Severe extremity injury in the adult patient
- Jeremy W Cannon, MD, FACS
Jeremy W Cannon, MD, FACS
- Associate Professor of Surgery
- Perelman School of Medicine at the University of Pennsylvania
- Todd E Rasmussen, MD, FACS
Todd E Rasmussen, MD, FACS
- Professor of Surgery
- Uniformed Services University of the Health Sciences
- Bethesda, Maryland
- Section Editors
- Eileen M Bulger, MD, FACS
Eileen M Bulger, MD, FACS
- Section Editor — Trauma Surgery
- Professor of Surgery
- University of Washington
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Sciences Center - Dallas Campus
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Trauma to the extremities represents one of the most common injury patterns seen in emergency medical and surgical practice. As extremity injuries are evaluated, each of four functional components (nerves, vessels, bones, and soft tissues) must be considered individually and together. If three of these four elements are injured, the patient has a “mangled extremity” [1,2]. Achieving the best outcome in patients with severe extremity injuries requires a multidisciplinary approach with oversight by the general or trauma surgeon and commitment from other specialists including orthopedic, vascular, and plastic surgeons, as well as rehabilitation specialists. In most instances, limb salvage can be attempted even if the patient has a mangled extremity. However, at times, the injury to the extremity is so severe that primary amputation at the initial operation is required to save the patient’s life.
The initial management of severe extremity injury will be reviewed here. The management of minor extremity injuries, including isolated fracture management, is discussed elsewhere. (See "General principles of fracture management: Bone healing and fracture description" and "General principles of fracture management: Early and late complications" and "General principles of acute fracture management" and "General principles of definitive fracture management".)
The etiology of extremity injuries ranges widely from falls and motor vehicle collisions to blast and fragmentation injuries. The nature and severity of extremity injuries differs between the military and civilian setting. Military extremity injuries are primarily due to penetrating or combined mechanisms, which are associated with high rates of open fracture and vascular injury . In contrast, most severe extremity injuries in civilians are due to blunt trauma, but about 12 percent of civilian extremity injures occur as a result of penetrating or combined mechanisms.
Civilian — Civilian extremity injuries occur most often due to falls (representing 50 to 60 percent of lower extremity injuries and 30 percent of upper extremity injuries), industrial or work-related accidents (up to 20 percent of upper extremity injuries), and motor vehicle crashes . Most upper extremity injuries occur as a result of using machinery or tools.
In civilians with nonfatal trauma, upper and lower extremity injuries are the most common reason for hospitalization, with more than one-third of those hospitalized having serious or limb-threatening injuries [4-6]. In a systematic review of 3187 lower extremity injuries requiring vascular repairs, the overall secondary amputation rate was 10 percent .
- Johansen K, Daines M, Howey T, et al. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990; 30:568.
- de Mestral C, Sharma S, Haas B, et al. A contemporary analysis of the management of the mangled lower extremity. J Trauma Acute Care Surg 2013; 74:597.
- Johnson BA, Carmack D, Neary M, et al. Operation Iraqi Freedom: the Landstuhl Regional Medical Center experience. J Foot Ankle Surg 2005; 44:177.
- Mackenzie EJ, Fowler CJ. Epidemiology. In: Trauma, 6th ed., Feliciano DV, Mattox KL, Moore EE (Eds), McGraw-Hill Medical, New York 2008. p.25.
- Nance ML. National Trauma Data Bank Annual Report. 2012. http://www.facs.org/trauma/ntdb/pdf/ntdb-annual-report-2012.pdf (Accessed on October 22, 2013).
- Finkelstein EA, Corso PS, Miller TR, et al. The incidence and economic burden of injuries in the United States, Oxford University Press, New York 2006.
- Perkins ZB, Yet B, Glasgow S, et al. Meta-analysis of prognostic factors for amputation following surgical repair of lower extremity vascular trauma. Br J Surg 2015; 102:436.
- Owens BD, Kragh JF Jr, Wenke JC, et al. Combat wounds in operation Iraqi Freedom and operation Enduring Freedom. J Trauma 2008; 64:295.
- Belmont PJ Jr, Goodman GP, Zacchilli M, et al. Incidence and epidemiology of combat injuries sustained during "the surge" portion of operation Iraqi Freedom by a U.S. Army brigade combat team. J Trauma 2010; 68:204.
- Fox CJ, Gillespie DL, O'Donnell SD, et al. Contemporary management of wartime vascular trauma. J Vasc Surg 2005; 41:638.
- Dillingham TR, Pezzin LE, MacKenzie EJ. Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study. Arch Phys Med Rehabil 1998; 79:279.
- Meling T, Harboe K, Søreide K. Incidence of traumatic long-bone fractures requiring in-hospital management: a prospective age- and gender-specific analysis of 4890 fractures. Injury 2009; 40:1212.
- Court-Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long bone fractures. Injury 1998; 29:529.
- Court-Brown CM, McBirnie J. The epidemiology of tibial fractures. J Bone Joint Surg Br 1995; 77:417.
- Schlickewei W, Kuner EH, Mullaji AB, Götze B. Upper and lower limb fractures with concomitant arterial injury. J Bone Joint Surg Br 1992; 74:181.
- Frykberg ER, Dennis JW, Bishop K, et al. The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: results at one year. J Trauma 1991; 31:502.
- Franz RW, Shah KJ, Halaharvi D, et al. A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center. J Vasc Surg 2011; 53:1604.
- White JM, Stannard A, Burkhardt GE, et al. The epidemiology of vascular injury in the wars in Iraq and Afghanistan. Ann Surg 2011; 253:1184.
- American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
- Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care 2014; 18:163.
- Dorlac WC, DeBakey ME, Holcomb JB, et al. Mortality from isolated civilian penetrating extremity injury. J Trauma 2005; 59:217.
- Swan KG Jr, Wright DS, Barbagiovanni SS, et al. Tourniquets revisited. J Trauma 2009; 66:672.
- Arrillaga A, Bynoe R, Frykberg ER, Nagy K. EAST Practice Management Guidelines for Penetrating Trauma to the Lower Extremity (2002). http://www.east.org/content/documents/lower_extremity_isolated_arterial_injuries_from_penetrating_trauma.pdf (Accessed on October 22, 2013).
- Fox N, Rajani RR, Bokhari F, et al. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012; 73:S315.
- Committee for Tactical Emergency Medical Care. Tactical Emergency Casualty Care Guidelines: Direct Threat Care. http://c-tecc.org/tactical-emergency-casualty-care-guidelines (Accessed on October 22, 2013).
- Beekley AC, Sebesta JA, Blackbourne LH, et al. Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control and outcomes. J Trauma 2008; 64:S28.
- Kragh JF Jr, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg 2009; 249:1.
- Walters TJ, Wenke JC, Kauvar DS, et al. Effectiveness of self-applied tourniquets in human volunteers. Prehosp Emerg Care 2005; 9:416.
- US Department of Health and Human Services Centers for Disease Control and Prevention. Tetanus. www.cdc.gov/vaccines/pubs/pinkbook/downloads/tetanus.pdf (Accessed on May 06, 2011).
- Graham B, Adkins P, Tsai TM, et al. Major replantation versus revision amputation and prosthetic fitting in the upper extremity: a late functional outcomes study. J Hand Surg Am 1998; 23:783.
- Ravindra KV, Buell JF, Kaufman CL, et al. Hand transplantation in the United States: experience with 3 patients. Surgery 2008; 144:638.
- Win TS, Henderson J. Management of traumatic amputations of the upper limb. BMJ 2014; 348:g255.
- Cavadas PC, Landín L, Ibáñez J, et al. Infrapopliteal lower extremity replantation. Plast Reconstr Surg 2009; 124:532.
- Sapega AA, Heppenstall RB, Sokolow DP, et al. The bioenergetics of preservation of limbs before replantation. The rationale for intermediate hypothermia. J Bone Joint Surg Am 1988; 70:1500.
- Wei FC, Chang YL, Chen HC, Chuang CC. Three successful digital replantations in a patient after 84, 86, and 94 hours of cold ischemia time. Plast Reconstr Surg 1988; 82:346.
- Cancio LC, Jimenez-Reyna JF, Barillo DJ, et al. One hundred ninety-five cases of high-voltage electric injury. J Burn Care Rehabil 2005; 26:331.
- Herrera FA, Hassanein AH, Potenza B, et al. Bilateral upper extremity vascular injury as a result of a high-voltage electrical burn. Ann Vasc Surg 2010; 24:825.e1.
- Bosse MJ, McCarthy ML, Jones AL, et al. The insensate foot following severe lower extremity trauma: an indication for amputation? J Bone Joint Surg Am 2005; 87:2601.
- Peterson SL, Lehman TP. Upper extremity injury. In: Trauma, 6th ed., Feliciano, DV, Mattox, KL, Moore, EE (Eds), McGraw-Hill Medical, New York p.871.
- Burkhardt GE, Cox M, Clouse WD, et al. Outcomes of selective tibial artery repair following combat-related extremity injury. J Vasc Surg 2010; 52:91.
- Lynch K, Johansen K. Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma? Ann Surg 1991; 214:737.
- Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma 2004; 56:1261.
- Wallin D, Yaghoubian A, Rosing D, et al. Computed tomographic angiography as the primary diagnostic modality in penetrating lower extremity vascular injuries: a level I trauma experience. Ann Vasc Surg 2011; 25:620.
- Uyeda JW, Anderson SW, Sakai O, Soto JA. CT angiography in trauma. Radiol Clin North Am 2010; 48:423.
- Soto JA, Múnera F, Cardoso N, et al. Diagnostic performance of helical CT angiography in trauma to large arteries of the extremities. J Comput Assist Tomogr 1999; 23:188.
- Soto JA, Múnera F, Morales C, et al. Focal arterial injuries of the proximal extremities: helical CT arteriography as the initial method of diagnosis. Radiology 2001; 218:188.
- Jens S, Kerstens MK, Legemate DA, et al. Diagnostic performance of computed tomography angiography in peripheral arterial injury due to trauma: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2013; 46:329.
- Melvin JS, Dombroski DG, Torbert JT, et al. Open tibial shaft fractures: I. Evaluation and initial wound management. J Am Acad Orthop Surg 2010; 18:10.
- Seamon MJ, Smoger D, Torres DM, et al. A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography. J Trauma 2009; 67:238.
- White PW, Gillespie DL, Feurstein I, et al. Sixty-four slice multidetector computed tomographic angiography in the evaluation of vascular trauma. J Trauma 2010; 68:96.
- Propper BW, Alley JB, Gifford SM, et al. Endovascular treatment of a blunt aortic injury in Iraq: extension of innovative endovascular capabilities to the modern battlefield. Ann Vasc Surg 2009; 23:687.e19.
- Yan H, Gao W, Li Z, et al. The management of degloving injury of lower extremities: technical refinement and classification. J Trauma Acute Care Surg 2013; 74:604.
- Harboe K, Søreide K. Tibial fracture with degloving injury of the foot. Br J Surg 2012; 99 Suppl 1:87.
- Nickerson TP, Zielinski MD, Jenkins DH, Schiller HJ. The Mayo Clinic experience with Morel-Lavallée lesions: establishment of a practice management guideline. J Trauma Acute Care Surg 2014; 76:493.
- Konda SR, Davidovitch RI, Egol KA. Computed tomography scan to detect traumatic arthrotomies and identify periarticular wounds not requiring surgical intervention: an improvement over the saline load test. J Orthop Trauma 2013; 27:498.
- Konda SR, Howard D, Davidovitch RI, Egol KA. The role of computed tomography in the assessment of open periarticular fractures associated with deep knee wounds. J Orthop Trauma 2013; 27:509.
- Nord RM, Quach T, Walsh M, et al. Detection of traumatic arthrotomy of the knee using the saline solution load test. J Bone Joint Surg Am 2009; 91:66.
- Keese GR, Boody AR, Wongworawat MD, Jobe CM. The accuracy of the saline load test in the diagnosis of traumatic knee arthrotomies. J Orthop Trauma 2007; 21:442.
- Konda SR, Howard D, Davidovitch RI, Egol KA. The saline load test of the knee redefined: a test to detect traumatic arthrotomies and rule out periarticular wounds not requiring surgical intervention. J Orthop Trauma 2013; 27:491.
- Owens BD, Kragh JF Jr, Macaitis J, et al. Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 2007; 21:254.
- Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24:742.
- Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 1976; 58:453.
- Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am 2006; 88:2739.
- Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am 1994; 76:1162.
- Orthopaedic Trauma Association: Open Fracture Study Group. A new classification scheme for open fractures. J Orthop Trauma 2010; 24:457.
- Patterson BM, Agel J, Swiontkowski MF, et al. Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study. J Trauma 2007; 63:855.
- Dua A, Desai SS, Shah JO, et al. Outcome predictors of limb salvage in traumatic popliteal artery injury. Ann Vasc Surg 2014; 28:108.
- American College of Surgeons Committee on Trauma ad hoc Committee on Outcomes. Management of Complex Extremity Trauma. www.facs.org/trauma/publications/mancompexttrauma.pdf (Accessed on May 06, 2011).
- Arrillaga A, Bynoe R, Frykberg ER, Nagy K. EAST Practice Management Guidelines for Penetrating Trauma to the Lower Extremity. http://www.east.org/Portal/Default.aspx?tabid=57 (Accessed on May 06, 2011).
- Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 2001; 83-A:3.
- Harris AM, Althausen PL, Kellam J, et al. Complications following limb-threatening lower extremity trauma. J Orthop Trauma 2009; 23:1.
- Rozycki GS, Tremblay LN, Feliciano DV, McClelland WB. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma 2003; 55:814.
- EXTREMITY ANATOMY
- INITIAL EVALUATION AND MANAGEMENT
- Control of hemorrhage
- Extremity radiography
- Tetanus prophylaxis
- Special situations
- - Traumatic amputation
- - Extremity electrical injury
- EXTREMITY EVALUATION
- Peripheral nerve assessment
- Vascular assessment
- - Hard signs of arterial injury
- - Injured extremity index
- - Arteriography
- Soft tissue and bone assessment
- INJURY SEVERITY SCORING
- Open fracture grading
- Predicting limb loss
- - Clinical predictors
- - Scoring systems
- MANAGEMENT APPROACH
- Hemodynamically unstable
- Hemodynamically stable with vascular injury
- Hemodynamically stable without vascular injury
- MORBIDITY AND MORTALITY
- SUMMARY AND RECOMMENDATIONS