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Limb salvage in severe trauma
Dr. Fathi Neana discusses limb salvage techniques in cases of severe trauma, focusing on complex multisystem injuries characterized by damage to soft tissue, bone, nerves, and vessels. The document outlines criteria for amputation versus limb salvage, including a scoring system for assessing the severity of injuries and factors influencing treatment decisions. Advances in medical practices now allow for the salvage of many limbs previously considered irreparable, but careful evaluation and management are critical to avoid prolonged suffering from failed salvages.
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Limb salvage in severe trauma
- 1. DR. Fathi Neana Chiefof Orthopaedics DR. Fakhry and Alrajhy Hospital Saudi Arabia November17, 2016 LIMB SALVAGE IN SEVERE TRAUMA
- 2. Mangled Extremity Skin/Soft tissueloss 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)
- 3. Limb Complex MultisystemInjury (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
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- 10. ETIOLOGY OF BONELOSS (BONE DEFECT) Traumatic (Open Fractures) Blast injuries Segmental Fractures Post debridement Non Traumatic Resection of swelling Infection Osteonecrosis
- 11. INJURY EVALUATION What weare dealing with
- 12. INJURY EVALUATION What weare dealing with 1- FRACTURE CLASSIFICATION 2- SKIN INJURY Closed fractures (IC ) 5 GRADES Open fractures (IO ) 5 GRADES 3- NEUROVASCULAR INJURY (NV) 5 GRADES 4- MUSCLE/TENDON INJURY (MT) 5 GRADES
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- 14. AO soft-tissue classification:closed skin lesions (IC). IC 1 No skin lesion IC 2 No skin laceration, but contusion IC 3 Circumscribed degloving IC 4 Extensive, closed degloving IC5 Necrosis from contusion AO soft-tissue classification: open skin lesions (IO). IO 1 Skin breakage from inside out IO 2 Skin breakage from outside in < 5 cm, contused edges IO 3 Skin breakage from outside in > 5 cm, increased contusion, devitalized edges IO 4 Considerable, full-thickness contusion, abrasion, extensive open degloving, skin loss IO5 Extensive degloving SKIN INJURY
- 15. CLOSED SKIN LESIONS(IC) 5 GRADES
- 16. OPEN SKIN LESIONSIO 5 GRADES
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- 19. Skeletal /42-C3 Soft Tissues/IO4-MT4-NV5 INJURY EVALUATION What we are dealing with
- 20. PERSONALITY OF THEINJURY Global 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
- 21. A DECISION HAVETO BE MADE Amputation + Prosthesis vs. Limb salvage procedure
- 22. AMPUTATION VS. SALVAGE PotentialScenarios Immediate amputation Attempted salvage with early amputation Successful salvage Unsuccessful salvage with late amputation
- 23. 1- Personality ofinjury The injured limb The patient The health care environment Psycho Social Resources 2- Scoring system ! AMPUTATION VS. SALVAGE GUIDELINES – OUTCOME
- 24. AMPUTATION VS. SALVAGE GUIDELINES SCORINGSYSTEM ! MANGLED EXTREMITY SEVERITY SCORE (MESS) AMPUTATION COSIDERED IN TOTAL SCORE > 7 BONE & SOFT TISSUE GROUP LOW ENERGY 1 MEDIUM ENERGY 2 HIGH ENERGY 3 MASSIVE CRUSH 4 SHOCK GROUP NORMOTENSIVE 0 TRANSIENT HYPOTENSION 1 PROLONGED HYPOTENSION 2 ADVANCED 3 ISCHAEMIA GROUP NONE 0 MILD 1 MODERATE 2 ADVANCED 3 AGE GROUP < 30 Y. 0 30-50 Y. 1 > 50 Y. 2
- 25. 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 Historically Mangled extremities have been associated with very high amputation rates
- 26. LIMB AMPUTATION Mangled ExtremitySeverity Score (MESS) > 7
- 27. The decision ofPrimary 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
- 28. The alternative isprolonged unsuccessful attempts at limb salvage Subjecting the patient to great physical, psychological, financial, and social suffering
- 29. LIMB SALVAGE Mangled ExtremitySeverity Score (MESS) < 7
- 30. 1-1- Prolonged hospitalstay 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
- 31. LIMB SALVAGE TREATMENT PHILSOPHY 1-Stopthe 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)
- 32. LIMB SALVAGE Management Priorities(6R) Resuscitate Restore blood supply Remove dead & infected tissue Restore soft tissue envelope Restore skeletal stability Rehabilitation
- 33. LIMB SALVAGE PROCEDURE Irrigation & Debridement External fixation Antibiotic bead spacers Soft tissue coverage Restore Skeletal Stability (Salvage of Bone Defect)
- 34. LIMB SALVAGE PROCEDURE Irrigation & Debridement External fixation Antibiotic bead spacers Soft tissue coverage Restore Skeletal Stability (Salvage of Bone Defect)
- 35. LIMB SALVAGE PROCEDURE Irrigation & Debridement External fixation Antibiotic bead spacers Soft tissue coverage Restore Skeletal Stability (Salvage of Bone Defect)
- 36. LIMB SALVAGE PROCEDURE Irrigation & Debridement External fixation Antibiotic bead spacers Soft tissue coverage Restore Skeletal Stability (Salvage of Bone Defect)
- 37. LIMB SALVAGE PROCEDURE Irrigation & Debridement External fixation Antibiotic bead spacers Soft tissue coverage Restore Skeletal Stability (Salvage of Bone Defect)