Definitive fracture fixation is performed when the patient's condition, even with concomitant injuries, is stable. It is ideal that for the treatment of open fractures, external fixation has been changed to internal fixation, and soft tissue defects are promptly covered. For relatively low-grade open fractures of long bones, fixation with intramedullary nailing is considered preferable. However, because there is little difference in the outcomes between reamed and unreamed medullary nailing for long bone open fractures, the benefit of these procedures remains controversial [22–24]. External fixation of fractures offers a safe and effective management

Factors influencing the functional prognosis after the main extremity artery injuries are proper treatment of the fracture and soft tissue injuries, including the nervous system, and the length of ischemic time. Because irreversible degeneration of muscle tissues is caused by ischemia of 6 hours or longer, the period between injury and revascularization should be as short as possible. The revascularization procedure includes vascular repair, vein grafting, inserting bypasses, stents, and/ or shunts, which should be performed by surgeons with extensive experience in treating such injuries. When there are multiple levels of vessel injuries, revascularization should be started caudally from the most proximal vessel to the injury. If revascularization is likely to take up to 4 hours or longer, a temporary shunt should be constructed. In severe extremity injuries, revascularization after constructing a temporary shunt will decrease the amputation rates (**Figure 2**) [26]. When there is a defect of the vessels or the tension in the anastomotic site is strong, revascularization is performed after vein grafting (**Figure 3**). When there is a problem with

venous return due to the injuries, revascularization of veins is performed.

The fracture and bruising cause the muscles to swell, and the inner pressure of fascial compartments to rise. The compartment syndrome is the state that muscles are swollen further with lowered perfusion pressure, and the nervous system and muscles become ischemic. Diagnosis is determined from the present medical history

*DOI: http://dx.doi.org/10.5772/intechopen.85544*

*4.2.1 Debridement and stabilization*

coverage are performed.

*4.2.2 Definitive fracture fixation*

option for children (**Figure 1**) [25].

**4.3 Revascularization**

**4.4 Extremity fasciotomy**

#### *4.2.1 Debridement and stabilization*

*Limb Amputation*

intraoperative findings, it is actually often used from the initial evaluation. This classification method provides indices for the infection rate and the bone union period following the treatment of open fractures. MESS is composed of injury mechanism, severity and duration of limb ischemia, severity of shock, and patient's

Surgical management for extremity injuries is performed under the condition of stable hemodynamics with controlled bleeding. The management procedures include damage control surgery, fracture management, revascularization, extremity fasciotomy, nerve repair, and soft tissue debridement and coverage. When the bleeding cannot be controlled in an unrepairable extremity injury, limb amputation

If bleeding from the extremities continues, it is stopped by compression. If the compression does not work, bleeding is controlled using tourniquet and damaged blood vessels are treated by ligation or vascular repair. Patients should undergo

revascularization within 6 hours, and if the ischemic time is prolonged, vascular shunt should be constructed. If the arteries and veins are both damaged, shunting is required for each artery and vein. However, if it is impossible, veins are occluded by ligation.

When the open fracture of extremities is severe, debridement and skeletal stabilization are performed in the operating room after the evaluation and stabilization of concomitant injuries that could be life-threatening. For the initial skeletal

age. When the score is ≥7, amputation is likely to be selected [15–18].

**4. Surgical management**

*Mangled Extremity Severity Score (MESS).*

**4.1 Damage control surgery**

**4.2 Fracture management**

stabilization, external fixation is useful.

is selected.

**Table 2.**

**34**

At the initial surgery, thorough debridement of mangled tissues and foreign bodies is performed. Low-pressure irrigation is used for the lavage. A delay in the debridement is likely to lead to high rate of infection and/or amputation [19–21]. The grade of the Gustilo-Anderson classification is evaluated by the assessment of conditions of conserved soft tissues and fractures. It is difficult to accurately evaluate the grade of the soft tissue injuries and the presence or absence of infection at the initial surgery. In most cases, a second-look and/or third-look debridement is required. External fixation is often selected as the initial skeletal stabilization for severe open fractures. When there are major vessel injuries, prompt skeletal stabilization and revascularization should be required. If it takes a long time for skeletal stabilization, a vascular shunt should be made to shorten the ischemic time. The defect of the surrounding soft tissues is reevaluated within 72 hours in the operating room, and additional debridement or definitive fracture fixation and soft tissue coverage are performed.

#### *4.2.2 Definitive fracture fixation*

Definitive fracture fixation is performed when the patient's condition, even with concomitant injuries, is stable. It is ideal that for the treatment of open fractures, external fixation has been changed to internal fixation, and soft tissue defects are promptly covered. For relatively low-grade open fractures of long bones, fixation with intramedullary nailing is considered preferable. However, because there is little difference in the outcomes between reamed and unreamed medullary nailing for long bone open fractures, the benefit of these procedures remains controversial [22–24]. External fixation of fractures offers a safe and effective management option for children (**Figure 1**) [25].

#### **4.3 Revascularization**

Factors influencing the functional prognosis after the main extremity artery injuries are proper treatment of the fracture and soft tissue injuries, including the nervous system, and the length of ischemic time. Because irreversible degeneration of muscle tissues is caused by ischemia of 6 hours or longer, the period between injury and revascularization should be as short as possible. The revascularization procedure includes vascular repair, vein grafting, inserting bypasses, stents, and/ or shunts, which should be performed by surgeons with extensive experience in treating such injuries. When there are multiple levels of vessel injuries, revascularization should be started caudally from the most proximal vessel to the injury. If revascularization is likely to take up to 4 hours or longer, a temporary shunt should be constructed. In severe extremity injuries, revascularization after constructing a temporary shunt will decrease the amputation rates (**Figure 2**) [26]. When there is a defect of the vessels or the tension in the anastomotic site is strong, revascularization is performed after vein grafting (**Figure 3**). When there is a problem with venous return due to the injuries, revascularization of veins is performed.

#### **4.4 Extremity fasciotomy**

The fracture and bruising cause the muscles to swell, and the inner pressure of fascial compartments to rise. The compartment syndrome is the state that muscles are swollen further with lowered perfusion pressure, and the nervous system and muscles become ischemic. Diagnosis is determined from the present medical history

#### **Figure 1.**

*(a) Open fracture of the left lower extremity was accompanied by a moderate soft tissue defect on the anterior lower extremity. (b) The fasciocutaneous flap was elevated from the lateral side. (c) Moderate soft tissue defect was covered by a fasciocutaneous flap, and skin grafting was applied to the donor site. (d) Intraoperative X-ray. (e) Postoperative view 84 months after surgery. (f) An X-ray of the leg 84 months after surgery, showing good bone union.*

#### **Figure 2.**

*(a) Crush injury of the left forearm was accompanied by injuries to the radial and ulnar arteries. (b) Temporary vascular shunts (arrowheads) were placed into the radial and ulnar arteries before definitive vascular repair.*

**37**

**4.5 Nerve repair**

**Figure 3.**

*Multidisciplinary Management of Severe Extremity Injuries*

and findings in physical examinations. Signs and symptoms are swelling in the overall area of the injury site, severe pain that cannot be alleviated by analgesics, increase of pain in the stretch test, and dysesthesia in the compartment region. Even though the compartment syndrome develops, peripheral arterial pulsation is usually palpable. During 48 hours after the injury, clinical signs and symptoms are periodically checked. Because clinical signs and symptoms cannot be checked if the patients have impaired consciousness or are under the effect of sedatives, inner pressure of the compartment is measured if the compartment syndrome is suspected. When the compartment inner pressure is ≥35–40 mmHg, a fasciotomy is performed (**Figure 4**). The open wound

*(a) Preoperative X-ray. (b, c) The supracondylar fracture is accompanied by brachial vessel injuries. (d) The saphenous vein was harvested from the right thigh. (e) X-ray findings after Kirchner wire fixation, intraoperatively. (f) The saphenous vein was cut in half, and then the two veins were interposed in way*

*of grafting to repair the defects in the brachial artery and vein.*

Nerve injury that occurs concomitantly with fractures and/or dislocations is treated by repositioning and simple fixation. It is important that nerve repair is carefully performed using an operating microscope or surgical loupes. Factors other than surgery, such as the patient's age, nerve injury at higher level, and the degree of injury, influence the recovery of nerve damage. In cases with life-threatening concomitant injuries and/or those with severe extremity injuries, nerve repair can be performed later, within 2 weeks, with good prognoses. If the torn nerve fiber can be identified, marking with a nylon suture at the end of the nerve fiber or fibers is

after a fasciotomy is treated by delayed primary closure and/or skin graft.

*DOI: http://dx.doi.org/10.5772/intechopen.85544*

*Multidisciplinary Management of Severe Extremity Injuries DOI: http://dx.doi.org/10.5772/intechopen.85544*

#### **Figure 3.**

*Limb Amputation*

**36**

**Figure 2.**

**Figure 1.**

*(a) Crush injury of the left forearm was accompanied by injuries to the radial and ulnar arteries. (b) Temporary vascular shunts (arrowheads) were placed into the radial and ulnar arteries before definitive vascular repair.*

*(a) Open fracture of the left lower extremity was accompanied by a moderate soft tissue defect on the anterior lower extremity. (b) The fasciocutaneous flap was elevated from the lateral side. (c) Moderate soft tissue defect was covered by a fasciocutaneous flap, and skin grafting was applied to the donor site. (d) Intraoperative X-ray. (e) Postoperative*

*view 84 months after surgery. (f) An X-ray of the leg 84 months after surgery, showing good bone union.*

*(a) Preoperative X-ray. (b, c) The supracondylar fracture is accompanied by brachial vessel injuries. (d) The saphenous vein was harvested from the right thigh. (e) X-ray findings after Kirchner wire fixation, intraoperatively. (f) The saphenous vein was cut in half, and then the two veins were interposed in way of grafting to repair the defects in the brachial artery and vein.*

and findings in physical examinations. Signs and symptoms are swelling in the overall area of the injury site, severe pain that cannot be alleviated by analgesics, increase of pain in the stretch test, and dysesthesia in the compartment region. Even though the compartment syndrome develops, peripheral arterial pulsation is usually palpable. During 48 hours after the injury, clinical signs and symptoms are periodically checked. Because clinical signs and symptoms cannot be checked if the patients have impaired consciousness or are under the effect of sedatives, inner pressure of the compartment is measured if the compartment syndrome is suspected. When the compartment inner pressure is ≥35–40 mmHg, a fasciotomy is performed (**Figure 4**). The open wound after a fasciotomy is treated by delayed primary closure and/or skin graft.

#### **4.5 Nerve repair**

Nerve injury that occurs concomitantly with fractures and/or dislocations is treated by repositioning and simple fixation. It is important that nerve repair is carefully performed using an operating microscope or surgical loupes. Factors other than surgery, such as the patient's age, nerve injury at higher level, and the degree of injury, influence the recovery of nerve damage. In cases with life-threatening concomitant injuries and/or those with severe extremity injuries, nerve repair can be performed later, within 2 weeks, with good prognoses. If the torn nerve fiber can be identified, marking with a nylon suture at the end of the nerve fiber or fibers is

#### **Figure 4.**

*(a) The left forearm was wringed by a industrial press machine, and the injury progressed to the compartment syndrome. (b) Fasciotomy was performed to alleviate the compartment pressure.*

#### **Figure 5.**

*(a) A penetrating wound was located in the middle of the right thigh. (b) The tibial nerve was ablated and crushed. (c) The sural nerve was divided in thirds and used as a cable graft to repair the severed tibial nerve.*

recommended for later surgical repair. To treat a complete tear of nerve fibers, the nerve fibers are sutured together after the cut ends are reinnervated. When there is a high tension at the suture site or suturing is difficult or impossible because of nerve gaps, autologous nerve grafting [27] (**Figure 5**) or reconstruction with artificial nerve conduit [28] is incorporated into the treatment.

#### **4.6 Soft tissue debridement and definitive coverage**

In open fractures, the degree of soft tissue injury is associated with prognosis [29]. Soft tissue wounds in severe extremity injuries have a high risk of infection and treatment should be begun immediately. There have been a few reports on immediate wound closure and primary wound closure [30–32]. However, because it is difficult to accurately evaluate the degree of soft tissue damage and the presence or absence of

**39**

**Figure 6.**

mosed are limited [42].

*Multidisciplinary Management of Severe Extremity Injuries*

infection in severe extremity injuries, the number of cases in which immediate wound closure and primary wound closure are possible is limited. In most cases with severe extremity injuries, second-look and/or third-look debridement are required. Open wounds had been recommended to be treated with moist dressings after debridement. Recently, although NPWT (negative pressure wound therapy) is used for open fracture wounds during the period after the debridement until coverage [33], there has been no

*(a) An open fracture located in the distal third of the left lower extremity, accompanied by massive soft tissue defect. (b) Intraoperative X-ray after intramedullary nailing fixation. (c) The anterolateral thigh fasciocutaneous flap was harvested from the right thigh. (d) The anterolateral thigh fasciocutaneous flap was applied to the soft tissue defect. Six months after internal fixation, autogenous bone grafting and transposition of the fasciocutaneous flap was performed on the tibia defect. (e) Postoperative view 12 months after bone*

Because the infection rate becomes higher with the passage of days after the injury of an open fracture, the open wound should be closed early if the patient's general condition is stable and there is no local infection [36, 37]. For the coverage of the defect of soft tissues after the bone fixation, a flap is recommended [36–41]. Even if wound coverage cannot be performed at the initial debridement, good functional prognosis can be expected when soft tissue coverage is performed within 72 hours after an injury [36, 38, 40]. For an extensive soft tissue defect, a free flap transfer is useful (**Figure 6**). A free flap transfer enables reconstruction of a soft tissue defect by an end to side or a flow-through type vascular anastomosis without sacrificing major vessels, even if the recipient vessels that can be anasto-

evidence that it is more useful than conventional moist dressing [34, 35].

*grafting. (f) X-ray at 12-month follow-up showing adequate bone union.*

*DOI: http://dx.doi.org/10.5772/intechopen.85544*

#### **Figure 6.**

*Limb Amputation*

**Figure 4.**

**Figure 5.**

**38**

recommended for later surgical repair. To treat a complete tear of nerve fibers, the nerve fibers are sutured together after the cut ends are reinnervated. When there is a high tension at the suture site or suturing is difficult or impossible because of nerve gaps, autologous nerve grafting [27] (**Figure 5**) or reconstruction with

*(a) A penetrating wound was located in the middle of the right thigh. (b) The tibial nerve was ablated and crushed. (c) The sural nerve was divided in thirds and used as a cable graft to repair the severed tibial nerve.*

*(a) The left forearm was wringed by a industrial press machine, and the injury progressed to the compartment*

*syndrome. (b) Fasciotomy was performed to alleviate the compartment pressure.*

In open fractures, the degree of soft tissue injury is associated with prognosis [29]. Soft tissue wounds in severe extremity injuries have a high risk of infection and treatment should be begun immediately. There have been a few reports on immediate wound closure and primary wound closure [30–32]. However, because it is difficult to accurately evaluate the degree of soft tissue damage and the presence or absence of

artificial nerve conduit [28] is incorporated into the treatment.

**4.6 Soft tissue debridement and definitive coverage**

*(a) An open fracture located in the distal third of the left lower extremity, accompanied by massive soft tissue defect. (b) Intraoperative X-ray after intramedullary nailing fixation. (c) The anterolateral thigh fasciocutaneous flap was harvested from the right thigh. (d) The anterolateral thigh fasciocutaneous flap was applied to the soft tissue defect. Six months after internal fixation, autogenous bone grafting and transposition of the fasciocutaneous flap was performed on the tibia defect. (e) Postoperative view 12 months after bone grafting. (f) X-ray at 12-month follow-up showing adequate bone union.*

infection in severe extremity injuries, the number of cases in which immediate wound closure and primary wound closure are possible is limited. In most cases with severe extremity injuries, second-look and/or third-look debridement are required. Open wounds had been recommended to be treated with moist dressings after debridement. Recently, although NPWT (negative pressure wound therapy) is used for open fracture wounds during the period after the debridement until coverage [33], there has been no evidence that it is more useful than conventional moist dressing [34, 35].

Because the infection rate becomes higher with the passage of days after the injury of an open fracture, the open wound should be closed early if the patient's general condition is stable and there is no local infection [36, 37]. For the coverage of the defect of soft tissues after the bone fixation, a flap is recommended [36–41]. Even if wound coverage cannot be performed at the initial debridement, good functional prognosis can be expected when soft tissue coverage is performed within 72 hours after an injury [36, 38, 40]. For an extensive soft tissue defect, a free flap transfer is useful (**Figure 6**). A free flap transfer enables reconstruction of a soft tissue defect by an end to side or a flow-through type vascular anastomosis without sacrificing major vessels, even if the recipient vessels that can be anastomosed are limited [42].

### **5. Complications**

Complications associated with severe extremity injuries include infection and/ or necrosis, pseudoarthrosis, osteomyelitis, venous thromboembolism, and rhabdomyolysis. If these complications occur, additional treatment is required and the treatment period would be prolonged.

#### **5.1 Wound complications**

Wound complications are caused by insufficient debridement and/or infection. The infection rate becomes higher with a higher grade of the Gustilo-Anderson classification. To prevent infection in severe extremity injuries, it is important to perform early and thorough debridement of necrotic tissues and construct coverage with tissues that have abundant blood flow.

#### **5.2 Venous thromboembolism**

Deep vein thrombosis (DVT) and pulmonary embolism (PE) occur in 2–58% of trauma patients [43–45]. Because severe extremity injuries have a high risk of DVT and PE, mechanical and pharmacologic prophylaxes are necessary [46].

#### **5.3 Rhabdomyolysis and myoglobinuria**

Rhabdomyolysis and myoglobinuria are observed in the crush syndrome, compartment syndrome, and reperfusion syndrome. Various substances released from necrotic striated muscle cells circulate throughout the body, causing hyperkalemia, metabolic acidosis, hypermyoglobinemia, and acute renal failure. Transfusion and correction of electrolytes are fundamental to preventing acute renal failure.

#### **6. Amputation versus limb salvage**

There is, as yet, no agreement on the selection criteria for amputation or limb salvage [47–49]. The injury severity scoring system is reported to be a good indictor in a few reports [50–53] but considered negatively in others [54–56]. Because the indications for amputation differ depending on the patient's age (whether an adult or a child), and occupation, the injury severity scoring system should be used carefully and judiciously [57–60]. Indications for amputation are as follows: (1) life-threatening

**Figure 7.** *(a and b) The left upper extremity was avulsed by an industrial machine. This mangled limb was not salvageable.*

**41**

**7. Conclusions**

**Figure 8.**

**Conflict of interest**

of this chapter.

*Multidisciplinary Management of Severe Extremity Injuries*

bleeding cannot be controlled, (2) preserving open injuries to the extremity is likely to cause the patients' mortality, and (3) the injuries are so severe that a specialist judges the salvage of the extremity to be impossible (**Figure 7**). Ultimately, the decision regarding choosing limb salvage or amputation should be made in discussion with the patients themselves and their family members (**Figure 8**). Primary delayed amputation, if deemed necessary, should be performed within 72 hours after the injury.

*(a) The left upper extremity was ablated at the elbow, the median and ulnar nerves were preserved; however, the radial nerve was avulsed in the middle third of the upper arm. (b) Immediate revascularization to the brachial vessels was performed followed by external fixation. (c and d) Postoperative view 12 months after reconstruction and a modified Riordan operation was performed on the radial nerve to cure the palsy.*

For the treatment of severe extremity injuries, multidisciplinary management is required from the primary survey through rehabilitation. Unless severe extremity injuries are treated properly within the proper time frames, complications may occur, resulting in severe sequelae. Multidisciplinary management by specialists, in the emergency department, orthopedics, plastic surgery, vascular surgery, and rehabilitation, insisting on employing their own individual abilities as much as possible, would not only help to salvage limbs in severe extremity injuries but also

The author declares that there is no conflict of interest regarding the publication

provide highly satisfactory functional and aesthetic outcomes for patients.

*DOI: http://dx.doi.org/10.5772/intechopen.85544*

**Figure 8.**

*Limb Amputation*

**5. Complications**

treatment period would be prolonged.

with tissues that have abundant blood flow.

**5.3 Rhabdomyolysis and myoglobinuria**

**6. Amputation versus limb salvage**

**5.1 Wound complications**

**5.2 Venous thromboembolism**

Complications associated with severe extremity injuries include infection and/ or necrosis, pseudoarthrosis, osteomyelitis, venous thromboembolism, and rhabdomyolysis. If these complications occur, additional treatment is required and the

Wound complications are caused by insufficient debridement and/or infection. The infection rate becomes higher with a higher grade of the Gustilo-Anderson classification. To prevent infection in severe extremity injuries, it is important to perform early and thorough debridement of necrotic tissues and construct coverage

Deep vein thrombosis (DVT) and pulmonary embolism (PE) occur in 2–58% of trauma patients [43–45]. Because severe extremity injuries have a high risk of DVT

Rhabdomyolysis and myoglobinuria are observed in the crush syndrome, compartment syndrome, and reperfusion syndrome. Various substances released from necrotic striated muscle cells circulate throughout the body, causing hyperkalemia, metabolic acidosis, hypermyoglobinemia, and acute renal failure. Transfusion and correction of electrolytes are fundamental to preventing acute renal failure.

There is, as yet, no agreement on the selection criteria for amputation or limb salvage [47–49]. The injury severity scoring system is reported to be a good indictor in a few reports [50–53] but considered negatively in others [54–56]. Because the indications for amputation differ depending on the patient's age (whether an adult or a child), and occupation, the injury severity scoring system should be used carefully and judiciously [57–60]. Indications for amputation are as follows: (1) life-threatening

*(a and b) The left upper extremity was avulsed by an industrial machine. This mangled limb was not salvageable.*

and PE, mechanical and pharmacologic prophylaxes are necessary [46].

**40**

**Figure 7.**

*(a) The left upper extremity was ablated at the elbow, the median and ulnar nerves were preserved; however, the radial nerve was avulsed in the middle third of the upper arm. (b) Immediate revascularization to the brachial vessels was performed followed by external fixation. (c and d) Postoperative view 12 months after reconstruction and a modified Riordan operation was performed on the radial nerve to cure the palsy.*

bleeding cannot be controlled, (2) preserving open injuries to the extremity is likely to cause the patients' mortality, and (3) the injuries are so severe that a specialist judges the salvage of the extremity to be impossible (**Figure 7**). Ultimately, the decision regarding choosing limb salvage or amputation should be made in discussion with the patients themselves and their family members (**Figure 8**). Primary delayed amputation, if deemed necessary, should be performed within 72 hours after the injury.

#### **7. Conclusions**

For the treatment of severe extremity injuries, multidisciplinary management is required from the primary survey through rehabilitation. Unless severe extremity injuries are treated properly within the proper time frames, complications may occur, resulting in severe sequelae. Multidisciplinary management by specialists, in the emergency department, orthopedics, plastic surgery, vascular surgery, and rehabilitation, insisting on employing their own individual abilities as much as possible, would not only help to salvage limbs in severe extremity injuries but also provide highly satisfactory functional and aesthetic outcomes for patients.

#### **Conflict of interest**

The author declares that there is no conflict of interest regarding the publication of this chapter.

*Limb Amputation*

#### **Author details**

Mitsuru Nemoto Department of Plastic and Aesthetic Surgery, Kitasato University School of Medicine, Japan

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**43**

*Multidisciplinary Management of Severe Extremity Injuries*

and prospective analyses. The Journal of Bone and Joint Surgery. 1976;**58**:453-458

[9] Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. The Journal of Trauma. 1984;**24**:742-746

[10] Gregory RT, Gould RJ, Peclet M, et al. The mangled extremity syndrome (M.E.S.): A severity grading system for multisystem injury of the extremity. The Journal of Trauma. 1985;**25**:1147-1150

[11] Howe HR Jr, Poole GV Jr, Hansen KJ, et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. The American Surgeon.

[12] Johansen K, Daines M, Howey T, et al. Objective criteria accurately predict amputation following lower extremity trauma. The Journal of

[13] Russell WL, Sailors DM, Whittle TB, et al. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Annals of

Trauma. 1990;**30**:568-573

Surgery. 1991;**213**:473-480

[14] McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective evaluation of the mangled extremity severity score (MESS). Journal of Orthopaedic Trauma. 1994;**8**:81-87

[15] Behdad S, Rafiei MH, Taheri H, et al. Evaluation of mangled extremity severity score (MESS) as a predictor of lower limb amputation in children with trauma. European Journal of Pediatric Surgery. 2012;**22**:465-469. DOI:

[16] Kumar MK, Badole C, Patond K. Salvage versus amputation: Utility of

10.1055/s-0032-1322541

1987;**53**:205-208

*DOI: http://dx.doi.org/10.5772/intechopen.85544*

[1] American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 9th ed. Chicago: American College of Surgeons; 2012

**References**

[2] Tan TW, Joglar FL, Hamburg NM, et al. Limb outcome and mortality in lower and upper extremity arterial injury: A comparison using the National Trauma Data Bank. Vascular and Endovascular Surgery. 2011;**45**:592-597.

DOI: 10.1177/1538574411415125

[4] Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: A prospective study. The Journal of Trauma. 2004;**56**:1261-1265

[5] Soto JA, Munera F, Cardoso N, et al. Diagnostic performance of helical CT angiography in trauma to large arteries of the extremities. Journal of Computer Assisted Tomography. 1999;**23**:188-196

[6] Busquets AR, Acosta JA, Colon E, et al. Helical computed tomographic angiography for the diagnosis of traumatic arterial injuries of the extremities. The Journal of Trauma.

[3] Lynch K, Johansen K. Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma? Annals of Surgery.

1991;**214**:737-741

2004;**56**:625-628

[7] Lack WD, Karunakar MA, Angerame MR, et al. Type III open tibia fractures: Immediate antibiotic prophylaxis minimizes infection. Journal of Orthopaedic Trauma. 2015;**29**:1-6. DOI: 10.1097/BOT.0000000000000262

[8] Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective

*Multidisciplinary Management of Severe Extremity Injuries DOI: http://dx.doi.org/10.5772/intechopen.85544*

#### **References**

*Limb Amputation*

**42**

**Author details**

Mitsuru Nemoto

Medicine, Japan

provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Department of Plastic and Aesthetic Surgery, Kitasato University School of

\*Address all correspondence to<EMAIL_ADDRESS>
[1] American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 9th ed. Chicago: American College of Surgeons; 2012

[2] Tan TW, Joglar FL, Hamburg NM, et al. Limb outcome and mortality in lower and upper extremity arterial injury: A comparison using the National Trauma Data Bank. Vascular and Endovascular Surgery. 2011;**45**:592-597. DOI: 10.1177/1538574411415125

[3] Lynch K, Johansen K. Can Doppler pressure measurement replace "exclusion" arteriography in the diagnosis of occult extremity arterial trauma? Annals of Surgery. 1991;**214**:737-741

[4] Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: A prospective study. The Journal of Trauma. 2004;**56**:1261-1265

[5] Soto JA, Munera F, Cardoso N, et al. Diagnostic performance of helical CT angiography in trauma to large arteries of the extremities. Journal of Computer Assisted Tomography. 1999;**23**:188-196

[6] Busquets AR, Acosta JA, Colon E, et al. Helical computed tomographic angiography for the diagnosis of traumatic arterial injuries of the extremities. The Journal of Trauma. 2004;**56**:625-628

[7] Lack WD, Karunakar MA, Angerame MR, et al. Type III open tibia fractures: Immediate antibiotic prophylaxis minimizes infection. Journal of Orthopaedic Trauma. 2015;**29**:1-6. DOI: 10.1097/BOT.0000000000000262

[8] 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. The Journal of Bone and Joint Surgery. 1976;**58**:453-458

[9] Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. The Journal of Trauma. 1984;**24**:742-746

[10] Gregory RT, Gould RJ, Peclet M, et al. The mangled extremity syndrome (M.E.S.): A severity grading system for multisystem injury of the extremity. The Journal of Trauma. 1985;**25**:1147-1150

[11] Howe HR Jr, Poole GV Jr, Hansen KJ, et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. The American Surgeon. 1987;**53**:205-208

[12] Johansen K, Daines M, Howey T, et al. Objective criteria accurately predict amputation following lower extremity trauma. The Journal of Trauma. 1990;**30**:568-573

[13] Russell WL, Sailors DM, Whittle TB, et al. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Annals of Surgery. 1991;**213**:473-480

[14] McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective evaluation of the mangled extremity severity score (MESS). Journal of Orthopaedic Trauma. 1994;**8**:81-87

[15] Behdad S, Rafiei MH, Taheri H, et al. Evaluation of mangled extremity severity score (MESS) as a predictor of lower limb amputation in children with trauma. European Journal of Pediatric Surgery. 2012;**22**:465-469. DOI: 10.1055/s-0032-1322541

[16] Kumar MK, Badole C, Patond K. Salvage versus amputation: Utility of mangled extremity severity score in severely injured lower limbs. Indian Journal of Orthopaedics. 2007;**41**: 183-187. DOI: 10.4103/0019-5413.33679

[17] Rush RM Jr, Kjorstad R, Starnes BW, et al. Application of the mangled extremity severity score in a combat setting. Military Medicine. 2007;**172**:777-781

[18] Robertson PA. Prediction of amputation after severe lower limb trauma. Journal of Bone and Joint Surgery. 1991;**73**:816-818

[19] Sears ED, Davis MM, Chung KC. Relationship between timing of emergency procedures and limb amputation in patients with open tibia fracture in the United States, 2003 to 2009. Plastic and Reconstructive Surgery. 2012;**130**:369-378. DOI: 10.1097/PRS.0b013e3182589e2d

[20] Hull PD, Johnson SC, Stephen DJ, et al. Delayed debridement of severe open fractures is associated with a higher rate of deep infection. The Bone & Joint Journal. 2014;**96**:379-384. DOI: 10.1302/0301-620x.96B3.32380

[21] Malhotra AK, Goldberg S, Graham J, et al. Open extremity fractures: Impact of delay in operative debridement and irrigation. Journal of Trauma and Acute Care Surgery. 2014;**76**:1201-1207. DOI: 10.1097/TA.0000000000000205

[22] Keating JF, O'Brien PJ, Blachut PA, et al. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. The Journal of Bone and Joint Surgery. 1997;**79**:334-341

[23] Forster MC, Bruce AS, Aster AS. Should the tibia be reamed when nailing? Injury. 2005;**36**:439-444

[24] Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators, Bhandari M, Guyatt G, Tornetta P 3rd, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. The Journal of Bone and Joint Surgery. 2008;**90**: 2567-2578. DOI: 10.2106/JBJS.G.01694

[25] Hull JB, Bell MJ. Modern trends for external fixation of fractures in children: A critical review. Journal of Pediatric Orthopaedics Part B. 1997;**6**:103-109

[26] Desai P, Audige L, Suk M. Combined orthopedic and vascular lower extremity injuries: Sequence of care and outcomes. American Journal of Orthopedics. 2012;**41**:182-186

[27] Stancic MF, Eskinja N, Bellinzona M, et al. The role of interfascular nerve grafting after gunshot wounds. A report of 44 cases. International Orthopaedics. 1996;**20**:87-91

[28] Mackinnon SE, Dellon AL. Clinical nerve reconstruction with a bioabsorbable polyglycolic acid tube. Plastic and Reconstructive Surgery. 1990;**85**:419-424

[29] MacKenzie EJ, Bosse MJ, Kellam JF, et al. Factors influencing the decision to amputate or reconstruct after highenergy lower extremity trauma. The Journal of Trauma. 2002;**52**:641-649

[30] Hertel R, Lambert SM, Muller S, et al. On the timing of soft-tissue reconstruction for open fractures of the lower leg. Archives of Orthopaedic and Trauma Surgery. 1999;**119**:7-12

[31] Hohmann E, Tetsworth K, Radziejowski MJ, Wiesniewski TF. Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Archives of Orthopaedic and Trauma Surgery. 2007;**127**:131-136

[32] Jenkinson RJ, Kiss A, Johnson S, et al. Delayed wound closure increases

**45**

*Multidisciplinary Management of Severe Extremity Injuries*

application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment

[40] Gopal S, Giannoudis PV, Murray A,

[41] Webb LX, Bosse MJ, Castillo RC, MacKenzie EJ, LEAP Study Group. Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. The Journal of Bone and Joint Surgery.

[42] Nemoto M, Ishikawa S, Kounoike N, et al. Free flap transfer to preserve

Hollingsworth-Fridlund P, et al. Venous thromboembolism in patients with major trauma. American Journal of

[45] Schultz DJ, Brasel KJ, Washington L,

[46] Rogers FB, Cipolle MD, Velmahos G, et al. Practice management guidelines

thromboembolism in trauma patients: The EAST practice management

et al. Incidence of asymptomatic pulmonary embolism in moderately to severely injured trauma patients. The Journal of Trauma. 2004;**56**:727-731

for the prevention of venous

Project (LEAP) Study Group. Journal of Bone and Joint Surgery.

et al. The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage. Journal of Bone and Joint Surgery.

2000;**82**:1681-1691

2004;**86**:861-867

2007;**89**:923-928

main arterial flow in early

[43] Shackford SR, Davis JW,

Surgery. 1990;**159**:365-369

1994;**331**:1601-1606

[44] Geerts WH, Code KI, Jay RM, et al. A prospective study of venous thromboembolism after major trauma. The New England Journal of Medicine.

10.1155/2015/213892

reconstruction of open fracture in the lower extremity. Plastic Surgery International. 2015;**2015**:213892. DOI:

*DOI: http://dx.doi.org/10.5772/intechopen.85544*

[33] Stannard JP, Volgas DA, Stewart R,

deep-infection rate associated with lower-grade open fractures: A propensitymatched cohort study. The Journal of Bone and Joint Surgery. 2014;**96**:380-386.

DOI: 10.2106/JBJS.L.00545

et al. Negative pressure wound therapy after severe open fractures: A prospective randomized study. Journal of Orthopaedic Trauma. 2009;**23**:552-557. DOI: 10.1097/ BOT.0b013e3181a2e2b6

[34] Krug E, Berg L, Lee C, et al. Evidence-based recommendations for the use of negative pressure wound therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus. Injury. 2011;**42**(Suppl 1):S1-S12. DOI: 10.1016/

[35] Iheozor-Ejiofor Z, Newton K, Dumville JC, et al. Negative pressure wound therapy for open traumatic wounds. Cochrane Database of Systematic Reviews. 3 Jul 2018;**7**:CD012522. DOI: 10.1002/14651858.CD012522.pub2

[36] Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plastic and Reconstructive

[37] D'Alleyrand JC, Manson TT, Dancy L, et al. Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications?

Journal of Orthopaedic Trauma. 2014;**28**:288-293. DOI: 10.1097/ BOT.0000000000000001

et al. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. Journal of Bone and Joint Surgery.

2000;**82**:959-966

[38] Gopal S, Majumder S, Batchelor AG,

[39] Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after

Surgery. 1986;**78**:285-292

S0020-1383(11)00041-6

*Multidisciplinary Management of Severe Extremity Injuries DOI: http://dx.doi.org/10.5772/intechopen.85544*

deep-infection rate associated with lower-grade open fractures: A propensitymatched cohort study. The Journal of Bone and Joint Surgery. 2014;**96**:380-386. DOI: 10.2106/JBJS.L.00545

*Limb Amputation*

2007;**172**:777-781

mangled extremity severity score in severely injured lower limbs. Indian Journal of Orthopaedics. 2007;**41**: 183-187. DOI: 10.4103/0019-5413.33679 with Tibial Fractures Investigators, Bhandari M, Guyatt G, Tornetta P 3rd, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. The Journal of Bone and Joint Surgery. 2008;**90**: 2567-2578. DOI: 10.2106/JBJS.G.01694

[25] Hull JB, Bell MJ. Modern trends for external fixation of fractures in children: A critical review. Journal of Pediatric Orthopaedics Part B.

[26] Desai P, Audige L, Suk M. Combined orthopedic and vascular lower extremity injuries: Sequence of care and outcomes. American Journal of

Orthopedics. 2012;**41**:182-186

nerve reconstruction with a

[27] Stancic MF, Eskinja N, Bellinzona M, et al. The role of interfascular nerve grafting after gunshot wounds. A report of 44 cases. International Orthopaedics.

[28] Mackinnon SE, Dellon AL. Clinical

bioabsorbable polyglycolic acid tube. Plastic and Reconstructive Surgery.

[29] MacKenzie EJ, Bosse MJ, Kellam JF, et al. Factors influencing the decision to amputate or reconstruct after highenergy lower extremity trauma. The Journal of Trauma. 2002;**52**:641-649

[30] Hertel R, Lambert SM, Muller S, et al. On the timing of soft-tissue reconstruction for open fractures of the lower leg. Archives of Orthopaedic and

Trauma Surgery. 1999;**119**:7-12

[31] Hohmann E, Tetsworth K, Radziejowski MJ, Wiesniewski TF. Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Archives of Orthopaedic and Trauma Surgery. 2007;**127**:131-136

[32] Jenkinson RJ, Kiss A, Johnson S, et al. Delayed wound closure increases

1997;**6**:103-109

1996;**20**:87-91

1990;**85**:419-424

[17] Rush RM Jr, Kjorstad R, Starnes BW,

et al. Application of the mangled extremity severity score in a combat setting. Military Medicine.

[18] Robertson PA. Prediction of amputation after severe lower limb trauma. Journal of Bone and Joint

[19] Sears ED, Davis MM, Chung KC. Relationship between timing of emergency procedures and limb amputation in patients with open tibia fracture in the United States, 2003 to 2009. Plastic and Reconstructive Surgery. 2012;**130**:369-378. DOI: 10.1097/PRS.0b013e3182589e2d

[20] Hull PD, Johnson SC, Stephen DJ, et al. Delayed debridement of severe open fractures is associated with a higher rate of deep infection. The Bone & Joint Journal. 2014;**96**:379-384. DOI:

[21] Malhotra AK, Goldberg S, Graham J, et al. Open extremity fractures: Impact of delay in operative debridement and irrigation. Journal of Trauma and Acute Care Surgery. 2014;**76**:1201-1207. DOI: 10.1097/TA.0000000000000205

[22] Keating JF, O'Brien PJ, Blachut PA, et al. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. The Journal of Bone and Joint Surgery.

[23] Forster MC, Bruce AS, Aster AS. Should the tibia be reamed when nailing? Injury. 2005;**36**:439-444

[24] Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients

10.1302/0301-620x.96B3.32380

Surgery. 1991;**73**:816-818

**44**

1997;**79**:334-341

[33] Stannard JP, Volgas DA, Stewart R, et al. Negative pressure wound therapy after severe open fractures: A prospective randomized study. Journal of Orthopaedic Trauma. 2009;**23**:552-557. DOI: 10.1097/ BOT.0b013e3181a2e2b6

[34] Krug E, Berg L, Lee C, et al. Evidence-based recommendations for the use of negative pressure wound therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus. Injury. 2011;**42**(Suppl 1):S1-S12. DOI: 10.1016/ S0020-1383(11)00041-6

[35] Iheozor-Ejiofor Z, Newton K, Dumville JC, et al. Negative pressure wound therapy for open traumatic wounds. Cochrane Database of Systematic Reviews. 3 Jul 2018;**7**:CD012522. DOI: 10.1002/14651858.CD012522.pub2

[36] Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plastic and Reconstructive Surgery. 1986;**78**:285-292

[37] D'Alleyrand JC, Manson TT, Dancy L, et al. Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications? Journal of Orthopaedic Trauma. 2014;**28**:288-293. DOI: 10.1097/ BOT.0000000000000001

[38] Gopal S, Majumder S, Batchelor AG, et al. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. Journal of Bone and Joint Surgery. 2000;**82**:959-966

[39] Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after

application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. Journal of Bone and Joint Surgery. 2000;**82**:1681-1691

[40] Gopal S, Giannoudis PV, Murray A, et al. The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage. Journal of Bone and Joint Surgery. 2004;**86**:861-867

[41] Webb LX, Bosse MJ, Castillo RC, MacKenzie EJ, LEAP Study Group. Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. The Journal of Bone and Joint Surgery. 2007;**89**:923-928

[42] Nemoto M, Ishikawa S, Kounoike N, et al. Free flap transfer to preserve main arterial flow in early reconstruction of open fracture in the lower extremity. Plastic Surgery International. 2015;**2015**:213892. DOI: 10.1155/2015/213892

[43] Shackford SR, Davis JW, Hollingsworth-Fridlund P, et al. Venous thromboembolism in patients with major trauma. American Journal of Surgery. 1990;**159**:365-369

[44] Geerts WH, Code KI, Jay RM, et al. A prospective study of venous thromboembolism after major trauma. The New England Journal of Medicine. 1994;**331**:1601-1606

[45] Schultz DJ, Brasel KJ, Washington L, et al. Incidence of asymptomatic pulmonary embolism in moderately to severely injured trauma patients. The Journal of Trauma. 2004;**56**:727-731

[46] Rogers FB, Cipolle MD, Velmahos G, et al. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: The EAST practice management

guidelines work group. The Journal of Trauma. 2002;**53**:142-164

[47] Francel TJ, Vander Kolk CA, Hoopes JE, et al. Microvascular softtissue transplantation for reconstruction of acute open tibial fractures: Timing of coverage and long-term functional results. Plastic and Reconstructive Surgery. 1992;**89**:478-489

[48] Hertel R, Strebel N, Ganz R. Amputation versus reconstruction in traumatic defects of the leg: Outcome and costs. Journal of Orthopaedic Trauma. 1996;**10**:223-229

[49] 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. Plastic and Reconstructive Surgery. 2009;**124**:1965-1973. DOI: 10.1097/ PRS.0b013e3181bcf156

[50] Fagelman MF, Epps HR, Rang M. Mangled extremity severity score in children. Journal of Pediatric Orthopedics. 2002;**22**:182-184

[51] Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score. Clinical Orthopaedics and Related Research. 1990;**256**:80-86

[52] Mommsen P, Zeckey C, Hildebrand F, et al. Traumatic extremity arterial injury in children: Epidemiology, diagnostics, treatment and prognostic value of mangled extremity severity score. Journal of Orthopaedic Surgery and Research. 2010;**5**:25. DOI: 10.1186/1749-799X-5-25

[53] Slauterbeck JR, Britton C, Moneim MS, Clevenger FW. Mangled extremity severity score: An accurate guide to treatment of the severely injured upper extremity. Journal of Orthopaedic Trauma. 1994;**8**:282-285

[54] Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. The Journal of Trauma. 1993;**34**:99-104

[55] Durham RM, Mistry BM, Mazuski JE, et al. Outcome and utility of scoring systems in the management of the mangled extremity. American Journal of Surgery. 1996;**172**:569-574

[56] Sheean AJ, Krueger CA, Napierala MA Skeletal Trauma and Research Consortium (STReC), et al.. Evaluation of the mangled extremity severity score in combat-related type III open tibia fracture. Journal of Orthopaedic Trauma 2014;**28**:523-526. DOI: 10.1097/ BOT.0000000000000054

[57] Stewart DA, Coombs CJ, Graham HK. Application of lower extremity injury severity scores in children. Journal of Children's Orthopaedics. 2012;**6**:427- 431. DOI: 10.1007/s11832-012-0439-6

[58] Brown KV, Ramasamy A, McLeod J, et al. Predicting the need for early amputation in ballistic mangled extremity injuries. The Journal of Trauma. 2009;**66**(4 Suppl):S93-S97. DOI: 10.1097/TA.0b013e31819cdcb0

[59] Doucet JJ, Galarneau MR, Potenza BM, et al. Combat versus civilian open tibia fractures: The effect of blast mechanism on limb salvage. The Journal of Trauma. 2011;**70**:1241-1247. DOI: 10.1097/TA.0b013e3182095b52

[60] Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. The Journal of Bone and Joint Surgery. 2001;**83**:3-14

**47**

**Chapter 4**

**Abstract**

scoring system

**1. Introduction**

Scoring Systems in Major

In the emergency room, every mangled extremity presents with its unique features. Each case requires a different approach and special care, while a surgeon has almost always the same facilities and armamentarium in her/his own setting. Thanks to the advancements in the bone fixation technologies and microsurgical field, the attempts to salvage mangled or even amputated limbs have increased. However, it is still controversial how the decision should be made for salvage or amputation. That is why several scoring systems have been proposed based on retrospective analysis of this group of patients in order to generate a systematic approach and to optimize the outcome. Although they help the surgeon to decide salvation over amputation, or vice versa, the same scores in different patient populations should be interpreted meticulously, and the treatment plan should be established accordingly. The ultimate success is being able to make the most accurate decision possible, and this can be only achieved with

experience and extensive knowledge along with sufficient surgical skills.

comes to salvaging of an injured or amputated limb.

**Keywords:** amputation, limb salvage, major trauma, mangled extremity,

Approach to major limb traumas is still a challenging subject. The decisionmaking process is the most critical part directly affecting the outcome. Although several factors such as the general status of the patient, the condition of the limb, and the experience of the surgeon along with the availability of the facilities help greatly determining what to do next, the outcome is mostly unpredictable when it

The decision for salvation should be done only after it is confirmed that the patient has no accompanying life-threatening injuries. Once the patient is stable, then the injured or amputated limb should be examined thoroughly. If the injured part is grossly contaminated, is severely avulsed, or contains vascular injuries at multiple levels, the patient would not benefit from any salvage procedures; more-

The main concerns in this decision-making process focus on the extent of vascular, skeletal, and soft tissue damage, the presence of shock, and warm ischemia time. However, additional criteria such as age, contamination, and patient-related comorbidities cannot be disregarded. The details of the incident are also of great importance such as when it happened, the time interval between the incident and arrival to the hospital and mechanism of injury. Like in every patient presenting with major trauma, the initial evaluation should include the establishment

over, any attempt to salvage the limb might put the patient's life at risk.

Extremity Traumas

*Isil Akgun Demir and Semra Karsidag*

#### **Chapter 4**

*Limb Amputation*

guidelines work group. The Journal of

[54] Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. The Journal of

[55] Durham RM, Mistry BM, Mazuski JE, et al. Outcome and utility of scoring systems in the management of the mangled extremity. American Journal of

[56] Sheean AJ, Krueger CA, Napierala MA Skeletal Trauma and Research Consortium (STReC), et al.. Evaluation of the mangled extremity severity score in combat-related type III open tibia fracture. Journal of Orthopaedic Trauma 2014;**28**:523-526. DOI: 10.1097/

[57] Stewart DA, Coombs CJ, Graham HK. Application of lower extremity injury severity scores in children. Journal of Children's Orthopaedics. 2012;**6**:427- 431. DOI: 10.1007/s11832-012-0439-6

[58] Brown KV, Ramasamy A, McLeod J, et al. Predicting the need for early amputation in ballistic mangled extremity injuries. The Journal of Trauma. 2009;**66**(4 Suppl):S93-S97. DOI: 10.1097/TA.0b013e31819cdcb0

[60] Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. The Journal of Bone and Joint Surgery. 2001;**83**:3-14

[59] Doucet JJ, Galarneau MR, Potenza BM, et al. Combat versus civilian open tibia fractures: The effect of blast mechanism on limb salvage. The Journal of Trauma. 2011;**70**:1241-1247. DOI: 10.1097/TA.0b013e3182095b52

Trauma. 1993;**34**:99-104

Surgery. 1996;**172**:569-574

BOT.0000000000000054

[47] Francel TJ, Vander Kolk CA, Hoopes JE, et al. Microvascular softtissue transplantation for reconstruction of acute open tibial fractures: Timing of coverage and long-term functional results. Plastic and Reconstructive

[48] Hertel R, Strebel N, Ganz R. Amputation versus reconstruction in traumatic defects of the leg: Outcome and costs. Journal of Orthopaedic

[49] 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. Plastic and Reconstructive Surgery. 2009;**124**:1965-1973. DOI: 10.1097/

[50] Fagelman MF, Epps HR, Rang M. Mangled extremity severity score in children. Journal of Pediatric Orthopedics. 2002;**22**:182-184

[51] Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score. Clinical Orthopaedics and Related

Research. 1990;**256**:80-86

[52] Mommsen P, Zeckey C, Hildebrand F, et al. Traumatic extremity arterial injury in children:

Epidemiology, diagnostics, treatment and prognostic value of mangled extremity severity score. Journal of Orthopaedic Surgery and Research. 2010;**5**:25. DOI: 10.1186/1749-799X-5-25

[53] Slauterbeck JR, Britton C,

Moneim MS, Clevenger FW. Mangled extremity severity score: An accurate guide to treatment of the severely injured upper extremity. Journal of Orthopaedic Trauma. 1994;**8**:282-285

Trauma. 2002;**53**:142-164

Surgery. 1992;**89**:478-489

Trauma. 1996;**10**:223-229

PRS.0b013e3181bcf156

**46**

### Scoring Systems in Major Extremity Traumas

*Isil Akgun Demir and Semra Karsidag*

#### **Abstract**

In the emergency room, every mangled extremity presents with its unique features. Each case requires a different approach and special care, while a surgeon has almost always the same facilities and armamentarium in her/his own setting. Thanks to the advancements in the bone fixation technologies and microsurgical field, the attempts to salvage mangled or even amputated limbs have increased. However, it is still controversial how the decision should be made for salvage or amputation. That is why several scoring systems have been proposed based on retrospective analysis of this group of patients in order to generate a systematic approach and to optimize the outcome. Although they help the surgeon to decide salvation over amputation, or vice versa, the same scores in different patient populations should be interpreted meticulously, and the treatment plan should be established accordingly. The ultimate success is being able to make the most accurate decision possible, and this can be only achieved with experience and extensive knowledge along with sufficient surgical skills.

**Keywords:** amputation, limb salvage, major trauma, mangled extremity, scoring system

#### **1. Introduction**

Approach to major limb traumas is still a challenging subject. The decisionmaking process is the most critical part directly affecting the outcome. Although several factors such as the general status of the patient, the condition of the limb, and the experience of the surgeon along with the availability of the facilities help greatly determining what to do next, the outcome is mostly unpredictable when it comes to salvaging of an injured or amputated limb.

The decision for salvation should be done only after it is confirmed that the patient has no accompanying life-threatening injuries. Once the patient is stable, then the injured or amputated limb should be examined thoroughly. If the injured part is grossly contaminated, is severely avulsed, or contains vascular injuries at multiple levels, the patient would not benefit from any salvage procedures; moreover, any attempt to salvage the limb might put the patient's life at risk.

The main concerns in this decision-making process focus on the extent of vascular, skeletal, and soft tissue damage, the presence of shock, and warm ischemia time. However, additional criteria such as age, contamination, and patient-related comorbidities cannot be disregarded. The details of the incident are also of great importance such as when it happened, the time interval between the incident and arrival to the hospital and mechanism of injury. Like in every patient presenting with major trauma, the initial evaluation should include the establishment

of a patent airway and optimization of ventilation and blood circulation. After the patient is stabilized, a thorough physical examination should be performed. In patients presenting with mangled extremities, pulsation, skin color and temperature, and capillary return on the distal segment of the involved limb should be checked. If fracture or dislocation of the involved limb is suspected, X-ray or computed tomography images should be obtained. Peripheral nerve examination should be also performed prior to any intervention. Meanwhile, antibiotic therapy should be initiated as soon as possible, especially in case of open fracture, and tetanus prophylaxis must be administered immediately.

### **2. Scoring systems for upper and lower extremities**

In order to be able to evaluate patients with major limb trauma in a more systematic way, several scoring systems have been proposed. The most widely used scoring systems are Mangled Extremity Syndrome Index (MESI); Mangled Extremity Severity Score (MESS); Predictive Salvage Index (PSI); Limb Salvage Index (LSI); Nerve injury, ischemia, soft tissue injury, skeletal injury, shock, age of patient score (NISSSA); and Ganga Hospital Open Injury Severity Scoring (GHOISS) (**Tables 1−6**).

Mangled Extremity Syndrome Index (**Table 1**) was described by Gregory et al. in 1985 [2]. The components of this index are injury severity score, bone, age, integument injury, nerve, lag time to operation, pre-existing disease, and shock. A cutoff score of 20 is considered for amputation.

**49**

*\**

**Table 2.**

**Table 3.**

*Predictive salvage index (PSI).*

gested as highly predictive for amputation.

value for amputation as 8 [4].

*Scoring Systems in Major Extremity Traumas DOI: http://dx.doi.org/10.5772/intechopen.85290*

*The score is doubled if the warm ischemia time >6 hours.*

*Mangled Extremity Severity Score (MESS).*

MESS (**Table 2**) is probably the most commonly used scoring system worldwide for both upper and lower extremity traumas. It was developed by Johansen et al. in 1990 following a retrospective evaluation of patients with lower mangled extremities [3]. The criteria for MESS include age, the presence of shock, warm ischemia time, and skeletal and soft tissue injury. In case the warm ischemia time is longer than 6 hours, the score is doubled. A MESS value equal to or greater than 7 is sug-

Skeletal and soft tissue injury Low-energy injury 1

Limb ischemia\* Normal perfusion despite reduced or non-palpable pulse 1

Shock status Systolic blood pressure > 90 mm Hg 0

Age <30 years 0

Bone injury Mild trauma 1

Muscle injury Mild trauma 1

Arterial injury Suprapopliteal 1

Delay to the operating room <6 hours 1

Medium-energy injury 2 High-energy injury 3

Slow capillary refill 2 No capillary refill 3

Transient hypotension 1 Persistent hypotension 2

> 30–50 years 1 >50 years 2

Moderate trauma 2 Severe trauma 3

Moderate trauma 2 Severe trauma 3

Popliteal 2 Infrapopliteal 3

6–12 hours 2 >12 hours 3

Very-high-energy injury or above injuries with gross contamination 4

In 1987 PSI (**Table 3**) was proposed by Howe et al. for scoring lower extremities

LSI (**Table 4**) was introduced by Russell et al. in 1991 [5]. Unlike the majority of scoring systems, age and the presence of shock are not included in LSI. On the other hand, there are seven evaluation criteria requiring extensive examination which can be only performed intraoperatively. A score of greater than 6 indicates amputation.

with orthopedic and vascular injury. In their study, they determined the cutoff

#### **Table 1.** *Mangled Extremity Severity Index (MESI).*

#### **Table 2.**

*Limb Amputation*

of a patent airway and optimization of ventilation and blood circulation. After the patient is stabilized, a thorough physical examination should be performed. In patients presenting with mangled extremities, pulsation, skin color and temperature, and capillary return on the distal segment of the involved limb should be checked. If fracture or dislocation of the involved limb is suspected, X-ray or computed tomography images should be obtained. Peripheral nerve examination should be also performed prior to any intervention. Meanwhile, antibiotic therapy should be initiated as soon as possible, especially in case of open fracture, and

In order to be able to evaluate patients with major limb trauma in a more systematic way, several scoring systems have been proposed. The most widely used scoring systems are Mangled Extremity Syndrome Index (MESI); Mangled Extremity Severity Score (MESS); Predictive Salvage Index (PSI); Limb Salvage Index (LSI); Nerve injury, ischemia, soft tissue injury, skeletal injury, shock, age of patient score (NISSSA); and

Mangled Extremity Syndrome Index (**Table 1**) was described by Gregory et al.

Injury severity score 0–25 1

Integument injury Guillotine 1

Nerve injury Contusion 1

Vascular injury Arterial transection 1

Bone injury Simple 1

Age <40 years 0

Lag time to operation For each hour over 6 hours 1 Pre-existing disease 1 Shock 2

25–50 2 >50 3

Crush/burn 2 Avulsion/degloving 3

Transection 2 Avulsion 3

Arterial thrombosis 2 Arterial avulsion 3 Vein 1

Segmental 2 Segmental comminuted 3 Bone loss <6 cm 4 Articular 5

> 40–50 years 1 50–60 years 2 >60 years 3

Articular with bone loss <6 cm 6

in 1985 [2]. The components of this index are injury severity score, bone, age, integument injury, nerve, lag time to operation, pre-existing disease, and shock. A

tetanus prophylaxis must be administered immediately.

**2. Scoring systems for upper and lower extremities**

cutoff score of 20 is considered for amputation.

Ganga Hospital Open Injury Severity Scoring (GHOISS) (**Tables 1−6**).

**48**

**Table 1.**

*Mangled Extremity Severity Index (MESI).*

*Mangled Extremity Severity Score (MESS).*

#### **Table 3.**

*Predictive salvage index (PSI).*

MESS (**Table 2**) is probably the most commonly used scoring system worldwide for both upper and lower extremity traumas. It was developed by Johansen et al. in 1990 following a retrospective evaluation of patients with lower mangled extremities [3]. The criteria for MESS include age, the presence of shock, warm ischemia time, and skeletal and soft tissue injury. In case the warm ischemia time is longer than 6 hours, the score is doubled. A MESS value equal to or greater than 7 is suggested as highly predictive for amputation.

In 1987 PSI (**Table 3**) was proposed by Howe et al. for scoring lower extremities with orthopedic and vascular injury. In their study, they determined the cutoff value for amputation as 8 [4].

LSI (**Table 4**) was introduced by Russell et al. in 1991 [5]. Unlike the majority of scoring systems, age and the presence of shock are not included in LSI. On the other hand, there are seven evaluation criteria requiring extensive examination which can be only performed intraoperatively. A score of greater than 6 indicates amputation.

#### **Table 4.**

*Limb salvage index (LSI).*

**51**

**Table 6.**

*\**

**Table 5.**

*Scoring Systems in Major Extremity Traumas DOI: http://dx.doi.org/10.5772/intechopen.85290*

> Transient hypotension

> Persistent hypotension

*Score doubles with ischemia >6 hours.*

Covering structures: skin and fascia

Skeletal structures: bone and joints

Functional tissues: MT and nerve units

Comorbid conditions

*MT, musculotendinous unit.*

Medium energy Transverse fracture, minimal comminution, small caliber

High energy Moderate displacement or comminution, high-velocity

Shock Normotensive Blood pressure normal, always >90 mm Hg systolic 0

Age Young <30 years 0

*Nerve injury, ischemia, soft tissue, skeletal injury, shock, age of patient score (NISSSA) [6].*

injury to posterior tibial nerve

increased anesthetic risk

fat embolism

*The Ganga Hospital Injury Severity Score (GHOISS) [1].*

Severe energy Segmental, severe comminution, bony loss 3

Middle 30–50 years 1 Old >50 years 2

*Wounds without skin loss* Not over the

*Wounds with skin loss* Not over the

Circumferential wound with skin loss 5

Transverse/oblique fracture/butterfly fragment <50% 1

Large butterfly fragment >50% circumference 2 Comminution/segmental fractures without bone loss 3 Bone loss <4 cm 4 Bone loss >4 cm 5

Partial injury to MT unit 1

Complete but repairable injury to MT units 2

Loss of one compartment of MT units 4 Loss of ≥2 compartments/subtotal amputation 5

Sewage or organic contamination/farmyard injuries 2 Age > 65 years 2 Injury-debridement interval > 12 hours 2 Polytrauma involving the chest or abdomen with injury severity score > 25/

Hypotension with systolic blood pressure < 90 mmHg at presentation 2 Another major injury to the same limb/compartment syndrome 2

Irreparable injury to MT units/partial loss of a compartment/complete

Drug-dependent diabetes mellitus/cardiorespiratory diseases leading to

gunshot wound

gunshot wound, butterfly fragments

Transient hypotension in field or emergency center 1

Persistent hypotension despite fluids 2

fracture

fracture

Over the fracture

Exposing the fracture 1

2

1

2

3

4

3

2

2

#### *Scoring Systems in Major Extremity Traumas DOI: http://dx.doi.org/10.5772/intechopen.85290*

#### **Table 5.**

*Limb Amputation*

Warm ischemia time

**Table 4.**

*Limb salvage index (LSI).*

Artery Contusion, intimal tear, partial laceration, or avulsion 0

Nerve Contusions, stretch injury, minimal clean laceration 0

Skin Clean laceration or small avulsion injuries with primary repair or first-degree burn 0 Delayed closure due to contamination; wounds requiring skin grafts or flaps; secondand third-degree burns

Muscle Avulsion or laceration of a single compartment or single tendon 0

Nerve Sensate No major nerve injury 0

Ischemia\* None Good to fair pulses, no ischemia 0

Soft tissue Low Minimal to no contusion, no contamination 0

Medium Moderate injury, low-velocity gunshot wound, moderate

High Moderate crush, deglove, high-velocity gunshot wound,

Severe Massive crush, farm injury, severe deglove, severe

Skeletal Low energy Spiral fracture, oblique fracture, no or minimal displacement 0

drainage; superficial vein injury

Complete laceration, avulsion, or thrombosis without adequate venous drainage 1

Dorsal Deep or superficial peroneal nerve injury 1 Plantar partial Tibial nerve injury 2 Plantar complete Sciatic nerve injury 3

Mild Reduced pulses, perfusion normal 1 Moderate No pulses, prolonged capillary refill, Doppler pulses present 2 Severe Pulseless, cool, ischemic, no Doppler pulses 3

contamination, minimal crush

moderate injury requiring flap, considerable contamination

contamination, requires flap

Deep vein Contusion, partial laceration, or avulsion; complete laceration or avulsion with intact

Bone Closed fracture in ≤2 sites; open fracture without comminution; closed dislocation

Partial transection or avulsion of sciatic nerve; complete/partial transection of femoral and peroneal/tibial nerve

without fracture; fibula fracture; open joint without foreign body

Closed fracture in at least three sites on same extremity; open fracture with comminution or moderate to large displacement; open joint with foreign body; bone loss <3 cm

Complete transection/avulsion of sciatic nerve or both peroneal and tibial nerves 2

Occlusion of ≥2 leg vessels, non-palpable pedal pulses 1 Complete occlusion of femoral or all three leg vessels 2

Bone loss >3 cm; Gustilo type IIIB,C fractures 2

Avulsion or laceration ≥2 compartments or tendons 1

Crush injury 2

<6 hours 0

6–9 hours 1 9–12 hours 2 12–15 hours 3 >15 hours 4

1

0

1

1

0

1

2

3

**50**

*Nerve injury, ischemia, soft tissue, skeletal injury, shock, age of patient score (NISSSA) [6].*

**Table 6.**

*The Ganga Hospital Injury Severity Score (GHOISS) [1].*

NISSSA score (**Table 5**) was proposed by McNamara et al. in 1994 [6]. It is a modified version of MESS with the addition of nerve injury. The cutoff value of NISSSA for amputation is 11.

The latest scoring system GHOISS was introduced by Rajasekaran et al. in 2006 [1]. The purpose of the authors was to address the paucity of the current scoring systems in tibial injuries without a vascular deficit (Gustilo type IIIB). GHOISS has the maximum number of components when compared with the other scoring systems (**Table 6**). A score of 14 or below is favored for the salvation of the limb, whereas a score of 17 or above indicates amputation. The scores falling between 14 and 17 indicate "the gray zone."

#### **3. Discussion**

The scoring systems were developed to provide a systematic therapeutic approach to mangled extremities.

by grading the severity of an injury. Like every concept that tries to tidy up a complicated clinical scenario, these systems have advantages and disadvantages. Most of the scoring systems address lower extremity injuries, while there is no scoring system specifically designed for upper extremity [7]. A single scoring system cannot be established for both upper and lower extremities since they differ in terms of the amount of muscle bulk and the availability of vascular supply [8]. The warm ischemia time is the single factor that has a direct impact on the extent of tissue necrosis and ischemia-reperfusion injury. Thus, it is included in all scoring systems, as demonstrated in **Table 7**.

The most commonly used systems for upper extremity injuries are MESI and MESS [8, 9]. It has been suggested that MESI scoring is more reliable than MESS in terms of prediction of amputation in mangled upper extremity injuries [8]. However, in order to calculate the MESI score, a thorough examination must be completed, and all the accompanying injuries must be identified, which is time-consuming and precludes practicality. On the other hand, although MESS was criticized by several authors in terms of its accuracy and predictive value, it can be still used preoperatively in many clinical settings with ease [10, 11]. The advantage of MESS is that its calculation relies on inspection and basic examination and is reproducible.

**53**

*Scoring Systems in Major Extremity Traumas DOI: http://dx.doi.org/10.5772/intechopen.85290*

ity of NISSSA have also been found controversial [13].

unbiased calculation [12].

The severity of muscle and bone injuries in PSI is graded as mild, moderate, and severe. However, the limits differentiating the severity levels from each other were not described well. Hence it is quite confusing how to grade those injuries with PSI. It would also result in a subjective evaluation rather than a systematic and

The critic regarding NISSSA is that the severity of nerve injury is only based on the plantar surface sensation indicating the integrity of the tibial nerve, which is no more an absolute contraindication for limb salvage [1]. The sensitivity and specific-

GHOISS is the first system to describe "gray zone" clearly meaning the scores between 14 and 17. It has been suggested that the outcome of the injuries in the gray zone is dependent on noninjury factors such as the skill and experience of the surgical team, the availability of facilities, and the patient's request. GHOISS was reported to be useful in children as well [14]. In their series of 107 patients with type IIIB injury, Rajasekaran et al. have reported that the Ganga hospital score showed higher sensitivity and specificity for predicting amputation; however, as they have mentioned in their article, this must be validated with multicenter trials [1]. The absolute contraindications for limb salvage or in other words absolute indications for amputations are still open for discussion. Although there is no established consensus about this topic, the presence of certain factors may favor amputation over salvage. First of all, if the patient has an accompanying lifethreatening injury, salvage procedure must not be attempted, and such situations render the scoring systems invalid. Another critical point is the warm ischemia time. Lange et al. have suggested that a crush injury with warm ischemia time longer than 6 hours is an absolute indication for amputation [7]. However, this cannot be applied to upper extremity injuries, since the upper extremity has less muscle bulk than the lower extremity and thus is less prone to develop ischemic injury [8]. Roessler et al. have put emphasis on the fluid balance and absence of a distal pulse on presentation that they are eventual indicators for amputation [12]; nevertheless, current advancements in both medical and surgical fields have overcome those concerns. Another historical indication for limb amputation was the nonfunctional posterior tibial nerve [7]. But, as the LEAP study group has demonstrated, the loss of plantar sensation is no more an indication for amputation [15]. Advanced age may also be included among the indications for primary amputation [16].

Albeit, these systems have been designed to enable the surgical team to make a decision, they are not 100% predictive of the ultimate outcome (salvage vs. amputation), and they are also not predictive of functional recovery among patients with successful extremity reconstruction [17–19]. The sensitivity and specificity rates are quite variable, and all the proposed scoring systems were found to be useful only to some extent [20]. Therefore, in addition to the scores calculated with these systems, patients must be evaluated along with injury pattern and pre-existing comorbidities, and the treatment should be planned also according to the patients' needs and demands. It is also imperative to take the experience and the skills of the microsurgeon into account. The optimal outcome would be achieved with a systematic multidisciplinary approach, availability of facilities, and always considering what is best for the patient. Raising high expectations both for the surgeon and the patient should be avoided. The technical and individual advancements in the microsurgical field cannot be overlooked; nevertheless, extreme attempts for limb salvage may be harmful to the patient. Moreover, it might become a huge burden for both sides in case it results in a nonfunctional extremity or requires secondary amputation. On the other hand, a patient can still prefer a nonfunctional but salvaged extremity, if there is no contraindication for performing salvage procedure. Therefore, patients' desire should also be considered as an additional subjective criterion during

#### **Table 7.**

*Comparison of the components of the scoring systems.*

#### *Scoring Systems in Major Extremity Traumas DOI: http://dx.doi.org/10.5772/intechopen.85290*

*Limb Amputation*

**3. Discussion**

NISSSA for amputation is 11.

and 17 indicate "the gray zone."

approach to mangled extremities.

systems, as demonstrated in **Table 7**.

NISSSA score (**Table 5**) was proposed by McNamara et al. in 1994 [6]. It is a modified version of MESS with the addition of nerve injury. The cutoff value of

The scoring systems were developed to provide a systematic therapeutic

by grading the severity of an injury. Like every concept that tries to tidy up a complicated clinical scenario, these systems have advantages and disadvantages. Most of the scoring systems address lower extremity injuries, while there is no scoring system specifically designed for upper extremity [7]. A single scoring system cannot be established for both upper and lower extremities since they differ in terms of the amount of muscle bulk and the availability of vascular supply [8]. The warm ischemia time is the single factor that has a direct impact on the extent of tissue necrosis and ischemia-reperfusion injury. Thus, it is included in all scoring

The most commonly used systems for upper extremity injuries are MESI and MESS [8, 9]. It has been suggested that MESI scoring is more reliable than MESS in terms of prediction of amputation in mangled upper extremity injuries [8]. However, in order to calculate the MESI score, a thorough examination must be completed, and all the accompanying injuries must be identified, which is time-consuming and precludes practicality. On the other hand, although MESS was criticized by several authors in terms of its accuracy and predictive value, it can be still used preoperatively in many clinical settings with ease [10, 11]. The advantage of MESS is that its calculation relies on inspection and basic examination and is reproducible.

*Age* ✓ ✓ ✓ ✓ Shock ✓ ✓ ✓ ✓ Warm ischemia time ✓ ✓ ✓ ✓ ✓ ✓ Bone injury ✓ ✓ ✓ ✓ Muscle injury ✓ ✓ ✓ Skin injury ✓ ✓ ✓

Contamination ✓ ✓

Co-morbidity ✓ ✓

Nerve injury ✓ ✓ ✓

Skeletal/soft tissue ✓ ✓

Deep vein injury ✓

Time to treatment ✓ ✓

*Comparison of the components of the scoring systems.*

**MESI MESS PSI LSI NISSSA GHOISS**

The latest scoring system GHOISS was introduced by Rajasekaran et al. in 2006 [1]. The purpose of the authors was to address the paucity of the current scoring systems in tibial injuries without a vascular deficit (Gustilo type IIIB). GHOISS has the maximum number of components when compared with the other scoring systems (**Table 6**). A score of 14 or below is favored for the salvation of the limb, whereas a score of 17 or above indicates amputation. The scores falling between 14

**52**

**Table 7.**

The severity of muscle and bone injuries in PSI is graded as mild, moderate, and severe. However, the limits differentiating the severity levels from each other were not described well. Hence it is quite confusing how to grade those injuries with PSI. It would also result in a subjective evaluation rather than a systematic and unbiased calculation [12].

The critic regarding NISSSA is that the severity of nerve injury is only based on the plantar surface sensation indicating the integrity of the tibial nerve, which is no more an absolute contraindication for limb salvage [1]. The sensitivity and specificity of NISSSA have also been found controversial [13].

GHOISS is the first system to describe "gray zone" clearly meaning the scores between 14 and 17. It has been suggested that the outcome of the injuries in the gray zone is dependent on noninjury factors such as the skill and experience of the surgical team, the availability of facilities, and the patient's request. GHOISS was reported to be useful in children as well [14]. In their series of 107 patients with type IIIB injury, Rajasekaran et al. have reported that the Ganga hospital score showed higher sensitivity and specificity for predicting amputation; however, as they have mentioned in their article, this must be validated with multicenter trials [1].

The absolute contraindications for limb salvage or in other words absolute indications for amputations are still open for discussion. Although there is no established consensus about this topic, the presence of certain factors may favor amputation over salvage. First of all, if the patient has an accompanying lifethreatening injury, salvage procedure must not be attempted, and such situations render the scoring systems invalid. Another critical point is the warm ischemia time. Lange et al. have suggested that a crush injury with warm ischemia time longer than 6 hours is an absolute indication for amputation [7]. However, this cannot be applied to upper extremity injuries, since the upper extremity has less muscle bulk than the lower extremity and thus is less prone to develop ischemic injury [8]. Roessler et al. have put emphasis on the fluid balance and absence of a distal pulse on presentation that they are eventual indicators for amputation [12]; nevertheless, current advancements in both medical and surgical fields have overcome those concerns. Another historical indication for limb amputation was the nonfunctional posterior tibial nerve [7]. But, as the LEAP study group has demonstrated, the loss of plantar sensation is no more an indication for amputation [15]. Advanced age may also be included among the indications for primary amputation [16].

Albeit, these systems have been designed to enable the surgical team to make a decision, they are not 100% predictive of the ultimate outcome (salvage vs. amputation), and they are also not predictive of functional recovery among patients with successful extremity reconstruction [17–19]. The sensitivity and specificity rates are quite variable, and all the proposed scoring systems were found to be useful only to some extent [20]. Therefore, in addition to the scores calculated with these systems, patients must be evaluated along with injury pattern and pre-existing comorbidities, and the treatment should be planned also according to the patients' needs and demands. It is also imperative to take the experience and the skills of the microsurgeon into account. The optimal outcome would be achieved with a systematic multidisciplinary approach, availability of facilities, and always considering what is best for the patient. Raising high expectations both for the surgeon and the patient should be avoided. The technical and individual advancements in the microsurgical field cannot be overlooked; nevertheless, extreme attempts for limb salvage may be harmful to the patient. Moreover, it might become a huge burden for both sides in case it results in a nonfunctional extremity or requires secondary amputation. On the other hand, a patient can still prefer a nonfunctional but salvaged extremity, if there is no contraindication for performing salvage procedure. Therefore, patients' desire should also be considered as an additional subjective criterion during

#### *Limb Amputation*

decision-making. In a nutshell, there is no single recommended scoring system either for upper or lower extremity injuries. They should be only utilized as guides during the planning of the treatment.

The decision for amputation should never be regarded as a failure. It would also be wise asking for consultation from more experienced colleagues before making the ultimate decision. It is the experience and the quality of clinical judgment that save the patient at the end of the day. The scoring systems are a collateral aid in this hard decision-making process. Their benefits are limited because they rely on retrospective data in small patient populations, and unfortunately it still seems to be unlikely to design a prospective model. What we can do better is to combine our experience, these proposed scoring systems for better interpretation of the scores, and narrowing the gray zone as much as possible. As Russel et al. put into words, "numbers cannot replace clinical judgment" [5].

#### **4. Conclusion**

Scoring systems are useful tools in the evaluation of patients with major extremity traumas. However, each patient requires an individual approach and would benefit from the surgeon's own experience.

#### **Conflict of interest**

The author declares no conflict of interest.

#### **Author details**

Isil Akgun Demir\* and Semra Karsidag University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Plastic and Reconstructive Surgery, Istanbul, Turkey

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**55**

*Scoring Systems in Major Extremity Traumas DOI: http://dx.doi.org/10.5772/intechopen.85290*

> [8] Kumar RS, Singhi PK, Chidambaram M. Are we justified doing salvage or amputation procedure based on mangled extremity severity score in mangled upper extremity injury. Journal of Orthopaedic Case Reports. 2017;**7**: 3-8. DOI: 10.13107/jocr.2250-0685.662

> [9] Durham RM, Mistry BM, Mazuski JE,

extremity. American Journal of Surgery. 1996;**172**:569-573; discussion 573-574. DOI: 10.1016/S0002-9610(96)00245-0

[10] Prasarn ML, Helfet DL, Kloen P. Management of the mangled extremity.

[11] Loja MN, Sammann A, DuBose J, Li CS, Liu Y, Savage S, et al. The mangled extremity score and amputation: Time for a revision. Journal of Trauma and Acute Care Surgery. 2017;**82**:518-523. DOI: 10.1097/TA.0000000000001339

[12] Roessler MS, Wisner DH, Holcroft JW.

1991;**126**:1243-1248; discussion 1248-1249

[13] Karna MB. Retrospective study on predictive scoring system for amputation in open fracture of tibia type III. International Journal of Research in Medical Sciences. 2016;**4**:3521-3524. DOI: 10.18203/2320-

[14] Venkatadass K, Grandhi TSP, Rajasekaran S. Use of Ganga Hospital Open Injury Severity scoring for determination of salvage versus amputation in open type IIIB injuries of lower limbs in children—An analysis of 52 type IIIB open fractures. Injury. 2017;**48**:2509-2514. DOI: 10.1016/j.

6012.ijrms20162323

injury.2017.09.010

The mangled extremity. When to amputate? Archives of Surgery.

Strategies in Trauma and Limb Reconstruction. 2012;**7**:57-66. DOI:

10.1007/s11751-012-0137-4

Shapiro M, Jacobs D. Outcome and utility of scoring systems in the management of the mangled

[1] Rajasekaran S, Naresh Babu J, Sheenadhayalan J, Shetty AP, Sundararajan SR, Kumar M, et al. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. Journal of Bone and Joint Surgery. British Volume (London). 2006;**88**:1351-1360. DOI: 10.1302/0301-620X.88B10.17631

[2] Gregory RT, Gould RJ, Peclet M, Wagner JS, Gilbert DA, Wheeler JR, et al. The mangled extremity

1985;**25**:1147-1150

discussion 572-573

discussion 480-481

syndrome (M.E.S.): A severity grading system for multisystem injury of the extremity. The Journal of Trauma.

[3] Johanesen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. The Journal of Trauma. 1990;**30**:568-572;

[4] Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. The American Surgeon. 1987;**53**:205-208

[5] Russell WL, Sailors DM, Whittle TB, Fisher DF Jr, Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Annals of Surgery. 1991;**213**:473-480;

[6] McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective evaluation of the Mangled Extremity Severity Score (MESS). Journal of Orthopaedic Trauma. 1994;**8**:81-87

[7] Dirschl DR, Dahners LE. The mangled extremity: When should it be amputated? The Journal of the American Academy of Orthopaedic

Surgeons. 1996;**4**:182-190

**References**

*Scoring Systems in Major Extremity Traumas DOI: http://dx.doi.org/10.5772/intechopen.85290*

#### **References**

*Limb Amputation*

**4. Conclusion**

**Conflict of interest**

during the planning of the treatment.

"numbers cannot replace clinical judgment" [5].

benefit from the surgeon's own experience.

The author declares no conflict of interest.

**54**

**Author details**

provided the original work is properly cited.

Isil Akgun Demir\* and Semra Karsidag

Plastic and Reconstructive Surgery, Istanbul, Turkey

\*Address all correspondence to<EMAIL_ADDRESS>
© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital,

decision-making. In a nutshell, there is no single recommended scoring system either for upper or lower extremity injuries. They should be only utilized as guides

The decision for amputation should never be regarded as a failure. It would also be wise asking for consultation from more experienced colleagues before making the ultimate decision. It is the experience and the quality of clinical judgment that save the patient at the end of the day. The scoring systems are a collateral aid in this hard decision-making process. Their benefits are limited because they rely on retrospective data in small patient populations, and unfortunately it still seems to be unlikely to design a prospective model. What we can do better is to combine our experience, these proposed scoring systems for better interpretation of the scores, and narrowing the gray zone as much as possible. As Russel et al. put into words,

Scoring systems are useful tools in the evaluation of patients with major extrem-

ity traumas. However, each patient requires an individual approach and would

[1] Rajasekaran S, Naresh Babu J, Sheenadhayalan J, Shetty AP, Sundararajan SR, Kumar M, et al. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. Journal of Bone and Joint Surgery. British Volume (London). 2006;**88**:1351-1360. DOI: 10.1302/0301-620X.88B10.17631

[2] Gregory RT, Gould RJ, Peclet M, Wagner JS, Gilbert DA, Wheeler JR, et al. The mangled extremity syndrome (M.E.S.): A severity grading system for multisystem injury of the extremity. The Journal of Trauma. 1985;**25**:1147-1150

[3] Johanesen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. The Journal of Trauma. 1990;**30**:568-572; discussion 572-573

[4] Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. The American Surgeon. 1987;**53**:205-208

[5] Russell WL, Sailors DM, Whittle TB, Fisher DF Jr, Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Annals of Surgery. 1991;**213**:473-480; discussion 480-481

[6] McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective evaluation of the Mangled Extremity Severity Score (MESS). Journal of Orthopaedic Trauma. 1994;**8**:81-87

[7] Dirschl DR, Dahners LE. The mangled extremity: When should it be amputated? The Journal of the American Academy of Orthopaedic Surgeons. 1996;**4**:182-190

[8] Kumar RS, Singhi PK, Chidambaram M. Are we justified doing salvage or amputation procedure based on mangled extremity severity score in mangled upper extremity injury. Journal of Orthopaedic Case Reports. 2017;**7**: 3-8. DOI: 10.13107/jocr.2250-0685.662

[9] Durham RM, Mistry BM, Mazuski JE, Shapiro M, Jacobs D. Outcome and utility of scoring systems in the management of the mangled extremity. American Journal of Surgery. 1996;**172**:569-573; discussion 573-574. DOI: 10.1016/S0002-9610(96)00245-0

[10] Prasarn ML, Helfet DL, Kloen P. Management of the mangled extremity. Strategies in Trauma and Limb Reconstruction. 2012;**7**:57-66. DOI: 10.1007/s11751-012-0137-4

[11] Loja MN, Sammann A, DuBose J, Li CS, Liu Y, Savage S, et al. The mangled extremity score and amputation: Time for a revision. Journal of Trauma and Acute Care Surgery. 2017;**82**:518-523. DOI: 10.1097/TA.0000000000001339

[12] Roessler MS, Wisner DH, Holcroft JW. The mangled extremity. When to amputate? Archives of Surgery. 1991;**126**:1243-1248; discussion 1248-1249

[13] Karna MB. Retrospective study on predictive scoring system for amputation in open fracture of tibia type III. International Journal of Research in Medical Sciences. 2016;**4**:3521-3524. DOI: 10.18203/2320- 6012.ijrms20162323

[14] Venkatadass K, Grandhi TSP, Rajasekaran S. Use of Ganga Hospital Open Injury Severity scoring for determination of salvage versus amputation in open type IIIB injuries of lower limbs in children—An analysis of 52 type IIIB open fractures. Injury. 2017;**48**:2509-2514. DOI: 10.1016/j. injury.2017.09.010

[15] Bosse MJ, McCarthy ML, Jones AL, Webb LX, Sims SH, Sanders RW, et al. The insensate foot following severe lower extremity trauma: An indication for amputation? The Journal of Bone and Joint Surgery. American Volume. 2005;**87**:2601-2608. DOI: 10.2106/ JBJS.C.00671

[16] Ninkovic M, Voigt S, Dornseifer U, Lorenz S, Ninkovic M. Microsurgical advances in extremity salvage. Clinics in Plastic Surgery. 2012;**39**:491-505. DOI: 10.1016/j.cps.2012.08.003

[17] Schirò GR, Sessa S, Piccioli A, Maccauro G. Primary amputation vs limb salvage in mangled extremity: A systematic review of the current scoring system. BMC Musculoskeletal Disorders. 2015;**16**:372. DOI: 10.1186/ s12891-015-0832-7

[18] Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ, LEAP Study Group. Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. The Journal of Bone and Joint Surgery. American Volume. 2008;**90**:1738-1743. DOI: 10.2106/JBJS.G.00136

[19] Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. The Journal of Trauma. 1993;**34**:99-104

[20] Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. The Journal of Bone and Joint Surgery. American Volume. 2001;**83**:3-14

**57**

**Chapter 5**

**Abstract**

children.

**1. Introduction**

**2. Incidence**

Stump Overgrowth after Limb

Stump overgrowth is the most common complication after limb amputation in children. Its morbidity is relatively high, that required frequent revisions of the stump and prosthesis. The incidence of stump overgrowth varies in the literature; depending on different factors. The exact pathogenesis is unclear, many hypotheses have been suggested. The treatment is a challenge; simple excision of the bone is associated with recurrence and further shorting of the stump. Many options of treatment have been used. This paper is an up-to date literature review that includes the definition, incidence, pathogenesis, clinical presentation, radiographic diagnosis, and treatment options of stump overgrowth in

**Keywords:** limb amputation, stump overgrowth, complication of amputation,

Overgrowth is the most common complication after stump amputation in children, and it leads to significant morbidity and multiple revisions of both the stump and prosthesis [1–3]. Overgrowth is characterized by the formation of bone spikes at the end of the amputated stump. At some point, the bone end becomes covered with a bursa, and skin adheres to the underlying bone. Finally, the skin perforates,

Stump overgrowth is the most common complication following limb amputation in children, and the incidence varies from 4 to 50% [2–8]. Age, location, reason for amputation, and level of amputation are known factors that affect the prevalence of stump overgrowth. Among them age and location are the most influencing factors. Osseous overgrowth is not observed in children older than 12 years or in cases of disarticulation amputations. Younger patients have a higher incidence of stump overgrowth [1, 7, 9]. The most frequent locations are the humerus, followed by the fibula and the tibia, whereas stump overgrowth is rare in the radius and ulna [7, 10]. Traumatic amputations carry a higher risk of overgrowth than elective surgical amputations, as stump overgrowth is very rare in congenital agenesis but common in amniotic band syndrome [1–3, 5, 11, 12].

stump capping procedures, heterotopic ossification

and bone and soft tissue infections develop, **Figure 1**.

Amputation in Children

*Rami Jahmani and Dror Paley*

#### **Chapter 5**

*Limb Amputation*

JBJS.C.00671

[15] Bosse MJ, McCarthy ML, Jones AL, Webb LX, Sims SH, Sanders RW, et al. The insensate foot following severe lower extremity trauma: An indication for amputation? The Journal of Bone and Joint Surgery. American Volume. 2005;**87**:2601-2608. DOI: 10.2106/

[16] Ninkovic M, Voigt S, Dornseifer U, Lorenz S, Ninkovic M. Microsurgical advances in extremity salvage. Clinics in Plastic Surgery. 2012;**39**:491-505. DOI:

10.1016/j.cps.2012.08.003

s12891-015-0832-7

[17] Schirò GR, Sessa S, Piccioli A, Maccauro G. Primary amputation vs limb salvage in mangled extremity: A systematic review of the current scoring system. BMC Musculoskeletal Disorders. 2015;**16**:372. DOI: 10.1186/

[18] Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ, LEAP Study Group. Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. The Journal of Bone and Joint Surgery. American Volume. 2008;**90**:1738-1743.

[19] Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. The Journal of

[20] Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. The Journal of Bone and Joint Surgery. American

DOI: 10.2106/JBJS.G.00136

Trauma. 1993;**34**:99-104

Volume. 2001;**83**:3-14

**56**

### Stump Overgrowth after Limb Amputation in Children

*Rami Jahmani and Dror Paley*

#### **Abstract**

Stump overgrowth is the most common complication after limb amputation in children. Its morbidity is relatively high, that required frequent revisions of the stump and prosthesis. The incidence of stump overgrowth varies in the literature; depending on different factors. The exact pathogenesis is unclear, many hypotheses have been suggested. The treatment is a challenge; simple excision of the bone is associated with recurrence and further shorting of the stump. Many options of treatment have been used. This paper is an up-to date literature review that includes the definition, incidence, pathogenesis, clinical presentation, radiographic diagnosis, and treatment options of stump overgrowth in children.

**Keywords:** limb amputation, stump overgrowth, complication of amputation, stump capping procedures, heterotopic ossification

#### **1. Introduction**

Overgrowth is the most common complication after stump amputation in children, and it leads to significant morbidity and multiple revisions of both the stump and prosthesis [1–3]. Overgrowth is characterized by the formation of bone spikes at the end of the amputated stump. At some point, the bone end becomes covered with a bursa, and skin adheres to the underlying bone. Finally, the skin perforates, and bone and soft tissue infections develop, **Figure 1**.

#### **2. Incidence**

Stump overgrowth is the most common complication following limb amputation in children, and the incidence varies from 4 to 50% [2–8]. Age, location, reason for amputation, and level of amputation are known factors that affect the prevalence of stump overgrowth. Among them age and location are the most influencing factors. Osseous overgrowth is not observed in children older than 12 years or in cases of disarticulation amputations. Younger patients have a higher incidence of stump overgrowth [1, 7, 9]. The most frequent locations are the humerus, followed by the fibula and the tibia, whereas stump overgrowth is rare in the radius and ulna [7, 10]. Traumatic amputations carry a higher risk of overgrowth than elective surgical amputations, as stump overgrowth is very rare in congenital agenesis but common in amniotic band syndrome [1–3, 5, 11, 12].

**Figure 1.** *X-ray of distal tibia and fibula overgrowth, arrow is indicating the sharp end of overgrown spike.*

Aitke postulated that bone overgrowth in congenital cases is due to intrauterine amputation (amniotic band syndrome) rather than true agenesis, considering that bone overgrowth does not occur in congenital agenesis; however, this assumption has not been proven [7]. An increased prevalence of overgrowth has been reported in patients who had previously undergone surgery for overgrowth [3, 11, 12]. Last, metaphyseal level amputations carry a higher risk of overgrowth than diaphyseal level amputations [1, 5].

#### **3. Pathogenesis**

Many hypotheses have been proposed to explain the phenomenon of bone overgrowth. Because overgrowth occurs in children, it has been suggested that overgrowth occurs as a result of disproportional growth between the remaining proximal physis and the contracted distal soft tissue and skin [13–15]. Pellicore et al. observed bone growth stimulation following amputation and concluded that stump overgrowth occurs because soft tissues cannot keep up with the rapid growth of the bone [16]; however, attempts to treat overgrowth by proximal epiphysiodesis and leaving long redundant soft tissue have failed [12, 17–19]. The incidence of the overgrowth phenomenon in cases of surgical and post-trauma amputations was higher [1–3, 5] compared with that of disarticulation amputation and congenital agenesis, [7, 20] which suggests that stump overgrowth might be a result of bone and soft tissue trauma rather than continuous growth of the proximal physis. This would mean that overgrowth is a local

**59**

**5. Treatment**

**Figure 2.**

*4 – Hematoma.*

**5.1 Conservative treatment**

*Stump Overgrowth after Limb Amputation in Children DOI: http://dx.doi.org/10.5772/intechopen.90532*

**4. Diagnosis and clinical picture**

process of bone formation and wound healing that occur in the distal stump. Studying the histology of stump overgrowth in rabbits, Hellstadius concluded that the medullary canal is the source of overgrowth [21]. Aitken implanted a radiographic marker in the bony stump and confirmed that overgrowth occurs distal to the marker, proving that overgrowth does not represent an epiphyseal contribution but rather a local phenomenon of bone healing [7, 8]. This explains why overgrowth does not occur in cases of disarticulation where there is intact articular cartilage rather than transected bone. If stump overgrowth is a local phenomenon, it is unclear why it is not observed following adult amputation. Speer, by conducting an experimental histological study on the immature skeleton of rabbits, described the pathogenesis of stump overgrowth and explained why it does not occur in the mature skeleton [22]. His study indicates that an amputation stump responds via wound healing and intramembranous bone formation. In the immature skeleton, the elastic characteristic of the periosteum allows it to pull away from the end of the amputee stump and leads to local bone formation, **Figure 2**.

*Pathogenesis of stump overgrowth: (a) initial stage, hematoma formation and periosteal elevation. (b) Organization of collagen fibers of scar and periosteum as continues mass. (c) Pulling the collagen fibers more distal by wound contracture and spike formation. 1 – Cotrex, 2 – Medullary canal, 3 – Periosteum,*

Patients with stump overgrowth present with pain, intolerance to the prosthesis, soft tissue irritation, pressure ulcers, skin perforation, and infection. The sharp edge of the bony spike can be palpated subcutaneously. The diagnosis is confirmed radiographically, with characteristic distal tapering of the bone to a narrow tip, with the absence of a medullary canal (the so-called licked candy sign), **Figure 1**. Orthopaedists should differentiate between stump overgrowth and bone spurs, which develop as a response to periosteal stimulation at the periphery of transected bone edges. Such bone spurs rarely necessitate stump revision. The cause of pain might also be an adventitious

The initial management of stump overgrowth includes prosthetic modifications and lifestyle adjustments. Before wearing the prosthesis, soft tissues should be pulled

bursa, which is common in soft tissues overlying an area of the stump.

*Stump Overgrowth after Limb Amputation in Children DOI: http://dx.doi.org/10.5772/intechopen.90532*

**Figure 2.**

*Limb Amputation*

Aitke postulated that bone overgrowth in congenital cases is due to intrauterine amputation (amniotic band syndrome) rather than true agenesis, considering that bone overgrowth does not occur in congenital agenesis; however, this assumption has not been proven [7]. An increased prevalence of overgrowth has been reported in patients who had previously undergone surgery for overgrowth [3, 11, 12]. Last, metaphyseal level amputations carry a higher risk of overgrowth than diaphyseal

*X-ray of distal tibia and fibula overgrowth, arrow is indicating the sharp end of overgrown spike.*

Many hypotheses have been proposed to explain the phenomenon of bone overgrowth. Because overgrowth occurs in children, it has been suggested that overgrowth occurs as a result of disproportional growth between the remaining proximal physis and the contracted distal soft tissue and skin [13–15]. Pellicore et al. observed bone growth stimulation following amputation and concluded that stump overgrowth occurs because soft tissues cannot keep up with the rapid growth of the bone [16]; however, attempts to treat overgrowth by proximal epiphysiodesis and leaving long redundant soft tissue have failed [12, 17–19]. The incidence of the overgrowth phenomenon in cases of surgical and post-trauma amputations was higher [1–3, 5] compared with that of disarticulation amputation and congenital agenesis, [7, 20] which suggests that stump overgrowth might be a result of bone and soft tissue trauma rather than continuous growth of the proximal physis. This would mean that overgrowth is a local

**58**

level amputations [1, 5].

**3. Pathogenesis**

**Figure 1.**

*Pathogenesis of stump overgrowth: (a) initial stage, hematoma formation and periosteal elevation. (b) Organization of collagen fibers of scar and periosteum as continues mass. (c) Pulling the collagen fibers more distal by wound contracture and spike formation. 1 – Cotrex, 2 – Medullary canal, 3 – Periosteum, 4 – Hematoma.*

process of bone formation and wound healing that occur in the distal stump. Studying the histology of stump overgrowth in rabbits, Hellstadius concluded that the medullary canal is the source of overgrowth [21]. Aitken implanted a radiographic marker in the bony stump and confirmed that overgrowth occurs distal to the marker, proving that overgrowth does not represent an epiphyseal contribution but rather a local phenomenon of bone healing [7, 8]. This explains why overgrowth does not occur in cases of disarticulation where there is intact articular cartilage rather than transected bone. If stump overgrowth is a local phenomenon, it is unclear why it is not observed following adult amputation. Speer, by conducting an experimental histological study on the immature skeleton of rabbits, described the pathogenesis of stump overgrowth and explained why it does not occur in the mature skeleton [22]. His study indicates that an amputation stump responds via wound healing and intramembranous bone formation. In the immature skeleton, the elastic characteristic of the periosteum allows it to pull away from the end of the amputee stump and leads to local bone formation, **Figure 2**.

#### **4. Diagnosis and clinical picture**

Patients with stump overgrowth present with pain, intolerance to the prosthesis, soft tissue irritation, pressure ulcers, skin perforation, and infection. The sharp edge of the bony spike can be palpated subcutaneously. The diagnosis is confirmed radiographically, with characteristic distal tapering of the bone to a narrow tip, with the absence of a medullary canal (the so-called licked candy sign), **Figure 1**. Orthopaedists should differentiate between stump overgrowth and bone spurs, which develop as a response to periosteal stimulation at the periphery of transected bone edges. Such bone spurs rarely necessitate stump revision. The cause of pain might also be an adventitious bursa, which is common in soft tissues overlying an area of the stump.

#### **5. Treatment**

#### **5.1 Conservative treatment**

The initial management of stump overgrowth includes prosthetic modifications and lifestyle adjustments. Before wearing the prosthesis, soft tissues should be pulled distally to prevent "mushrooming" of the soft tissue proximally into the socket. In many cases, the cause of pain is attributed to bone spurs and adventitious bursae, which can be treated with aspiration, steroid injections, and stump wrapping.

The skin traction method, first described by Marquardt in the late 1960s, has been reported to be successful in selected cases [10, 23]. This method has become the standard in very young children with very short stumps, in whom further shortening may preclude the use of prosthetics. The method involves a lengthy treatment and requires a cooperative parent. Older children can be taught to apply traction by themselves. The early period at the beginning of the treatment, before the skin becomes adherent to the underlying bursa, is important. The method is less successful for amputations below the knee due to the presence of the interosseous membrane and related tissue that hold the soft tissue firmly to the bone. Traction should be applied 23 hours a day, with 1 hour off for cleaning, and should be continued until skeletal maturity. A skin adhesive, such as Hollister medical skin adhesive, is applied to the distal stump. Cotton or nylon stockinettes are placed on the limb over the adhesive and pressed onto the skin firmly. After the adhesive dry, the loose end of the fabric is split into medial and lateral "tails." The tails are cut to the skin margin where the stockinette is adherent to the skin and are used to counter-pull through a D-ring attached to the outside of the socket after being looped around a rod built into the prosthesis. Night traction is achieved by attaching the tail of the stockinette to rob with appropriate weight over a pulley on the side of the bed.1

#### **5.2 Surgical treatment**

The surgical treatment of stump overgrowth has always been a challenge. Simple excision of the overgrown bone is associated with high recurrence; Davids et al. [11] reported a rate of revision as high as 87% after simple bone excision, multiple revisions (more than one revision) have been reported in 18% of cases, and one case with six revisions has been reported [5, 12]. Repeated surgical excision, while it is temporarily effective, leads to progressive shortening of the stump. A lack of understanding of the pathogenesis has led to a wide variety of treatment recommendations. Disproportional growth between bone and soft tissue has been considered a reason for overgrowth in the immature skeleton. Attempts to treat the condition by proximal epiphysiodesis and leaving a redundant soft tissue envelope have failed to stop overgrowth [12, 17–19]. The recent hypothesis, which considers overgrowth a local appositional overgrowth as a result of the healing process [6–8, 21], has directed surgical treatment for reducing the intensity of the bone healing process. Attempts to stop local bone formation by sclerosing the end of the stump by periosteal excision and cauterization have failed to treat the condition, and histological studies of the excised-periosteum distal stump have shown viable bony tissue [3]. To interrupt the interaction between the endosteum and surrounding outside soft and bony tissues, capping of the medullary canal has been suggested. The first capping procedure was performed by Swanson in 1969 with the use of silicon rubber [24, 25]. Marquardt, in 1974, has been credited as being the first to propose the application of a biological cap to prevent bone overgrowth in children. He described his procedure of using an epiphysis taken from the amputated limb as a cap to prevent overgrowth of a distal tibia amputation [26]. The goal was to convert a diaphyseal amputation into a stump resembling a disarticulation type, **Figure 3**. Many animal and human studies have been conducted to study the result of capping procedures using different materials, including 1 – biological caps: cancellous, cortical, and cartilaginous caps from the amputated distal stump and iliac crest; and

**61**

**Figure 3.**

*Tibia stump plugged by cartilaginous cap.*

*Stump Overgrowth after Limb Amputation in Children DOI: http://dx.doi.org/10.5772/intechopen.90532*

and cartilaginous cap [32].

2 – synthetic caps: rubber, polyethylene, titanium, and Teflon caps [1, 3, 4, 11, 24, 26–32] (**Table 1**). Animal studies on rabbits, with transplantation of the metatarsal epiphyses and fixation to the end of the amputated bone, have shown epiphyseal capping to be a very successful procedure to prevent overgrowth [31]. Many further publications have shown capping of the stump with an osteochondral cap to be the most effective treatment, with a revision rate of 0–10% [4, 29, 32, 33]. A controlled study compared osteochondral capping of the stump with simple resection and found a revision rate of 10% and, subsequently, of 86% [11, 28]. The distal epiphysis of the amputated stump, distal tibia, distal ulna, head of the metatarsal bone, and calcaneus serve as donors for the osteochondral cap for primary amputation (amputation where a distal stump is available). Finding a donor for the osteochondral cap is a challenge in secondary amputation (revision cases and cases where the distal part is absent), and the proximal fibula of the ipsilateral knee can be used in these situations [4, 29, 31, 33]. To avoid donor site morbidity (knee instability), Paley D used the apophysis of the iliac crest as a cap in a case series of patients [34]. Bernd et al. [27] studied the relationship between the revision rate in cartilaginous stump plasty and different factors and found no relationship with sex, reason for amputation, origin of the graft or method of fixation (screw vs. wires). However, revision was related to age and site; there were no revisions in patients below the age of 10 years old, and there were more revisions in the humerus; the high revision rate in the humerus was attributed to a loose interference fit between the humeral shaft

To avoid donor site morbidity and to substitute biological caps when unavailable, synthetic cap usage has been attractive for orthopedist. Silicon rubber, polyethylene and titanium caps have shown poor results [3, 11, 24]. Although capping

<sup>1</sup> The technique is furthered described in [23].

*Stump Overgrowth after Limb Amputation in Children DOI: http://dx.doi.org/10.5772/intechopen.90532*

*Limb Amputation*

**5.2 Surgical treatment**

distally to prevent "mushrooming" of the soft tissue proximally into the socket. In many cases, the cause of pain is attributed to bone spurs and adventitious bursae, which can be treated with aspiration, steroid injections, and stump wrapping. The skin traction method, first described by Marquardt in the late 1960s, has been reported to be successful in selected cases [10, 23]. This method has become the standard in very young children with very short stumps, in whom further shortening may preclude the use of prosthetics. The method involves a lengthy treatment and requires a cooperative parent. Older children can be taught to apply traction by themselves. The early period at the beginning of the treatment, before the skin becomes adherent to the underlying bursa, is important. The method is less successful for amputations below the knee due to the presence of the interosseous membrane and related tissue that hold the soft tissue firmly to the bone. Traction should be applied 23 hours a day, with 1 hour off for cleaning, and should be continued until skeletal maturity. A skin adhesive, such as Hollister medical skin adhesive, is applied to the distal stump. Cotton or nylon stockinettes are placed on the limb over the adhesive and pressed onto the skin firmly. After the adhesive dry, the loose end of the fabric is split into medial and lateral "tails." The tails are cut to the skin margin where the stockinette is adherent to the skin and are used to counter-pull through a D-ring attached to the outside of the socket after being looped around a rod built into the prosthesis. Night traction is achieved by attaching the tail of the stockinette to rob with appropriate weight over a pulley on the side of the bed.1

The surgical treatment of stump overgrowth has always been a challenge. Simple

excision of the overgrown bone is associated with high recurrence; Davids et al. [11] reported a rate of revision as high as 87% after simple bone excision, multiple revisions (more than one revision) have been reported in 18% of cases, and one case with six revisions has been reported [5, 12]. Repeated surgical excision, while it is temporarily effective, leads to progressive shortening of the stump. A lack of understanding of the pathogenesis has led to a wide variety of treatment recommendations. Disproportional growth between bone and soft tissue has been considered a reason for overgrowth in the immature skeleton. Attempts to treat the condition by proximal epiphysiodesis and leaving a redundant soft tissue envelope have failed to stop overgrowth [12, 17–19]. The recent hypothesis, which considers overgrowth a local appositional overgrowth as a result of the healing process [6–8, 21], has directed surgical treatment for reducing the intensity of the bone healing process. Attempts to stop local bone formation by sclerosing the end of the stump by periosteal excision and cauterization have failed to treat the condition, and histological studies of the excised-periosteum distal stump have shown viable bony tissue [3]. To interrupt the interaction between the endosteum and surrounding outside soft and bony tissues, capping of the medullary canal has been suggested. The first capping procedure was performed by Swanson in 1969 with the use of silicon rubber [24, 25]. Marquardt, in 1974, has been credited as being the first to propose the application of a biological cap to prevent bone overgrowth in children. He described his procedure of using an epiphysis taken from the amputated limb as a cap to prevent overgrowth of a distal tibia amputation [26]. The goal was to convert a diaphyseal amputation into a stump resembling a disarticulation type, **Figure 3**. Many animal and human studies have been conducted to study the result of capping procedures using different materials, including 1 – biological caps: cancellous, cortical, and cartilaginous caps from the amputated distal stump and iliac crest; and

**60**

<sup>1</sup> The technique is furthered described in [23].

2 – synthetic caps: rubber, polyethylene, titanium, and Teflon caps [1, 3, 4, 11, 24, 26–32] (**Table 1**). Animal studies on rabbits, with transplantation of the metatarsal epiphyses and fixation to the end of the amputated bone, have shown epiphyseal capping to be a very successful procedure to prevent overgrowth [31]. Many further publications have shown capping of the stump with an osteochondral cap to be the most effective treatment, with a revision rate of 0–10% [4, 29, 32, 33]. A controlled study compared osteochondral capping of the stump with simple resection and found a revision rate of 10% and, subsequently, of 86% [11, 28]. The distal epiphysis of the amputated stump, distal tibia, distal ulna, head of the metatarsal bone, and calcaneus serve as donors for the osteochondral cap for primary amputation (amputation where a distal stump is available). Finding a donor for the osteochondral cap is a challenge in secondary amputation (revision cases and cases where the distal part is absent), and the proximal fibula of the ipsilateral knee can be used in these situations [4, 29, 31, 33]. To avoid donor site morbidity (knee instability), Paley D used the apophysis of the iliac crest as a cap in a case series of patients [34]. Bernd et al. [27] studied the relationship between the revision rate in cartilaginous stump plasty and different factors and found no relationship with sex, reason for amputation, origin of the graft or method of fixation (screw vs. wires). However, revision was related to age and site; there were no revisions in patients below the age of 10 years old, and there were more revisions in the humerus; the high revision rate in the humerus was attributed to a loose interference fit between the humeral shaft and cartilaginous cap [32].

To avoid donor site morbidity and to substitute biological caps when unavailable, synthetic cap usage has been attractive for orthopedist. Silicon rubber, polyethylene and titanium caps have shown poor results [3, 11, 24]. Although capping

**Figure 3.** *Tibia stump plugged by cartilaginous cap.*

#### **Table 1.**

*Result of caping procedure by different authors using different capping materials.*

with synthetic material is successful for reducing the intensity of bony growth, the revision rate is high because of failure of fixation, infection, implant fracture, and difficulty covering with soft tissue. The synthetic cap must be biologically inert and durable. Teflon caps show better results than other synthetic materials, with a 29% revision rate. This result is comparable to capping of the stump with bone grafts; the cause of failure is mainly due to infection and painful bursa rather than overgrowth [3].

Conclusion of treatment: conservative treatment (prosthesis and lifestyle modification) is the initial treatment, and the skin traction method can be used in selected cases, especially in very young patients and cases of short stumps. When performing amputations, prophylactic transplantation of an osteochondral graft to plug the stump is recommended when a graft is available. In revision cases and cases in which the osteochondral graft is unavailable, the head of the fibula and Teflon caps can be used to plug the stump.

**63**

**Author details**

Rami Jahmani1

Florida, USA

\* and Dror Paley2

provided the original work is properly cited.

Jordan University of Science and Technology, Irbid, Jordan

\*Address all correspondence to<EMAIL_ADDRESS>
1 Department of Special Surgery/Orthopaedic Division, Faculty of Medicine,

2 Paley Orthopedic and Spine Institute, St. Mary's Hospital, West Palm Beach,

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*Stump Overgrowth after Limb Amputation in Children DOI: http://dx.doi.org/10.5772/intechopen.90532*

#### **Acknowledgements**

The authors are thankful to Maha Almaani for drawing the figures.

*Stump Overgrowth after Limb Amputation in Children DOI: http://dx.doi.org/10.5772/intechopen.90532*

*Limb Amputation*

**N Year Author Revision**

et al.

et al.

et al.

et al.

Jahmani

3 1992 Benevenia

8 2015 Fedorak

9 2017 Fedorak

10 2017 Fedorak

11 2019 Paley and

**rate**

1 1978 Wang et al. Zero Epiphyseal cap from

2 1991 Bernd et al. 12% Bone graft

4 1992 Hugh et al. Zero Ipsilateral fibula

6 1995 Davids et al. 27% Bone graft 7 2004 Davids et al. 29% Teflon

*Result of caping procedure by different authors using different capping materials.*

**Type of cap Note**

Animal study

prosthesis loosening, difficult soft tissue coverage

High failure rate in humerii treated by osteochondral transplantation

A case series

amputated limb of rabbits

amputated segment

transplanted to tibias

transplanted to humerii

ileac crest

10% Epiphyseal cap form