Primary amputation versus limb salvage in upper limb major trauma: a systematic review

Dafydd S. Edwards,Sandeep Krishan Nayar,Harry M. F. Alcock

doi:10.1007/s00590-021-03008-x

Abstract

PurposeSevere upper limb injuries can result in devastating consequences to functional and psychological well-being. Primary objectives of this review were to evaluate indications for amputation versus limb salvage in upper limb major trauma and whether any existing scoring systems can aid in decision-making. Secondary objectives were to assess the functional and psychological outcomes from amputation versus limb salvage.MethodsA systematic review was carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool. The review protocol was registered in PROSPERO.ResultsA total of 15 studies met inclusion criteria, encompassing 6113 patients. 141 underwent primary amputation and 5972 limb salvage. General indications for amputation included at least two of the following: uncontrollable haemodynamic instability; extensive and concurrent soft tissue, bone, vascular and/or nerve injuries; prolonged limb ischaemia; and blunt arterial trauma or crush injury. The Mangled Extremity Severity Score alone does not accurately predict need for amputation, however, the Mangled Extremity Syndrome Index may be a more precise tool. Comparable patient-reported functional and psychological outcomes are seen between the two treatment modalities.ConclusionsDecision regarding amputation versus limb salvage of the upper limb is multifactorial. Current scoring systems are predominantly based on lower limb trauma, with lack of robust evidence to guide management of the upper extremity. Further high-quality studies are required to validate scoring systems which may aid in decision-making and provide further information on the outcomes from the two treatment options.

Highlights

The upper limb plays a vital role in our daily function; synergistic movements from the shoulder girdle, elbow, forearm and wrist provide the hand freedom to move around the body during activities of living [1]
Whilst limb injuries are a common feature in trauma, major upper extremity trauma where there is a decision on whether to carry out amputation versus limb salvage is a rare occurrence [23, 37], which is reflected by the lack of high-quality evidence available in the literature
This systematic review has demonstrated that there are a number of factors to consider when making this decision

Summary

Introduction

The upper limb plays a vital role in our daily function; synergistic movements from the shoulder girdle, elbow, forearm and wrist provide the hand freedom to move around the body during activities of living [1] Injuries to this vital structure can result in devastating consequences to functional, psychological and social well-being. This is true in cases of a “mangled” upper extremity, defined as injury to three out of four components from assessment of the bones, vessels, nerves and soft tissue [2]. Salvage surgery is often lengthy and complex, with failure potentially leading to multiple subsequent revision surgeries, which may further exacerbate the negative impact from the trauma In these cases, primary amputation would be a more suitable path to achieve better functional and psychological recovery

Methods

Discussion

Conclusion