Management of the Mangled Extremity

Annotation for Point F

In patients who require emergent operative therapy to address ongoing hemorrhage from the extremity or other sources, careful consideration should be given to the appropriateness of limb salvage. Familiarity with the factors associated with poor outcome of a mangled extremity (Table 1) can assist in the decision-making process in these instances.^2,3,4–9,^21–24 The stratification of the relative importance of these risk factors, as outlined in “Historical Perspective,” above, is difficult because of the absence of conclusive data. Other potential risk modifiers, including diabetes, peripheral vascular disease, smoking history, obesity, and hypercoagulability should also be considered in management decisions.

Sometimes, the decision is clear, for example, a limb that is attached only by skin and subcutaneous tissue. Other cases are not as clear. In these cases, beginning an attempt at limb salvage is reasonable. If further evaluation deems limb salvage not wise, amputation can be completed at that time. In the patients with severe multiple injuries, an extremity that might be salvageable as an isolated injury may represent an additional injury burden that the patient will not tolerate when considered in to. In such cases, primary amputation allows the surgeon to concentrate on more pressing injuries. The condition of the patient and the constellation of associated injuries must be considered carefully in these “life over limb” situations.

Good communication with the anesthesiology team throughout the operative intervention is paramount to optimizing outcome. Aggressive resuscitation may be required in these cases; to such an extent that sequela of considerable fluid resuscitation, including secondary abdominal compartment syndrome, may manifest precipitously. Optimizing communication with anesthesiology colleagues will alert the surgeon to these potential issues and prevent focus on the extremity from delaying recognition that aggressive resuscitative needs are indicative of bleeding source elsewhere.

Level of Supporting Evidence: Level 4