Management of the Mangled Extremity
Annotation for Point I
Definitive evaluation of a mangled extremity should universally be completed in the operating room. In this setting, the patient can be resuscitated and additional diagnostics performed, including radiographic bony evaluation using plain films or fluoroscopy, on-table angiography, and direct examination of the soft tissues and anatomic structures. The factors influencing the decision to attempt limb salvage or proceed with amputation are complex. These include systemic, bony skeletal, soft tissue, nerve, and vascular factors (Table 1, Table 2, and Table 3). The evaluation of these factors should repeatedly be weighed against the overall patient injury burden to insure that limb evaluation and salvage efforts are not counter to the efforts to sustain the life and overall patient outcome.
The degree of soft tissue debridement needed is an important factor in deciding on the advisability of limb salvage and/or the level of amputation. Circumferential loss of soft tissue makes limb salvage less attractive. Vascular and bony structures require soft tissue coverage. The more extreme the loss of soft tissue, the fewer the options for this coverage. The level of amputation needed is another important decision. Salvaging a below knee amputation makes the patient far more functional than if an above knee amputation is needed. Longer above knee amputation stumps are preferable to shorter ones. Transfemoral amputations are far more functional than hip disarticulations. The integrity of soft tissue is often critical in this decision making. Overall, a well-constructed longer residual limb will prove more functional and, when possible, reconstructive procedures may permit subsequent salvage of a lower level of amputation to improve ultimate function.
Consultation from orthopedic and/or microvascular reconstructive surgeons may be helpful in providing additional innovative options including free tissue transfer to help salvage a more functional amputation level. Although consultation may often be helpful, it is important that the general trauma surgeon remain in charge and act as “captain of the ship.” Consultants offer expertise about a specific anatomic area and/or facet of the problem. However, only the general surgeon has responsibility for the entire patient and has the best overall understanding of total patient physiology. Occasionally, complicated solutions may be possible and attractive to a subspecialist but not be the best overall plan for the patient. In particular, decisions about the appropriateness of limb salvage should remain the general surgeon’s responsibility to avoid attempts at limb salvage that may put the patient’s life in jeopardy.
Level of Supporting Evidence: Level 4