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Severe extremity injury in the adult patient
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Severe extremity injury in the adult patient
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Literature review current through: Nov 2017. | This topic last updated: Jun 16, 2017.

INTRODUCTION — 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".)

ETIOLOGY — 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 settings. Military extremity injuries are primarily due to penetrating or combined mechanisms, which are associated with high rates of open fracture and vascular injury [3]. In contrast, most severe extremity injuries in civilians are due to blunt trauma, but approximately 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 [4]. 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 [7].

Military — Approximately 50 percent of the injuries recorded in the Joint Theater Trauma Registry involve the extremities [8,9]. Many soldiers with extremity injuries also have other serious life-threatening injuries that complicate limb salvage [10]. In one series, 25 percent had an extremity injury associated with another serious nonextremity injury [3].

Most extremity wounds during combat have a penetrating component, typically resulting from explosions (81 percent) or gunshot wounds (17 percent). Only 2 percent of extremity injuries during combat are due to isolated blunt trauma [8]. Because of the predominantly penetrating mechanism and war environment, many of these injuries involve multiple functional components (bone, nerve, vessel and soft-tissue damage), resulting in a high rate of mangled extremities.

INCIDENCE — In 2012, 278,100 lower extremity injuries and 223,650 upper extremity injuries were entered into the civilian National Trauma Data Bank (NTDB) [5]. Traumatic injury in civilians results in an estimated 3700 major amputations annually [4,11]. The contemporary incidence of extremity injuries during combat is lower than in previous recorded conflicts, representing approximately 50 percent of injuries, compared with approximately 59 percent during World War II, 60.2 percent during the Korean War, and 61.1 percent in the Vietnam War [9].

The presence of an open fracture significantly increases the risk of osteomyelitis and, ultimately, limb loss depending upon the severity of injury to the associated soft tissues. Open fractures occur in approximately 3 percent of long bone fractures for an annual incidence of between 11.5 and 13 per 100,000 [12,13]. The long bone that is most commonly involved in open fracture is the tibia. In one study, 24 percent of tibial fractures were open [14]. High-energy motor vehicle collisions were responsible for 58 percent of these injuries [13].

Associated vascular injuries occur in <1 percent of all civilian fractures (0.4 percent in one series) [15]. The risk of vascular injury increases with increasing injury severity. In retrospective reviews, the incidence of vascular injury was cited at 5 percent for severe fractures [12] and 6.6 percent for penetrating extremity injuries [16]. Among patients with arterial injury, bony injuries were present in 43 percent of patients, in a five-year retrospective review [17]. Venous injuries occurred in 20 percent of the patients studied.

The presence of a vascular injury also increases the risk for limb loss. In a contemporary combat review (2002 to 2009), 1570 patients with vascular injuries were identified out of 13,076 casualties (12 percent). Of these, 79 percent involved the upper and lower extremities. Isolated extremity arterial injuries were documented in 63 percent, isolated extremity venous injuries in 15 percent, and combined arterial and venous injuries in 22 percent. Rates of vascular injury in prior conflicts ranged from 1 percent in World War II to 2 to 3 percent in Korea and Vietnam [18].

EXTREMITY ANATOMY — Knowledge of extremity anatomy and functional physiology is important for proper preoperative and postoperative extremity assessment. The anatomy of the upper and lower extremity is reviewed elsewhere. (See "Surgical management of severe extremity injury", section on 'Extremity anatomy'.)

INITIAL EVALUATION AND MANAGEMENT — We perform initial resuscitation, diagnostic evaluation, and management of the trauma patient with blunt or penetrating trauma based upon protocols from the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma [19]. The initial resuscitation and evaluation of the patient with blunt or penetrating head, thoracic, or abdominal trauma is discussed in detail elsewhere. Resuscitation and management of these life-threatening injuries takes precedence over the extremity injury. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults".)

Control of hemorrhage — External bleeding from the extremity, and particularly bleeding from the junctional segment of the extremity vasculature (ie, axillary artery, common femoral artery), is life-threatening and should be controlled as soon as possible [20].

Bleeding from extremity vascular injury can usually be controlled using direct pressure. However, because prolonged application of direct pressure, particularly bleeding from junctional vessels, is not practical during transport in the prehospital or tactical environment, other approaches have been used including topical agents, external compression clamps, and endovascular occlusion devices [20]. These methods are not widely accepted in mainstream civilian clinical practice but have been endorsed by the American College of Surgeons in the prehospital setting [20]. (See "Prehospital care of the adult trauma patient", section on 'Hemorrhage control'.)

Bleeding can also be controlled using a tourniquet [21,22] or direct clamping of visible vessels. Clamping vessels that cannot be clearly identified should not be performed. Pneumatic tourniquets are commonly used to lessen bleeding during the course of upper and lower extremity surgery. There is renewed interest in the civilian community in the use of tourniquets for control of extremity hemorrhage. ATLS endorses the judicious use of a tourniquet for major extremity arterial hemorrhage, and several civilian guidelines now include tourniquet application as a temporary adjunct to control extremity hemorrhage when direct pressure is unsuccessful [19,23,24] or during tactical civilian events, which are situations where ballistic or explosive wounds are possible (eg, an active shooter standoff) [25]. (See "Prehospital care of the adult trauma patient", section on 'Hemorrhage control'.)

A variety of tourniquets have been developed to manage combat-related extremity hemorrhage with a low risk of ischemia and neurologic complications [26,27]. The Combat Application Tourniquet (CAT), Emergency and Medical Tourniquet (EMT), and Special Operations Forces Tactical Tourniquet (SOFTT) meet the effectiveness standard of the United States military and occlude distal flow in >80 percent of subjects [26,27]. The relative effectiveness of these tourniquets has been evaluated in human volunteers with each shown to attenuate the distal arterial pulse in upper and lower extremities [28]. The benefits of tourniquet application are illustrated in the following studies in combat casualty populations:

In a study that evaluated 165 patients, 67 of whom had a prehospital tourniquet applied, control of bleeding was significantly improved with tourniquet application versus no tourniquet (83.3 versus 60.7 percent), and there were no differences in secondary amputation rates [26].

A prospective study of 232 combat casualties found a significantly improved survival rate (77 versus 0 percent) when using a tourniquet (prehospital or emergency department) versus no tourniquet [27]. In this study, no amputations were required due to tourniquet use, but four transient nerve palsies were reported.

Extremity radiography — Patients with any of the following findings on primary trauma survey should undergo plain radiographs. Radiographic assessment should focus on the area of abnormality to include a joint above and below the potential injury, and the study should be performed with two projections (eg, anterior-posterior and lateral).

Extremity deformity

Point tenderness

Ecchymosis  

Laceration deep to the muscle fascia

Laceration in proximity to a joint

Joint laxity

Bony injuries, particularly comminuted fractures, increase the risk of concomitant arterial injury (table 1) and include fractures of the proximal humerus, humeral shaft (image 1), distal radius or ulna, mid-femur (image 2), and mid- or distal tibia-fibula fractures (image 3). The presence of these fractures on radiographic survey should prompt full vascular assessment. (See 'Vascular assessment' below.)

Antibiotics — Systemic antibiotics should be started at the time of the diagnosis of open fracture. The open fracture site should be cleaned of any foreign debris and dressed with a moist sterile dressing. (See "Treatment and prevention of osteomyelitis following trauma in adults".)

Tetanus prophylaxis — Tetanus prophylaxis should be given according to the Centers for Disease Control (CDC) guidelines [29]. (See "Tetanus-diphtheria toxoid vaccination in adults", section on 'Immunization for patients with injuries'.)

Special situations — Two clinical scenarios involving extremity injury require specific management: traumatic amputation and electrical injury.

Traumatic amputation — Traumatic amputation refers to limb loss that occurs in the field at the time of the initial trauma and is a special form of the mangled extremity. It is distinguished from primary amputation, which is removal of the limb during initial operative management, and secondary amputation, which is removal of the limb following attempted limb salvage. (See "Surgical management of severe extremity injury", section on 'Limb salvage versus amputation' and "Lower extremity amputation".)

Upper or lower limb replantation may be possible if the distal detached extremity is relatively uninjured [30-32]. Replantation is performed more commonly for traumatic upper extremity amputations. In the lower extremity, a prosthesis provides a good functional outcome that, in some cases, may be superior to that achieved with replantation [33].

Warm ischemia time should be limited by wrapping the amputated body part in saline-soaked gauze or by indirect cooling (placing the body part in a container and then placing the container on ice). The extremity should not be exposed directly to ice. Replantation is generally not recommended if warm ischemia time is more than six to eight hours for major traumatic amputation, and 10 to 12 hours for a digit [34]; however, successful finger replantation has been reported after a delay of 94 hours [32,35].  

A multidisciplinary decision for replantation is made at the receiving facility with input from the trauma surgeon overseeing the patient's care, taking into consideration the patient's other injuries, and with input from subspecialists in orthopedic, plastic, and vascular surgery regarding feasibility of replantation and likely projected outcomes.

Extremity electrical injury — The upper extremity is commonly involved in electrical injuries, which can result in significant soft tissue damage. These injuries are stratified into two groups based upon the voltage involved: low voltage (ie, <1000 volts) and high voltage (≥1000 volts). The epidemiology, diagnosis, and general issues of the treatment of electrical injuries are discussed in detail elsewhere. (See "Environmental and weapon-related electrical injuries".)

Soft tissue damage occurring between the entrance and exit wounds can be substantial with high-voltage injuries. Amputation is necessary in up to 40 percent of these cases, which is not surprising given the large volume of soft tissue loss [36]. The involved soft tissues should be closely monitored for necrosis and vascular thrombosis [37]. Reconstruction can be undertaken once the full extent of soft tissue injury has manifested.

Compartment syndrome should be anticipated with high-voltage injuries, and early fasciotomy should be performed as indicated. (See "Lower extremity fasciotomy techniques" and "Patient management following extremity fasciotomy".)

EXTREMITY EVALUATION — A brief extremity exam is performed during the initial trauma assessment (primary survey) but should be repeated in more detail once life-threatening injuries have been addressed and any active external bleeding is controlled. The extremity evaluation should proceed in an orderly fashion using the four functional elements of the extremity as a framework, which includes assessment of the nerves, vessels, bones, and soft tissues.

Peripheral nerve assessment — The neurologic exam in alert, cooperative patients should easily identify associated motor or sensory deficits. In the unconscious or uncooperative patient, gross deficits should be noted, such as a lack of movement in all or part of an extremity, or asymmetric movements. Detailed ongoing extremity evaluation should be performed as the patient's neurologic status improves to identify specific deficits referable to peripheral nerve injury.

In the lower extremity, function of the femoral, sciatic, tibial, and peroneal nerves should be assessed since these nerves are more likely to be directly injured or affected by ischemia.

Injury to the femoral nerve results in decreased sensation on the anterior thigh and weakness of hip flexion and knee extension.

Injury to the sciatic nerve causes decreased sensation in the lateral leg and the lateral, dorsal, and plantar aspects of the foot; weakness of knee flexion; and loss of motor function of the leg and foot.

Deep peroneal nerve injury causes decreased sensation in the first dorsal webspace and causes foot drop.

Injury to the tibial nerve results in loss of sensation to the heel, inability to plantar flex the foot, and cavus deformity of the foot.

Although lack of plantar sensation has historically been taught as a useful indicator of an unsalvageable extremity, subsequent data have found that this is not a reliable physical finding. Some patients with an insensate foot on initial exam can subsequently regain function [38]. (See "Surgical management of severe extremity injury", section on 'Lower extremity anatomy'.)

In the upper extremity, the axillary nerve, radial nerve, and median nerve are all vulnerable to injury given their anatomic course. The game of "rock, paper, scissors" is a quick way to assess the motor function of the median, radial, and ulnar nerves, respectively [39]. (See "Surgical management of severe extremity injury", section on 'Upper extremity anatomy'.)

Injury to the axillary nerve (proximal humerus fractures) results in loss of arm abduction and an area of numbness or paresthesia along the lateral aspect of the upper arm.

Radial nerve injury leads to loss of sensation on the dorsum of the hand and weakness of the wrist and finger extensors.

Injury to the median nerve leads to decreased sensation on the palmar aspect of the first three digits and weakness of the thenar musculature.

Injury to the ulnar nerve leads to decreased sensation on the palmar aspect of the fourth and fifth digits and weakness of the flexors of these digits.

Vascular assessment — A detailed vascular assessment of the injured extremity begins with a complete pulse examination (common femoral, popliteal, dorsalis pedis and posterior tibial arteries, axillary, brachial, radial, ulnar arteries) to identify asymmetry of pulses or the absence of palpable pulses. Auscultation over the injury site may reveal a bruit that may be indicative of a partially thrombosed or compressed vessel. (See "Surgical management of severe extremity injury", section on 'Lower extremity anatomy' and "Surgical management of severe extremity injury", section on 'Upper extremity anatomy'.)

In the setting of a shock or the presence of joint dislocation or angulated fracture, the pulse assessment should be repeated after resuscitation and/or reduction of the abnormality. In a study of combat injuries, 74 percent of patients who had no pulses on initial examination had reestablished blood flow to the foot following resuscitation and limb stabilization [40].

Hard signs of arterial injury — Hard signs of vascular injury include the following [5]:

Active hemorrhage

Expanding or pulsatile hematoma

Bruit or thrill over wound

Absent distal pulses

Extremity ischemia (pain, pallor, paralysis, cool to touch)

In a large observational study of penetrating extremity trauma, the presence of a hard sign of arterial injury was nearly 100 percent predictive of a vascular injury warranting surgical repair [16]. These patients should be taken directly to the operating room where the injury can be surgically explored. If arteriography is needed to clarify arterial anatomy, it can be performed intraoperatively.  

With blunt trauma, hard signs are less reliable and false positives are common. Repeat physical examination after resuscitation, warming, and reduction of any orthopedic injuries should be performed. If a diminished pulse or other signs of vascular injury persist in the hemodynamically stable patient with blunt extremity injury, angiography should be performed to further delineate the location and nature of the injury. (See 'Arteriography' below.)

Injured extremity index — The injured extremity index (IEI) or arterial pressure index (API) is analogous to the ankle-brachial index (ABI) and should be performed in any patient who does not have hard signs of vascular injury. The term "injured extremity index" is a trauma-specific term that is broader and can be applied to the upper or lower extremity. (See "Noninvasive diagnosis of arterial disease", section on 'Ankle-brachial index'.)

The IEI is the ratio of the highest systolic occlusion pressure in the injured extremity at the level of the dorsalis pedis/posterior tibial (or radial/ulnar arteries) divided by the systolic pressure in a proximal vessel in an uninjured extremity (most often the brachial artery). As an example, for an injured upper extremity, the higher value of the radial or ulnar occlusion pressure in the injured extremity would be divided by the occlusion pressure of the contralateral brachial artery.

A normal IEI (ie, >0.9) has a high negative predictive value for vascular injury, allowing the patient to be observed or managed without immediate vascular imaging [41,42].

An IEI that is abnormal (ie, ≤0.9) may indicate an occult vascular injury. For patients who are hypothermic or hypotensive during the initial assessment, the IEI should be repeated 10 to 15 minutes after resuscitation and warming. An IEI that is persistently below 0.9 is predictive of vascular injury that requires additional vascular evaluation [41,42].

The diagnostic approach for patients with an IEI ≤0.9 should be within the context of the patient's overall clinical status and other associated injuries. In patients with multiple injuries who require head, torso, and abdominal computed tomography (CT), adding extremity CT angiography is a rational choice. The information obtained with respect to the extremity (positive or negative) assists the trauma surgeon in determining which injuries to manage first.

For isolated extremity injuries or injuries with less complex associated injuries, the approach should be more individualized. Some patients may benefit from immediate surgical exploration and others from digital subtraction arteriography (DSA) rather than CT angiography. Every effort should be made to avoid an algorithm that exposes the patient to excessive radiation and intravenous contrast load such as CT angiography followed by DSA, which usually occurs in the context of seeking to better define subtle irregularities [43]. Consultation with a vascular surgeon can help aid with decision making.

Arteriography — Arteriography, which can be accomplished using CT or conventional DSA, may be necessary to exclude vascular injury in hemodynamically stable patients with clinical signs consistent with potential vascular injury, such as an equivocal pulse examination, persistently diminished IEI in spite of resuscitation, and posterior knee dislocation. (See 'Injured extremity index' above.)

The need for vascular repair (open or endovascular) should be determined in the context of clinical findings in conjunction with an arteriographic study that shows a vascular injury. The clinical findings also establish the timing or urgency of the operation. In the context of a clinical examination, the following findings on arteriography (CT or DSA) strongly indicate the need for exploration and vascular repair. (See "Surgical management of severe extremity injury", section on 'Revascularization'.)

Extravasation of contrast or pseudoaneurysm

Arteriovenous fistula

Flow-limiting intimal flap (flow limiting based upon clinical exam). If the injured extremity index is normal, any observed flap is not considered to be flow limiting.

Occlusion of axial extremity arteries

Distal embolism (may occur even in the presence of a relatively minor proximal injury)

The high sensitivity and speed of modern CT makes it attractive as a noninvasive study to identify and characterize suspected vascular injury. To obtain optimal images, contrast injection should be performed remote from the extremity of interest. In upper extremity exams, the arms should be raised above the head [44]. The sensitivity of helical CT angiography with three-dimensional reconstruction ranges from 90 to 100 percent, with specificities >99 percent [45-47]. Interobserver agreement is approximately 90 percent. Newer-generation multidetector scanners (16- or 64-slice) have sensitivity and specificity approaching 100 percent for clinically significant injuries [48,49]. In one study, multidetector CT angiography adequately imaged the extremity vasculature in spite of the artifact caused by orthopedic hardware and retained fragments [50]. Three-dimensional reconstruction is not an absolute requirement with higher-slice scanners. We use a 64-slice scanner without reconstruction but consider it ideal to have the trauma or vascular surgeon review the cross-sectional images together with the radiologist.

CT angiography is often preferred in patients with multiple trauma because it is less invasive than conventional arteriography and can be performed at the same time as head, chest, or abdominal CT, which are frequently needed in trauma patients. As a single study, CT angiography is less expensive than conventional arteriography [49]. However, the cost of additional studies to sort out nondiagnostic findings on CT angiography and the cost of unnecessary surgical explorations or other interventions based upon the results of CT angiography need to be taken into account. As an example, in a study of 132 patients with penetrating trauma, 59 patients underwent CT angiography, of which 28 were performed as a completion of a head/chest/abdominal series and 31 were for isolated extremity injury [43]. Ten percent of the studies were indeterminate with two of these patients requiring exploration. There was no difference in the rate of indeterminate studies between whole body studies and those done for isolated extremity injury.

Conventional DSA may be preferred initially in some patients and can be performed in a dedicated interventional suite or in the operating room. Arteriography in the operating room has the advantage of eliminating unnecessary patient transport. A hybrid operating room (operating suite with interventional capabilities) is ideal but not necessary. Intraoperative arteriography can be performed using a portable power injector and portable digital subtraction arteriography, which are generally available in the operating room at civilian and military hospitals [51].

Soft tissue and bone assessment — The soft tissue envelope of muscle, subcutaneous fat, and skin should be evaluated for signs that indicate a potential underlying fracture and to assess the severity of soft tissue damage, which is important for determining the potential risk of limb loss.

The soft tissue injury should identify areas of missile entry and exit, soft tissue avulsion, skin or muscle flap formation, and evidence of contamination. In penetrating injuries, such as high-velocity gunshot wounds or fragmentation injuries, the external wound may be relatively small; however, underlying soft tissue destruction can be significant.

Rotational (shearing) injuries to the extremities can avulse the skin and subcutaneous fat off the underlying tissues, which are termed degloving injuries [52]. These can be classified as pure degloving injuries involving the skin only (open or closed), those that involve the deep soft tissues, and those associated with long-bone fracture [53]. Traumatic separation of the skin and subcutaneous tissues from the underlying fascia without a break in the skin constitutes a closed degloving injury (Morel-Lavallee, post-traumatic seroma) [54]. Closed degloving occurs most frequently overlying the hip and in the proximal thigh. Free-floating segments of skin and soft tissue can become ischemic and slough completely, resulting in large areas of soft tissue loss that must then be skin grafted. (See "Surgical management of severe extremity injury", section on 'Degloving injuries'.)

Severe or extensive muscle tissue damage can lead to rhabdomyolysis, independent of other risk factors such as ischemia-reperfusion or acute compartment syndrome. The diagnosis and management of rhabdomyolysis is reviewed elsewhere. (See "Surgical management of severe extremity injury", section on 'Rhabdomyolysis and myoglobinuria'.)

Lacerations should be assessed for proximity to fracture sites and joint spaces. Extremity injuries with suspected joint space involvement (traumatic arthrotomy) can be further evaluated by injecting the joint with saline (ie, saline load test). However, using CT may be preferred unless it is not available or not practical. In one study of 62 patients, the sensitivity and specificity of CT for detecting a traumatic open arthrotomy at the knee was significantly higher compared with the saline load test (100 versus 92 percent) [55]. An additional advantage of CT is the ability to detect open periarticular knee fracture. In one study, CT altered the fracture classification in 48 percent of patients [56]. When a saline load test is used, the joint should be assessed to identify any distension and the associated wound or laceration evaluated for fluid extravasation. Available studies indicate that as much as 194 mL of saline may need to be injected to achieve 95 percent sensitivity for identifying traumatic arthrotomy of the knee [57-59]. In a retrospective study of the saline load test used in 50 trauma patients at risk for a traumatic arthrotomy of the knee, the at-risk joint was loaded until fluid was noted to extravasate from the wound or to the maximum volume tolerated by the patient [59]. This technique resulted in a sensitivity of 94 percent and a negative predictive value of 97 percent with injected volumes ranging from 40 to 180 mL.

The muscle compartments of the affected extremity should also be evaluated on initial exam. Soft tissue injury and swelling can result in compartment syndrome. The lower extremity is more prone to compartment syndrome compared with the upper extremity because of its greater muscle mass and possibly because of its dependent position. The diagnosis and management of compartment syndrome are discussed elsewhere. (See "Acute compartment syndrome of the extremities" and "Lower extremity fasciotomy techniques" and "Patient management following extremity fasciotomy".)

Extremity deformity, point tenderness, ecchymosis, laceration deep to the muscle fascia, laceration near a joint, and joint laxity are signs of a potential fracture. Plain radiography should be performed to establish a diagnosis. (See 'Extremity radiography' above.)

Detailed discussions of specific fractures are found in separate topic reviews:

Hip and thigh – (See "Hip fractures in adults" and "Midshaft femur fractures in adults".)

Leg and ankle – (See "Proximal tibial fractures in adults" and "Tibial shaft fractures in adults" and "Overview of ankle fractures in adults".)

Arm – (See "Proximal humeral fractures in adults" and "Midshaft humeral fractures in adults" and "Tarsometatarsal (Lisfranc) joint complex injuries".)

Forearm – (See "Radial head and neck fractures in adults" and "Distal radius fractures in adults".)

An open fracture is defined as a bony fracture and soft tissue laceration that are in communication with each other (picture 1). In civilian series, open fractures occur in up to 24 percent of tibia fractures [13,14]. In a review of 1281 soldiers with extremity injuries, 915 fractures were identified, of which 82 percent were open [60]. Open fracture significantly increases the risk of osteomyelitis and, ultimately, limb loss depending upon the severity of the associated soft tissue injury. (See 'Open fracture grading' below and "Surgical management of severe extremity injury", section on 'Wound complications'.)

Following the initial assessment, the affected bone(s) should be aligned as well as possible and stabilized with a splint or traction to minimize soft tissue injury and to optimize distal perfusion. Open wounds should be irrigated with saline to eliminate gross contamination prior to the application of temporary gauze dressings. The patient can then undergo further diagnostic workup for associated injuries. Techniques for splinting musculoskeletal injuries are discussed elsewhere. (See "Basic techniques for splinting of musculoskeletal injuries".)

Posterior knee dislocation is associated with popliteal artery injury, and a careful vascular examination should be performed when this injury is identified. Following reduction of the dislocation, the vascular examination should be repeated, and, if normal, the patient should continue to be observed. If the pulses remain abnormal, vascular imaging is indicated (arteriography), and management depends upon the findings (algorithm 1). (See "Knee (tibiofemoral) dislocation and reduction".)

INJURY SEVERITY SCORING — Following examination of the extremity, overall injury severity should be assessed to determine whether a primary amputation should be performed or if the limb is potentially salvageable. The utility of using injury severity scores in predicting the success of limb salvage is discussed elsewhere. (See 'Predicting limb loss' below.)

Various extremity injury severity scores are described, including the Mangled Extremity Severity Score (MESS); the Limb Salvage Index (LSI); the Predictive Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score (NISSSA); the Hannover Fracture Scale-97 (HFS-97); and the Gustilo-Anderson open fracture grading system [1,61-65].

MESS — The Mangled Extremity Severity Score (MESS) is the most widely applied scoring system to categorize the degree of extremity injury [1]. The term "mangled" refers to a limb in which at least three of the four functional components (bone, vessels, nerves, and soft tissue) are injured.

The MESS is calculated by scoring each of the areas listed below (calculator 1). Component scores are then added to yield the MESS, which ranges from 2 to 14. "Severity and duration of ischemia" scores are doubled if perfusion has not been restored within six hours of injury. Patients with a truly mangled extremity will typically have MESS scores of 4 or greater.

Severity of skeletal and/or soft tissue injury

Severity and duration of limb ischemia

Severity of shock

Patient age

Open fracture grading — Open fractures should be graded using the Gustilo-Anderson system (table 2), which is usually performed intraoperatively; however, the severity of the orthopedic injury can generally be estimated during the initial extremity evaluation. An increasing grade of open fracture has been correlated to an increased risk of infection and rate of amputation [61,62]. A disadvantage of this scoring system is the low interobserver agreement of 60 percent [63,64].

The Orthopaedic Trauma Association has recently proposed a framework for developing a new classification scheme for open fractures [65]. Over time, this descriptive framework may replace the Gustillo-Anderson system, but it has yet to be validated and correlated with complications and outcomes.

Predicting limb loss — The likelihood that extremity injury will result in limb loss can be estimated based upon clinical findings with the aid of scoring systems. No injury severity scoring system has been found to be sufficiently sensitive for determining whether efforts at limb salvage will fail; however, determining the factors that may influence outcomes may be helpful when counseling the patient (or family members) about options for treatment and may guide a decision for primary amputation. (See "Surgical management of severe extremity injury", section on 'Limb salvage versus amputation'.)

Clinical predictors — Some injuries are associated with high amputation rates in spite of best efforts at limb salvage. The risk of limb loss is the greatest for injuries with combined bony instability, vascular injury (particularly combined arterial and venous injury), and soft tissue injury. An example is blunt injury to the popliteal region, which can injure the popliteal artery and vein [66,67]. High-energy and penetrating injuries can also lead to combined bony, vascular, and soft tissue injury [18].  

Guidelines for the management of complex extremity injuries prepared by the American College of Surgeons Committee on Trauma ad hoc Committee on Outcomes [68], supplemented by the Eastern Association for the Surgery of Trauma (EAST) [69], cite the following as factors that increase the risk for limb loss:

Delay in revascularization

Blunt trauma

High-velocity penetrating trauma

Lower extremity versus upper extremity vascular involvement (especially popliteal artery)

Associated injuries

Older age and older physiologic health

Shock and obvious limb ischemia

Forward combat zone

Resource-limited environment

Multi-casualty event

A study of the National Trauma Data Bank in the United States noted that high-energy trauma mechanisms, crush injury at or above the knee, systolic blood pressure <90 mmHg in the Emergency Department, and severe head injury independently predicted amputation within the first hospital day [2].

Lower extremity injuries requiring vascular repair have a high rate of amputation. Amputation rates are higher for blunt compared with penetrating injury. For below-the-knee arterial injuries, the need for amputation correlates with the number of vessels injured [70,71]. In a systematic review, other factors that increase the risk of amputation include major soft tissue injury (26 versus 8 percent for no soft tissue injury), associated fracture (14 versus 2 percent), and mechanism of injury (blast: 19 percent, blunt: 16 percent, penetrating: 5 percent). In this review, shock and nerve or venous injuries were not significant prognostic factors for secondary amputation [7]. (See "Surgical management of severe extremity injury", section on 'Amputation and functional outcomes'.)

Efficacy of scoring systems — Injury severity scoring systems are widely applied but are not highly sensitive for predicting the need for amputation following extremity injury. (See 'Injury severity scoring' above.)

The mangled extremity severity score (MESS) (calculator 1) is a commonly cited tool that provides a frame of reference for comparing extremity injuries; however, it is limited in its ability to predict need for amputation. The MESS is best used alongside clinical exam and patient comorbidities to help in the decision for or against limb salvage. A low score suggests limb salvage potential; however, a high score does not reliably predict the need for eventual amputation.

The Lower Extremity Assessment Program (LEAP) investigators evaluated 556 patients with lower extremity injuries using five injury severity scoring systems, including MESS [72]. Each of the scoring systems were highly specific (0.84 to 0.98) but not sensitive (0.37 to 0.67) for predicting limb loss. Specifically, regarding the MESS, these authors found that a MESS of 7 had a sensitivity of 0.45 but a specificity of 0.93 for predicting amputation.

MANAGEMENT APPROACH — Once a severe extremity injury has been identified, a management plan should be developed taking into consideration the patient's other injuries. In multiply injured trauma patients, the management plan should be made by one lead surgeon in collaboration with the orthopedic, vascular, and neurosurgery services, as needed. The priority of, timing to, and approach to each injury should be determined in advance.

Hemodynamically unstable — Based upon Advanced Trauma Life Support (ATLS) principles, the hemodynamically unstable trauma patient with indications for surgery (eg, positive Focused Assessment with Sonography for Trauma [FAST], hard signs of vascular injury) should be taken to the operating room to identify and control bleeding. Life-threatening injuries to the head, neck, chest, or abdomen take precedence over the extremity injury. A damage control or staged approach to the injured extremity is warranted once external bleeding from the extremity is controlled. In some cases, the severity of the extremity injury or time constraints due to the need to manage life-threatening injuries will preclude meaningful attempts at limb salvage, and primary amputation may be the best option. If the extremity is the primary (or only) injury, a more definitive approach to repair can be taken at the outset. (See 'Hard signs of arterial injury' above and "Surgical management of severe extremity injury", section on 'Damage control surgery'.)

Hemodynamically stable with vascular injury — For hemodynamically stable patients, the timing of the management of extremity injury when vascular injury is present depends upon the degree and duration of ischemia. Patients with hard signs of vascular injury should be taken immediately to the operating room for evaluation and management. Patients with clinical signs of arterial injury, including an injured extremity index (IEI) <0.9, should be evaluated using computed tomographic (CT) angiography or conventional arteriography depending upon institutional resources. In the presence of bony instability, arterial revascularization is fraught with difficulties. Under these circumstances, arterial shunting, if needed, and fracture stabilization followed by definitive vascular repair once the bones have been stabilized may be the most appropriate sequence of care. (See "Surgical management of severe extremity injury", section on 'Revascularization' and "Surgical management of severe extremity injury", section on 'Fracture management'.)

Hemodynamically stable without vascular injury — The timing and management of extremity injury when no vascular injury is present depends upon the severity of fracture and the degree of soft tissue loss. Open fracture debridement and fracture stabilization should be performed as soon as is feasible depending upon the nature and extent of nonextremity injuries. Multiple debridement procedures are frequently required before definitive fracture fixation and soft tissue coverage can be achieved. (See "Surgical management of severe extremity injury", section on 'Soft tissue debridement/coverage' and "Surgical management of severe extremity injury", section on 'Fracture management'.)

MORBIDITY AND MORTALITY — Patients with severe lower extremity injuries have a high incidence of complication, including wound complications (infection, necrosis, nonunion, osteomyelitis), venous thromboembolism, rhabdomyolysis, and late complications including amputation and heterotopic ossification in residual limbs. Most of these complications require or prolong hospitalization or require additional operative treatment [73]. These complications are discussed elsewhere. (See "Surgical management of severe extremity injury", section on 'Complications'.)

In blunt civilian extremity injury, mortality ranges from 5 to 10 percent and is greater with blunt compared with penetrating injuries [17,74]. Mortality correlates to the volume of blood lost as a result of the extremity injury, which can be significant with injuries involving the junctional vasculature [21]. Higher mortality rates reflect more severe extremity injury, coexistent injury, and development of complications (eg, venous thromboembolism). Mortality rates are lowest for isolated extremity injuries.

SUMMARY AND RECOMMENDATIONS

Trauma to the extremities represents one of the most common injury patterns seen in emergency practice. Civilian extremity injuries are most commonly due to blunt mechanisms, whereas combat injuries are predominantly due to penetrating or mixed mechanisms. In combat, extremity injuries are present in one-half of all casualties. (See 'Introduction' above and 'Incidence' above and 'Etiology' above.)

A brief extremity exam is performed during the initial trauma assessment (primary survey) but should be repeated once life-threatening injuries have been addressed. The extremity evaluation should be structured to assess the four functional components of the extremity (nerves, vessels, bones, soft tissues). Injury to three of these four elements constitutes a "mangled extremity." Patients with extremity deformity, point tenderness, ecchymosis, deep laceration, laceration near a joint, or joint laxity should undergo plain radiographs to evaluate for extremity fracture. (See 'Initial evaluation and management' above.)

Patients with hard signs of a vascular injury (eg, pulsatile bleeding, an expanding hematoma, distal ischemia) should be taken directly to the operating room for further examination and management. Direct pressure is usually effective in controlling extremity hemorrhage. For extremity hemorrhage that is not adequately controlled with direct pressure, we suggest placement of an extremity tourniquet (Grade 2C). Although not widely used for civilian injuries, military experience with prehospital and emergency department tourniquet application has shown that tourniquets save lives with a low rate of complications. (See 'Control of hemorrhage' above and "Prehospital care of the adult trauma patient", section on 'Hemorrhage control'.)

For patients without hard signs of vascular injury, an injured extremity index (IEI) should be performed, which is analogous to the ankle-brachial index (ABI). An abnormal IEI (<0.9) suggests the presence of a vascular injury. Hemodynamically stable patients with an abnormal IEI should undergo further imaging to exclude vascular injury. Arteriography is often performed using computed tomographic (CT) angiography because it is less invasive than conventional arteriography; has high sensitivity and specificity; and can be performed at the same time as head, chest, or abdominal CT, which are frequently needed. Where an appropriately sensitive CT scanner is not immediately available, conventional arteriography can be performed to exclude vascular injury either in a dedicated interventional suite or in the operating room. (See 'Injured extremity index' above and 'Arteriography' above.)

Every effort should be made to salvage the limb if there is no clear indication for primary amputation. An attempt to salvage a mangled extremity is reasonable in most instances; however, in a patient with severe multisystem injuries and a mangled extremity, a primary amputation may be indicated to save the patient's life. Although clinical scoring systems can indicate when limb salvage is likely to be successful, these are not accurate for determining the need for emergent primary amputation. Following every initial limb salvage attempt, the extremity should be reevaluated in the short term for signs of sensorimotor function and tissue viability. Factors that increase the risk of limb loss include lower extremity vascular injury, delayed revascularization, blunt or high-velocity mechanism, multiple additional injuries, advanced age and multiple comorbidities, shock and obvious limb ischemia, and a severe extremity injury sustained in a resource-limited environment or during a mass casualty event. (See 'MESS' above and 'Predicting limb loss' above and "Surgical management of severe extremity injury", section on 'Revascularization'.)

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