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, COL, USAF, MC
Todd E Rasmussen, MD, FACS, COL, USAF, MC
- Harris B Shumacker, Jr. Professor of Surgery
- Associate Dean for Research
- F. Edward Hebért School of Medicine
- Uniformed Services University of the Health Sciences
- Bethesda, MD
- Attending Vascular Surgeon
- Walter Reed National Military Medical Center
- Bethesda, MD
- 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 Science Center
- 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. 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).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Scalea TM, DuBose J, Moore EE, et al. Western Trauma Association critical decisions in trauma: management of the mangled extremity. J Trauma Acute Care Surg 2012; 72:86.
- MacKenzie EJ, Bosse MJ, Kellam JF, et al. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 2002; 52:641.
- Chung KC, Saddawi-Konefka D, Haase SC, Kaul G. A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg 2009; 124:1965.
- Gordon WT, O'Brien FP, Strauss JE, et al. Outcomes associated with the internal fixation of long-bone fractures proximal to traumatic amputations. J Bone Joint Surg Am 2010; 92:2312.
- Hancock H, Rasmussen TE, Walker AJ, Rich NM. History of temporary intravascular shunts in the management of vascular injury. J Vasc Surg 2010; 52:1405.
- Borut LT, Acosta CJ, Tadlock LC, et al. The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up. J Trauma 2010; 69:174.
- Gifford SM, Aidinian G, Clouse WD, et al. Effect of temporary shunting on extremity vascular injury: an outcome analysis from the Global War on Terror vascular injury initiative. J Vasc Surg 2009; 50:549.
- Rasmussen TE, Clouse WD, Jenkins DH, et al. The use of temporary vascular shunts as a damage control adjunct in the management of wartime vascular injury. J Trauma 2006; 61:8.
- Subramanian A, Vercruysse G, Dente C, et al. A decade's experience with temporary intravascular shunts at a civilian level I trauma center. J Trauma 2008; 65:316.
- Fox CJ, Gillespie DL, Cox ED, et al. Damage control resuscitation for vascular surgery in a combat support hospital. J Trauma 2008; 65:1.
- Taller J, Kamdar JP, Greene JA, et al. Temporary vascular shunts as initial treatment of proximal extremity vascular injuries during combat operations: the new standard of care at Echelon II facilities? J Trauma 2008; 65:595.
- Hancock HM, Stannard A, Burkhardt GE, et al. Hemorrhagic shock worsens neuromuscular recovery in a porcine model of hind limb vascular injury and ischemia-reperfusion. J Vasc Surg 2011; 53:1052.
- 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.
- Hassinger SM, Harding G, Wongworawat MD. High-pressure pulsatile lavage propagates bacteria into soft tissue. Clin Orthop Relat Res 2005; 439:27.
- Boyd JI 3rd, Wongworawat MD. High-pressure pulsatile lavage causes soft tissue damage. Clin Orthop Relat Res 2004; :13.
- Polzin B, Ellis T, Dirschl DR. Effects of varying pulsatile lavage pressure on cancellous bone structure and fracture healing. J Orthop Trauma 2006; 20:261.
- FLOW Investigators, Bhandari M, Jeray KJ, et al. A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds. N Engl J Med 2015; 373:2629.
- FLOW Investigators, Petrisor B, Sun X, et al. Fluid lavage of open wounds (FLOW): a multicenter, blinded, factorial pilot trial comparing alternative irrigating solutions and pressures in patients with open fractures. J Trauma 2011; 71:596.
- Possley DR, Burns TC, Stinner DJ, et al. Temporary external fixation is safe in a combat environment. J Trauma 2010; 69 Suppl 1:S135.
- McHenry TP, Holcomb JB, Aoki N, Lindsey RW. Fractures with major vascular injuries from gunshot wounds: implications of surgical sequence. J Trauma 2002; 53:717.
- Moehring HD, Gravel C, Chapman MW, Olson SA. Comparison of antibiotic beads and intravenous antibiotics in open fractures. Clin Orthop Relat Res 2000; :254.
- Bhandari M, Zlowodzki M, Tornetta P 3rd, et al. Intramedullary nailing following external fixation in femoral and tibial shaft fractures. J Orthop Trauma 2005; 19:140.
- Melvin JS, Dombroski DG, Torbert JT, et al. Open tibial shaft fractures: II. Definitive management and limb salvage. J Am Acad Orthop Surg 2010; 18:108.
- Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators, Bhandari M, Guyatt G, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am 2008; 90:2567.
- Williams MM, Askins V, Hinkes EW, Zych GA. Primary reamed intramedullary nailing of open femoral shaft fractures. Clin Orthop Relat Res 1995; :182.
- Brumback RJ, Ellison PS Jr, Poka A, et al. Intramedullary nailing of open fractures of the femoral shaft. J Bone Joint Surg Am 1989; 71:1324.
- Garrison KR, Shemilt I, Donell S, et al. Bone morphogenetic protein (BMP) for fracture healing in adults. Cochrane Database Syst Rev 2010; :CD006950.
- Rozbruch SR, Pugsley JS, Fragomen AT, Ilizarov S. Repair of tibial nonunions and bone defects with the Taylor Spatial Frame. J Orthop Trauma 2008; 22:88.
- 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.
- Burkhardt GE, Gifford SM, Propper B, et al. The impact of ischemic intervals on neuromuscular recovery in a porcine (Sus scrofa) survival model of extremity vascular injury. J Vasc Surg 2011; 53:165.
- 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.
- Watson JD, Houston R 4th, Morrison JJ, et al. A retrospective cohort comparison of expanded polytetrafluorethylene to autologous vein for vascular reconstruction in modern combat casualty care. Ann Vasc Surg 2015; 29:822.
- Vertrees A, Fox CJ, Quan RW, et al. The use of prosthetic grafts in complex military vascular trauma: a limb salvage strategy for patients with severely limited autologous conduit. J Trauma 2009; 66:980.
- Quan RW, Gillespie DL, Stuart RP, et al. The effect of vein repair on the risk of venous thromboembolic events: a review of more than 100 traumatic military venous injuries. J Vasc Surg 2008; 47:571.
- Clouse WD, Rasmussen TE, Peck MA, et al. In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg 2007; 204:625.
- Rich NM, Jarstfer BS, Geer TM. Popliteal artery repair failure: causes and possible prevention. J Cardiovasc Surg (Torino) 1974; 15:340.
- Chopra A, Modrall JG, Knowles M, et al. Uncertain Patency of Covered Stents Placed for Traumatic Axillosubclavian Artery Injury. J Am Coll Surg 2016; 223:174.
- Worni M, Scarborough JE, Gandhi M, et al. Use of endovascular therapy for peripheral arterial lesions: an analysis of the National Trauma Data Bank from 2007 to 2009. Ann Vasc Surg 2013; 27:299.
- Piffaretti G, Tozzi M, Lomazzi C, et al. Endovascular treatment for traumatic injuries of the peripheral arteries following blunt trauma. Injury 2007; 38:1091.
- Chuang DC. Adult brachial plexus reconstruction with the level of injury: review and personal experience. Plast Reconstr Surg 2009; 124:e359.
- Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. Plast Reconstr Surg 2006; 117:1315.
- Dedmond BT, Kortesis B, Punger K, et al. The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures. J Orthop Trauma 2007; 21:11.
- Leininger BE, Rasmussen TE, Smith DL, et al. Experience with wound VAC and delayed primary closure of contaminated soft tissue injuries in Iraq. J Trauma 2006; 61:1207.
- Wood T, Sameem M, Avram R, et al. A systematic review of early versus delayed wound closure in patients with open fractures requiring flap coverage. J Trauma Acute Care Surg 2012; 72:1078.
- Burns TC, Stinner DJ, Possley DR, et al. Does the zone of injury in combat-related Type III open tibia fractures preclude the use of local soft tissue coverage? J Orthop Trauma 2010; 24:697.
- Pollak AN, Ficke JR, Extremity War Injuries III Session Moderators. Extremity war injuries: challenges in definitive reconstruction. J Am Acad Orthop Surg 2008; 16:628.
- DeLong WG Jr, Born CT, Wei SY, et al. Aggressive treatment of 119 open fracture wounds. J Trauma 1999; 46:1049.
- Pollak AN, Jones AL, Castillo RC, et al. The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. J Bone Joint Surg Am 2010; 92:7.
- Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78:285.
- Fischer MD, Gustilo RB, Varecka TF. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. J Bone Joint Surg Am 1991; 73:1316.
- Nathens AB, McMurray MK, Cuschieri J, et al. The practice of venous thromboembolism prophylaxis in the major trauma patient. J Trauma 2007; 62:557.
- Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. N Engl J Med 1998; 338:409.
- Smoot RL, Koch CA, Heller SF, et al. Inferior vena cava filters in trauma patients: efficacy, morbidity, and retrievability. J Trauma 2010; 68:899.
- Hobson RW 2nd, Yeager RA, Lynch TG, et al. Femoral venous trauma: techniques for surgical management and early results. Am J Surg 1983; 146:220.
- Harris AM, Althausen PL, Kellam J, et al. Complications following limb-threatening lower extremity trauma. J Orthop Trauma 2009; 23:1.
- 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.
- Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am 2006; 88:2739.
- Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics 1987; 10:1781.
- Murray CK, Obremskey WT, Hsu JR, et al. Prevention of infections associated with combat-related extremity injuries. J Trauma 2011; 71:S235.
- Brown KV, Murray CK, Clasper JC. Infectious complications of combat-related mangled extremity injuries in the British military. J Trauma 2010; 69 Suppl 1:S109.
- Huh J, Stinner DJ, Burns TC, et al. Infectious complications and soft tissue injury contribute to late amputation after severe lower extremity trauma. J Trauma 2011; 71:S47.
- Geerts WH, Jay RM, Code KI, et al. A comparison of low-dose heparin with low-molecular-weight heparin as prophylaxis against venous thromboembolism after major trauma. N Engl J Med 1996; 335:701.
- Schultz DJ, Brasel KJ, Washington L, et al. Incidence of asymptomatic pulmonary embolism in moderately to severely injured trauma patients. J Trauma 2004; 56:727.
- Schuerer DJ, Whinney RR, Freeman BD, et al. Evaluation of the applicability, efficacy, and safety of a thromboembolic event prophylaxis guideline designed for quality improvement of the traumatically injured patient. J Trauma 2005; 58:731.
- Potter BK, Forsberg JA, Davis TA, et al. Heterotopic ossification following combat-related trauma. J Bone Joint Surg Am 2010; 92 Suppl 2:74.
- Blokhuis TJ, Frölke JP. Is radiation superior to indomethacin to prevent heterotopic ossification in acetabular fractures?: a systematic review. Clin Orthop Relat Res 2009; 467:526.
- Milakovic M, Popovic M, Raman S, et al. Radiotherapy for the prophylaxis of heterotopic ossification: A systematic review and meta-analysis of randomized controlled trials. Radiother Oncol 2015; 116:4.
- Potter BK, Burns TC, Lacap AP, et al. Heterotopic ossification following traumatic and combat-related amputations. Prevalence, risk factors, and preliminary results of excision. J Bone Joint Surg Am 2007; 89:476.
- Seekamp A, Regel G, Tscherne H. Rehabilitation and reintegration of multiply injured patients: an outcome study with special reference to multiple lower limb fractures. Injury 1996; 27:133.
- MacKenzie EJ, Bosse MJ, Pollak AN, et al. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am 2005; 87:1801.
- Perkins ZB, De'Ath HD, Sharp G, Tai NR. Factors affecting outcome after traumatic limb amputation. Br J Surg 2012; 99 Suppl 1:75.
- Khan F, Amatya B, Hoffman K. Systematic review of multidisciplinary rehabilitation in patients with multiple trauma. Br J Surg 2012; 99 Suppl 1:88.
- Cannada LK, Jones AL. Demographic, social and economic variables that affect lower extremity injury outcomes. Injury 2006; 37:1109.
- Rozycki GS, Tremblay LN, Feliciano DV, McClelland WB. Blunt vascular trauma in the extremity: diagnosis, management, and outcome. J Trauma 2003; 55:814.
- Asensio JA, Kuncir EJ, García-Núñez LM, Petrone P. Femoral vessel injuries: analysis of factors predictive of outcomes. J Am Coll Surg 2006; 203:512.
- Scalea JR, Crawford R, Scurci S, et al. Below-the-knee arterial injury: the type of vessel may be more important than the number of vessels injured. J Trauma Acute Care Surg 2014; 77:920.
- Klocker J, Bertoldi A, Benda B, et al. Outcome after interposition of vein grafts for arterial repair of extremity injuries in civilians. J Vasc Surg 2014; 59:1633.
- Branco BC, Linnebur M, Boutrous ML, et al. The predictive value of multidetector CTA on outcomes in patients with below-the-knee vascular injury. Injury 2015; 46:1520.
- Stinner DJ, Burns TC, Kirk KL, Ficke JR. Return to duty rate of amputee soldiers in the current conflicts in Afghanistan and Iraq. J Trauma 2010; 68:1476.
- Penn-Barwell JG. Outcomes in lower limb amputation following trauma: a systematic review and meta-analysis. Injury 2011; 42:1474.
- Helgeson MD, Potter BK, Burns TC, et al. Risk factors for and results of late or delayed amputation following combat-related extremity injuries. Orthopedics 2010; 33:669.
- Fochtmann A, Mittlböck M, Binder H, et al. Potential prognostic factors predicting secondary amputation in third-degree open lower limb fractures. J Trauma Acute Care Surg 2014; 76:1076.
- Doucet JJ, Galarneau MR, Potenza BM, et al. Combat versus civilian open tibia fractures: the effect of blast mechanism on limb salvage. J Trauma 2011; 70:1241.
- Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002; 347:1924.
- Busse JW, Jacobs CL, Swiontkowski MF, et al. Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma 2007; 21:70.
- 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.
- Dorlac WC, DeBakey ME, Holcomb JB, et al. Mortality from isolated civilian penetrating extremity injury. J Trauma 2005; 59:217.
- 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