Management of the mangled extremity

Abstract

The management of a mangled extremity continues to be a matter of debate. With modern advances in trauma resuscitation, microvascular tissue transfer, and fracture fixation, severe traumatic extremity injuries that would historically have been amputated are often salvaged. Even if preserving a mangled limb is a technical possibility, the question is often raised whether the end result will also be functional and what treatment would lead to the best patient outcome. The road to salvage is often prolonged with significant morbidity, reoperations, financial costs, and even mortality in some instances. Numerous factors have been implicated in the outcome of these injuries, and a number of scoring systems have been designed in an attempt to help guide the treating surgeon in the acute phase. However, much controversy remains on the ability of these grading systems to predict successful salvage of the mangled extremity. In this review, we discuss the mechanisms of injury, various available scoring systems, initial management, outcome and specific differences between lower and upper extremity trauma injuries.

Fig. 1

A 21-year-old male presented to the emergency department following a motorcycle collision with bilateral lower extremity injuries. a Left-sided pulse-less (Grade IIIC) “mangled” knee/lower extremity injuries and a right-sided bicondylar closed tibial plateau fracture with compartment syndrome (top image). b Left-sided completion of the above knee amputation retaining as much viable soft tissue as possible (middle image). c Application of negative-pressure wound therapy dressing to left-sided amputation site, as well as external fixation of right bicondylar tibial plateau fracture and leg fasciotomies for compartment syndrome (bottom image)

Fig. 2

A 17-year-old male was involved in a head-on collision with a tractor trailer. After being trapped inside the vehicle for approximately one hour, he was extricated and flown to a local trauma center. He was diagnosed with an open, Grade IIIC left-sided AO/OTA Type C3.3 distal femur fracture with segmental defect and an ipsilateral tibial shaft fracture. External fixation was placed for initial stabilization, and antibiotic beads were subsequently placed in the defect at 3 days following injury. Open reduction and internal fixation (ORIF) was performed with placement of an intramedullary (IM) locked nail for treatment of the tibial shaft fracture and then ORIF of the distal femur fracture with placement of a less invasive stabilization system (LISS) locking plate and screws. One week later, the antibiotic beads were removed and the defect was prepared for bone graft placement. A second incision was made along the lateral border of the ipsilateral fibula, and a free vascularized fibula bone graft was harvested for transplant to the femoral defect. It was docked in a double barrel fashion and stabilized using screw fixation. Following surgery, he returned for regular follow-up visits. Three months after surgery, all of the fractures were healing with incorporation of bone graft. The LISS plate was removed 4.5 years following the initial surgery. The clinical and radiographic follow-up illustrated excellent results with bony union, full range of motion, and complete resolution of pain and return to preinjury activities. a, b, c Anteroposterior (AP) x-rays illustrating an AO/OTA Type C3.3 distal femur fracture with segmental bone defect and an ipsilateral tibial shaft fracture. d, e, f AP and lateral radiographs following placement of external fixation and antibiotic beads at the site of the segmental bone defect. g Clockwise from top-left; preoperative plan, fluoroscopic images showing placement of intramedullary nail for the tibial shaft fracture and locking screws and ORIF of the distal femur fracture with placement of a LISS locking plate and screws. h, i, j Immediate postoperative radiographs demonstrating adequate fixation and alignment. k AP radiographs illustrating preparation of distal femoral bone defect for placement of vascular bone graft. l AP x-radiograph following free vascularized fibular bone and placement of screw fixation. m, n, o, p AP and lateral x-rays 3.5 years following ORIF showing healed a distal femur fracture with incorporation of the fibular bone graft and a healed tibial shaft fracture. q, r AP and lateral x-rays 8 months following removal of LISS plate and screws and 4.5 years following fracture surgery

Fig. 2

A 17-year-old male was involved in a head-on collision with a tractor trailer. After being trapped inside the vehicle for approximately one hour, he was extricated and flown to a local trauma center. He was diagnosed with an open, Grade IIIC left-sided AO/OTA Type C3.3 distal femur fracture with segmental defect and an ipsilateral tibial shaft fracture. External fixation was placed for initial stabilization, and antibiotic beads were subsequently placed in the defect at 3 days following injury. Open reduction and internal fixation (ORIF) was performed with placement of an intramedullary (IM) locked nail for treatment of the tibial shaft fracture and then ORIF of the distal femur fracture with placement of a less invasive stabilization system (LISS) locking plate and screws. One week later, the antibiotic beads were removed and the defect was prepared for bone graft placement. A second incision was made along the lateral border of the ipsilateral fibula, and a free vascularized fibula bone graft was harvested for transplant to the femoral defect. It was docked in a double barrel fashion and stabilized using screw fixation. Following surgery, he returned for regular follow-up visits. Three months after surgery, all of the fractures were healing with incorporation of bone graft. The LISS plate was removed 4.5 years following the initial surgery. The clinical and radiographic follow-up illustrated excellent results with bony union, full range of motion, and complete resolution of pain and return to preinjury activities. a, b, c Anteroposterior (AP) x-rays illustrating an AO/OTA Type C3.3 distal femur fracture with segmental bone defect and an ipsilateral tibial shaft fracture. d, e, f AP and lateral radiographs following placement of external fixation and antibiotic beads at the site of the segmental bone defect. g Clockwise from top-left; preoperative plan, fluoroscopic images showing placement of intramedullary nail for the tibial shaft fracture and locking screws and ORIF of the distal femur fracture with placement of a LISS locking plate and screws. h, i, j Immediate postoperative radiographs demonstrating adequate fixation and alignment. k AP radiographs illustrating preparation of distal femoral bone defect for placement of vascular bone graft. l AP x-radiograph following free vascularized fibular bone and placement of screw fixation. m, n, o, p AP and lateral x-rays 3.5 years following ORIF showing healed a distal femur fracture with incorporation of the fibular bone graft and a healed tibial shaft fracture. q, r AP and lateral x-rays 8 months following removal of LISS plate and screws and 4.5 years following fracture surgery