MANGLED EXTREMITY Trauma Case 62 ANSWER

This is a clinical photograph of a patient brought to the emergency department after being hit by a car that crushed and pinned his leg to a wall.

1. Describe this clinical picture.

This is a clinical photograph of a patient with an obviously mangled and deformed leg. The wounds are ragged and the soft tissues appear dusky. There is obvious bone and soft tissue loss. It is not possible to tell from this photograph if this is an isolated injury.

2. Assuming that this is an isolated injury, how would you manage this patient in the emergency department?

This patient would be treated along ATLS principles with concurrent resuscita- tion to treat life- and limb-threatening injuries and to address any catastrophic

haemorrhage early. I would address active haemorrhage from the wound with limb elevation and direct pressure and the use of a tourniquet if required. I would treat the patient with intravenous fluid and blood resuscitation as required and activate our major haemorrhage protocol if clinically indicated based on the patient’s initial state, response to resuscitation and mechanism of injury triggers as per our local major haemorrhage policy. I would administer intravenous antibiotics, tetanus tox- oid and analgesia. A clinical photograph should be taken before gross contamina- tion is removed and saline swab dressings and a bandage are applied. Radiographs to confirm the bony injury and to help identify any proximal foreign body contami- nation should be taken. I would carefully assess and record the neurovascular status and include an assessment of pulses with Doppler ultrasound.

I would look closely for any suggestion of compartment syndrome, and an early senior surgical opinion is required as to whether limb salvage or early amputation for trauma is required. In any case, I would plan to take this patient to the operating theatre to perform a wound debridement. I would plan to provide temporary stabil- ity using an external fixator or plaster of Paris, but I would also consent the patient for amputation of the limb.

3. How would you decide between limb salvage and primary amputation?

There are a number of scoring systems to guide this decision. The Mangled Extremity Scoring System (MESS) is the most widely known but has largely fallen from favour. Loss of plantar sensation has also been used as a predictor of a poor outcome for limb salvage, as indicative of injury to the posterior tibial nerve, but this is also no longer used since the LEAP study demonstrated that at 2 years almost 50% of patients regained some plantar sensation.

The agreement of two experienced surgeons as to the need for amputation should be sought. In general, absolute indications for amputation are taken to include a contaminated traumatic amputation, a mangled extremity in a shocked and severely injured patient, and a crushed extremity with arterial injury and a warm ischemia time of greater than 6 hours. Relative indications include severe bone or soft-tissue loss, an anatomic transection of the tibial nerve, an open tibial fracture with serious associated polytrauma or a severe ipsilateral foot injury, or a prolonged predicted course to obtain soft-tissue coverage and tibial reconstruction. Despite this, the LEAP study suggests that the outcomes for both limb salvage and primary amputa- tion are poor and that there is a high complication and re-operation rate. Where there is doubt about the state of limb perfusion, a CT angiogram can be helpful, but this should not introduce unnecessary delay in moving to the operating theatre to undertake debridement, restore limb perfusion if required and stabilisation.

4. At what level would you plan to undertake this amputation and what are the principles that would guide your surgery?

Current guidance from the BOA and BAPRAS is that open tibial fractures should be operated on within 24 hours with a combined ‘orthoplastic’ approach. Surgery should be undertaken more urgently if there is gross contamination or an arte- rial injury requiring repair. The level of amputation should be guided by the soft tissue injury and the level at which adequate soft tissue coverage can be obtained. Preservation of length improves energy expenditure during rehabilitation for the patient but should not compromise the adequacy of the debridement. In a clean wound, it would be usual to perform a definitive procedure at the time, fashioning flaps at the index surgery. For this injury, it may be possible to undertake a below