Severe Open Fractures of the Lower Extremity

Management of the mangled extremity

“…In contrast, a larger study by Brown et al [8] in British military patients (Iraq and Afghanistan conflicts) with mangled extremity ballistic injuries found that the MESS did not help decide whether or not an amputation was appropriate. Others have criticized the subjectivity of the MESS, and review of larger series of patients has shown lower sensitivity of the index than initially reported [22, 25–28]. …”

“…The Nerve injury, Ischemia, Soft-tissue contamination, Skeletal injury, Shock and Age (NISSA) was introduced by McNamara et al [28] in 1994. This system is a more complex modification of the MESS that separates the skeletal and soft-tissue injury and adds a nerve injury component.…”

Successful Salvage of a Mangled Injury of the Ankle in a Young Male

“…The MESS recommends a primary amputation in injuries when the MESS score is ≥7[ 3 , 4 ]. Absolute indications for primary amputation of the mangled lower extremity are complete anatomical disruption of the posterior tibial nerve or crush injuries with a warm ischemia time longer than 6 h. These indications did not apply to the current patient.…”

“…A 19-year-old young man, with no underlying disease, sustained a crush injury to his leg and ankle in a motorbike crash in RTA. He had sustained open fractures of the right leg and ankle bones (Gustilo-Anderson classification [GAC] Type III-B)[ 3 ]. His right distal tibia, fibula, and talus bones were crushed, and the large parts of the bones were protruding out from the wound ( Fig.…”

“…There was no damage to important internal organs, such as the brain or heart, but he was hypotensive and responded to fluids and blood transfusions. The Mangled Extremity Severity Score (MESS) was 7 [ 3 , 4 ], and the Ganga Hospital Scoring System (GHSS) [ 5 ] was 12 on arrival. The patient was advised for a below-knee amputation based on clinical judgment, poor financial status, risk of sepsis, and expected multiple surgeries.…”