterial occlusion
Pulselessness Pallor Paresthesia Pain Paralysis Poikilothermia
PRINCIPLES OF MANAGEMENT
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Vascular Assessment◦ Soft signs
history of arterial bleeding nonexpanding hematoma a pulse deficit without ischemia neurological deficit originating in a nerve adjacent to
a named artery the proximity of a penetrating wound, fracture, or
dislocation near to a named artery
PRINCIPLES OF MANAGEMENT
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Vascular Assessment◦ Limb deformities + decrease pulse : Reduction
and reevaluate◦ Arterial Pressure Indices(API)
<0.9 suspected vascular inj
PRINCIPLES OF MANAGEMENT
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patient with a pulseless but perfused limb◦ Stable Fracture
Vascular repair before EF◦ Unstable Fracture
EF before vascular repair Ischemic limb
◦ Temporary intraluminal vascular shunting first◦ Debridement+EF◦ Vascular repair
Fasciotomy in all pts prevent compartment syndrome
PRINCIPLES OF MANAGEMENT
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Placed Tourniquet but not inflate (Inflate when bloody field)-prevent further ischemic injury
irrigation and debridement -most important step
Zone of injuries◦ central zone of necrotic tissue-non viable tissue◦ zone of marginal stasis+/-viable tissue◦ the periphery zone of the injury
Operative Debridement
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Extend open wound and remove all necrotic tissue in central zone
Serial debridement require(zone of marginal stasis)
Operative Debridement
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Prevents ongoing soft tissue damage Promotes wound healing Thought to protect against infection Most managed with temporizing external
fixation◦ applied relatively quickly◦ without the use of fluoroscopy◦ providing excellent stability and alignment◦ allows for redisplacement of the fracture fragments
for a more thorough evaluation and débridement of the soft tissues during any repeat procedures
Skeletal Stabilization
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thought to enhance oxygen delivery to injured tissues affected by vascular disruption – Improve wound healing
most beneficial in the peripheral zone of injury
Hyperbaric Oxygen
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Principle◦ Type of Flap coverage
Local rotational flap : beware for flap necrosis from initial trauma(may be in zone of injury)
Free flap◦ Timing :controversial
>7d increase infection rate
Soft Tissue Coverage
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Variables◦ Patient Variables◦ Extremities Variables◦ Associated Variables
Survivability : Amputation when severely injured extremity with an irreparable vascular
injury prolonged warm ischemia (longer than 6 hours) critically injured with significant hemodynamic instability
PATIENT ASSESSMENT AND DECISION MAKING
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Plantar sensation◦ Before 1980, believed that absent plantar
sensation was a reason to amputate a limb Chronic complications
◦ Now , the study concluded that plantar sensation should not be included as a factor in the decision making for limb salvage in lower extremity trauma
PATIENT ASSESSMENT AND DECISION MAKING
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To help decision making : amputate vs salvage
Many index◦ MESI◦ PSI◦ MESS◦ LSI◦ NISSSA
Limb Salvage Scores
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Amputation threshold ≥7 Only prediction not indication Cautiously decision base on clinical
MESS
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Functional outcome of the patients with foot injuries was significantly worse than that of the patients without foot injuries
amputation may indeed be a better long-term option
Foot and ankle injuries
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Delayed bone healing◦ Delayed union◦ Nonunion
Infection◦ Osteomyelitis
Flap necrosis
Smoking
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Outcomes
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References
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Imagination is more important than knowledge
Thank you