Surgical management of severe extremity injury
- 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
- University of South Carolina School of Medicine Greenville
- 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. Achieving an optimal 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, and rehabilitation specialists. In most instances, a course of limb salvage can be attempted even if the patient has a mangled extremity; however, occasionally, the injury to the extremity is so severe that primary amputation at the initial operation is required to save the patient’s life. Complications of surgical treatment for severe extremity injury are common; early recognition and treatment are important to minimize morbidity and mortality.
The surgical management of severe extremity injuries will be reviewed here. The initial management of severe extremity injury is discussed elsewhere. (See "Severe extremity injury in the adult patient".)
The extremity evaluation is structured around the four functional components of the extremity (nerves, vessels, bones, soft tissues). Injury to three of these four elements constitutes a “mangled extremity.” The evaluation and radiologic evaluation of the severely injured extremity is discussed elsewhere. (See "Severe extremity injury in the adult patient", section on 'Initial evaluation and management' and "Severe extremity injury in the adult patient", section on 'Extremity evaluation'.)
Knowledge of extremity anatomy and functional physiology is important for proper preoperative and postoperative extremity assessment.
Lower extremity anatomy — The bony structures of the lower extremity include the femur, tibia and fibula. The musculature is contained within defined compartments including the anterior, posterior and medial compartments of the thigh (figure 1), and the anterior, lateral, posterior, and deep posterior compartments of the leg (figure 2).
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- EXTREMITY EVALUATION
- EXTREMITY ANATOMY
- Lower extremity anatomy
- - Collateral circulation
- Upper extremity anatomy
- - Collateral circulation
- LIMB SALVAGE VERSUS AMPUTATION
- SURGICAL MANAGEMENT
- Damage control surgery
- - Vascular ligation
- - Vascular shunting
- Fracture management
- - Debridement and stabilization
- - Definitive fracture fixation
- - Role of endovascular repair
- Extremity fasciotomy
- Nerve repair
- Soft tissue debridement/coverage
- - Degloving injuries
- POSTOPERATIVE CARE AND FOLLOW UP
- Antithrombotic therapy
- - VTE prophylaxis
- - Antiplatelet therapy
- Surveillance of the vascular repair
- Wound complications
- Venous thromboembolism
- Rhabdomyolysis and myoglobinuria
- Heterotopic ossification
- AMPUTATION AND FUNCTIONAL OUTCOMES
- SUMMARY AND RECOMMENDATIONS