Current management of the mangled upper extremity

Abstract

Mangled describes an injury caused by cutting, tearing, or crushing, which leads to the limb becoming unrecognizable; in essence, there are two treatment options for mangled upper extremities, amputation and salvage reconstruction. With advances in our understanding of human physiology and basic science, and with the development of new fixation devices, modern microsurgical techniques and the possibility of different types of bony and soft tissue reconstruction, the clinical and functional outcomes are often good, and certainly preferable to those of contemporary prosthetics. Early or even immediate (emergency) complete upper extremity reconstruction appears to give better results than delayed or late reconstruction and should be the treatment of choice where possible. Before any reconstruction is attempted, injuries to other organs must be excluded. Each step in the assessment and treatment of a mangled extremity is of utmost importance. These include radical tissue debridement, prophylactic antibiotics, copious irrigation with a lavage system, stable bone fixation, revascularization, nerve repair, and soft tissue coverage. Well-planned and early rehabilitation leads to a better functional outcome. Despite the use of scoring systems to help guide decisions and predict outcomes, the decision to reconstruct or to amputate still ultimately lies with the surgical judgment and experience of the treating surgeon.

Complete major amputation of the upper extremity

“…19 Besides the overall injury pattern, patient-specific risk factors (comorbidities, age, ASA [American Society of Anesthesiologists]) have been shown to significantly influence the outcome and the postoperative risk profile. 10 In contrast to other algorithms, 16 we prioritize the initial reestablishment of bony integrity (either by plating or external fixation) to ensure an optimal environment for vessel reconstruction 16,19,26 and to protect the anastomoses against shear and traction forces during further management. Once the decision is made, all initial efforts aim to restore the essential functions (bony stability, blood supply, soft tissue coverage) and to decrease the risk of secondary complications (Fig.…”

“…We recommend to perform an internal osteosynthesis whenever feasible because no further procedures are required, thus decreasing the risk for secondary complications to reconstructed vessels (obliteration), tendons, or muscles (rerupture). 26,27,29,30 While some authors recommend to prioritize the revascularization (direct repair, venous graft, temporary shunting), 26,27 others recommend to reestablish blood flow to decrease total ischemia time 29 before bony stabilization. 10,20 Thus, the need for grafts for vessel and nerve reconstruction can potentially be avoided, and compartment pressure can significantly be relieved.…”

Free vascularised fibular grafts in orthopaedics

“…The approach to these injuries is in the standard manner, with tetanus and antibiotic prophylaxis, copious irrigation and radical wound debridement. Immediate bony stabilisation is usually achieved with an external fixator [26,27]. In the context of large injury zones with significant irreversible tissue damage/loss and bone defects >6 cm, FVFGs can facilitate a complete one-stage reconstruction (such as with an osteocutaneous graft) and can be performed in the early biological healing stages of these injuries [28,29].…”

Management of Soft Tissue Defects of the Hand

“…Within the United States, only 55% of level 1 trauma centers have immediate access to surgeons who are proficient in microsurgery. 1 Patients who have suffered traumatic or trauma-related amputations of the upper extremity face a difficult rehabilitative course and develop persistent pain in as many as 79% of cases. 2 Subsequently, greater than 30% of patients fitted for prostheses ultimately discontinue their use altogether.…”