The utility of scores in the decision to salvage or amputation in severely injured limbs

Abstract

The decision to amputate or salvage a severely injured limb can be very challenging to the trauma surgeon. A misjudgment will result in either an unnecessary amputation of a valuable limb or a secondary amputation after failed salvage. Numerous scores have been proposed to provide guidelines to the treating surgeon, the notable of which are Mangled extremity severity score (MESS); the predictive salvage index (PSI); the Limb Salvage Index (LSI); the Nerve Injury, Ischemia, Soft tissue injury, Skeletal injury, Shock and Age of patient (NISSSA) score; and the Hannover fracture scale-97 (HFS-97). These scores have all been designed to evaluate limbs with combined orthopaedic and vascular injuries and have a poor sensitivity and specificity in evaluating IIIB injuries. Recently the Ganga Hospital Score (GHS) has been proposed which is specifically designed to evaluate a IIIB injury. Another notable feature of GHS is that it offers guidelines in the choice of the appropriate reconstruction protocol. The basis of the commonly used scores with their utility have been discussed in this paper.

Keywords: Open fractures; limb injury severity score; severely injured limbs.

Figure 1

(a) Clinical photograph shows severe open injury of tibia with soft tissue loss. (b) X-rays (anteroposterior view) showing severe communition of the bones in proximal 1/3rd of tibia. (c) X-ray (anteroposterior view) showing gap non-union upper end tibia. (d) Clinical photograph of same patient showing an infected non-union with sinuses and a deformed foot. (e) Clinical photograph of same patient showing above-knee amputation. f) Clinical photograph after rehabilitation

Figure 2

Clinical photograph of four different injuries, (a-d) which are all Gustilo IIIB by definition. Management and outcome of all these injuries, although grouped together under IIIB, are completely different

Figure 3

(a) Clinical photograph of leg with severe crushing of soft tissues with absence of a vascular injury. (b) X-ray of left leg bones (AP view) was showing comminuted fracture tibia with bone loss. MESS has poor senstivity for amputation. Attempted salvage of this leg wound have led to prolonged surgeries and probably a secondary amputation. In contrast, Ganga Hospital Score was 17 indicating the need for amputation. In IIIB injuries, Ganga Hospital Score was more sensitive than a MESS in predicting amputation

Figure 4

The various components in the respective scores of the Ganga Hospital Score

Figure 5

(a & b) Clinical photograph showing open injury of the tibia with exposed bone. (c) X-ray anteroposterior and lateral views of leg bones showing comminuted fracture of tibia. As per the Ganga Hospital Score, the total score is less than 5 and the skin score is less than 3. (d) X-ray anteroposterior and lateral view of leg bones showing skeletal fixation and union. (e) Clinical photograph showing result after immediate skin closure and a thorough debridement leading to good result

Figure 6

(a) Clinical photograph shows severe open injury of tibia with Ganga Hospital score more than 10. A score above 10 indicates a high velocity injury and primary reconstruction will not be successful. (b) Radiograph (anteroposterior and lateral) shows temporary stabilization. (c) Clinical photograph after debridement. (d) Radiograph (anteroposterior) shows bone transport procedure. (e) Clinical photograph shows cross leg flap. (f) Radiograph (anteroposterior and lateral) shows union at final follow up. (g) Clinical photograph shows weight bearing extremity with limb length equality