Mangled Extremity Severity Score Score Research Articles

The role of Mangled Extremity Severity Score in amputation triage in a transport health facility with catastrophic earthquake admissions

BackgroundThe purpose of this study is to assess the diagnostic utility of the Mangled Extremity Severity Score (MESS) in the prediction of amputation after a major earthquake, and its utility in disaster triage. MethodsStudy results were presented from a tertiary hospital in Diyarbakır, which was affected by the earthquake but served as a transport hub for other cities in the region affected by the earthquake. MESS was calculated and its diagnostic value is analyzed in predicting amputations. MESS scores were divided into low risk, intermediate risk, and high risk groups by the researchers based on their diagnostic value analysis. Results79 patients were included in the study. Based on the outcome of amputation or salvage, patients were divided into two groups. 24.1% (n = 19) of the patients had amputations. Both gender and mean age did not differ statistically significantly between the groups (p > 0.05). Compared with the salvage group, the amputation group had a significantly longer prehospital stay and higher rate of vascular injury and higher median MESS (p = 0.007, p < 0.001, p < 0.001; respectively). Based on MESS scores, amputation outcomes were predicted with an accuracy of 0.889 (95% CI 0.798–0.949). Those with a MESS score below 9 were considered low risk (sensitivity = 100%) whereas those with a MESS score above 12 were considered high risk (specificity = 98.33%). ConclusionIn transport centers, MESS may be useful for surgical triage of earthquake-induced limb crush injuries.

Hyperbaric oxygen therapy does not change the amputation level in patients with fasciotomy after an earthquake: Our single-center experience after 2023 Kahramanmaras earthquake.

This study aims to evaluate the effect of hyperbaric oxygen therapy (HBOT) on the amputation level in patients undergoing fasciotomy with a Mangled Extremity Severity Score (MESS) score of ≥7 after 2023 Kahramanmaras earthquake. Between February 6th, 2023 and March 10th, 2023, a total of 23 patients (14 males, 9 females; mean age: 36.8±13.2 years; range, 17 to 64 years) who needed amputation with a MESS score of ≥7 and refused amputation were included in the study. All fasciotomies were performed in an external center, and five of them was incomplete. First, incomplete fasciotomies were completed with debridement due to deep muscle necrosis. Daily two HBOT sessions were performed for the first three days. In the following days, daily one HBOT session was performed. The HBOT was terminated for the patients who were decided by the council that they did not benefit from HBOT treatment. Six (26.08%) of the patients had a bone fracture (n=2 forearm, n=1 femur, n=2 tibia, and n=1 ankle fracture). The mean number of HBOT session was 13.24±5.4 (range, 7 to 30) and the mean duration of HBOT was 26.5±10.8 (range, 14 to 60) h. The mean MESS score was 9.96±1.36 (range, 7 to 12). All of the patients were trapped under the rubble with a mean time of 12.3±5.4 (range, 6 to 23) h. All fasciotomies were performed within the first 30 h. Twenty-two of the patients were amputated at the level previously determined by the experienced trauma surgeons. The amputation level changed in only one patient. After 38 h of HBOT, transradial amputation was performed to the patient in whom transhumeral amputation level was determined previously. None of the patients had any adverse event related to HBOT. Our study results suggest that the MESS is a useful scoring system for amputation decision after a high-energy trauma, such as an earthquake, with a high accuracy rate. The outcomes of HBOT are not satisfactory for high-energy traumas, such as earthquakes, in those requiring fasciotomy having more muscle necrosis and a MESS score of ≥7.

Revisiting the Mangled Extremity Severity Score (MESS) in Popliteal Artery Injury: A Single-Centre Experience in Vietnam.

Popliteal artery injury is a severe condition that can lead to limb loss. Early intervention is essential to achieve optimal outcomes, including limb salvage. The Mangled Extremity Severity Score (MESS) is a scoring system used to predict amputation rates for mangled limb injuries. The effectiveness of the MESS in predicting amputationin patients with traumaticpopliteal artery injury is unclear, particularly in settings with a high prevalence of motorcycle accidents. This retrospective study was conducted at a single center in Vietnam between January 2018 and June 2020. The study included 120 patients who underwent surgical treatment for popliteal artery injury. Data were collected from electronic medical records, radiology reports, and operative notes. Logistic regression model and the area under the curve (AUC) were used to evaluate the predictive value of the MESS. Patients with a MESS score of ≥8 had a higher rate of amputation compared to those with a MESS score of <8. However, the predictive value of the MESS was limited, with an AUC of 0.68. Higher skeletal/soft tissue injury score, limb ischemia score, and shock score were associated with a higher risk of amputation. The age score of the MESS was unexpectedly higher in the limb salvage group. The MESS score can be useful in predicting amputation rates in patients with popliteal artery injury, but its predictive value is limited. A team approach involving experienced surgeons is recommended for decision-making regarding amputation.

Mangled Extremity Severity Score in the Assessment of Extremity Injuries - Is it Reliable?

The mangled extremity severity score (MESS) was established 28years ago to decide performing an amputation in cases of limb trauma. It assigns points for 4 aspects of the injury: the extent of soft tissue and skeletal injury, limb ischemia and ischemic duration, shock, and age. A score of 7 or higher indicates that primary amputation is required. Thirty-one patients with MESS scores of 7 to 8 underwent limb salvage surgeries, with 13 limbs being saved and 18 limbs being amputated. Upper extremities trauma had a salvage rate of 62.5%, whereas lower extremity trauma had a salvage rate of 20%. MESS is not a sensitive predictor of amputation in upper limb trauma, but it is useful in lower limb injuries.

Factors Predicting the Outcome of Musculoskeletal Injuries Associated with Vascular Trauma at a Tertiary Care Trauma Centre in South India

Introduction: Vascular injuries are uncommon in civilian settings and present after blunt and or penetrating trauma. These injuries require timely intervention to prevent loss of limb or life. The impact of vascular injuries is well described in the Western population; however, there is a lack of evidence of factors predicting the outcomes of vascular injuries associated with musculoskeletal trauma in the Indian population. Methods: The retrospective data of consecutive trauma patients presenting to our emergency/outpatient department were collected over 5 years from January 2014 to December 2019 from our electronic medical records. After clinical assessment and/or radiological findings, patients were considered for either nonoperative management or vascular repair. Orthopedic intervention preceded vascular repair to attain skeletal stabilization and to protect vascular repair. Outcomes were measured in terms of baseline demographic variables, clinical determinants, pattern of injury, type of management, limb salvage, and primary or secondary amputations and mortality. Results: There were a total of 109 (92%) males and 3 (8%) females with an age range from 11 to 71 years (median = 35.5). The majority of the injuries were in the 30–50 years age group (n = 50, 50%). Limb salvageability was attained in 81 (72.3%) patients. Twenty patients (17.9%) underwent primary amputations and 11 (9.8%) patients required secondary amputations. Blunt trauma, lower limb involvement, multiple fractures, the Mangled Extremity Severity Score (MESS), and popliteal artery injury were significant predictors of limb salvageability. Stepwise multiple regression analysis identified multiple fractures (P = 0.011) and MESS (P = 0.000) as ultimate predictors of limb outcome. Conclusion: Revascularization is critical to the success of limb salvage in patients with traumatic vascular injury. Concomitant orthopedic injuries pose significant challenges and are associated with a high risk of limb loss. Multiple fractures and MESS score ≥6 prognosticates poor limb salvageability.

Analysis of Traumatic Axillo-Subclavian Vessel Injuries: Endovascular Management is a Viable Option to Open Surgical Reconstruction

In traumatic axillo-subclavian vessel injuries, endovascular repair has been increasingly described, despite ongoing questions regarding infection risk and long-term durability. We sought to compare the clinical and safety outcomes between endovascular and surgical treatment of traumatic axillo-subclavian vessel injuries. A search query of the prospectively maintained PROOVIT registry for patients older than 18 years of age with a diagnosis of axillary or subclavian vessel injury between 2014-2019 was performed at a Level 1 Trauma Center. Patient demographics, severity of injury, Mangled Extremity Severity Score (MESS), Injury Severity Score (ISS), procedural interventions, complications, and patency outcomes were collected and analyzed. Twenty-three patients with traumatic axillo-subclavian vessel injuries were included. There were similar rates of penetrating and blunt injuries (48% vs. 52%, respectively). Eighteen patients (78%) underwent intervention: 11 underwent endovascular stenting or diagnostic angiography; 7 underwent open surgical repair. There was similar severity of arterial injuries between the endovascular and open surgical groups: transection (30% vs. 40%, respectively), occlusion (30% vs. 40%, respectively). The open surgical group had worse initial clinical comorbidities: higher ISS scores (17.0 vs 13.5, p=0.034), higher median MESS scores (6 vs. 3.5, P=0.001). The technical success for the endovascular group was 100%. The endovascular group had a lower estimated procedural blood loss (27.5 mL vs. 624 mL, P=0.03). The endovascular arterial group trended toward a shorter length of hospital stay (5.6 days vs. 27.6 days, P=0.09) and slightly reduced procedural time (191.0 min vs. 223.5 min, P=0.165). Regarding imaging follow up (average of 60 days post-discharge), 7 patients (54%) underwent surveillance imaging (5 with duplex ultrasound, 2 with computed tomography angiography CTA) that demonstrated 100% patency. Regardless of ISS or MESS scores, at long term clinical follow up (average of 214 days), there were no limb losses, graft infections or vascular complications in either the endovascular or open surgical group. Endovascular treatment is a viable option for axillo-subclavian vessel injuries. Preliminary results demonstrate that endovascular treatment, when compared to open surgical repair, can have similar rates of technical success and long-term outcomes in patency, infection and vascular complications.

Outcomes of severe lower limb injury with Mangled Extremity Severity Score ≥ 7

Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J2021;103-B(4):769-774.

Revalidation of Mangled Extremity Severity Score in lower limb traumatic vascular injury

Extreme horrendous lower appendages wounds have been related with high rate of different frameworks included. That is settle on trouble and weight on specialist's dynamic either to sever or protect the harmed appendages. the evaluation of seriousness of injury to the appendage is generally done dependent on abstract rules as opposed to target rules. The error of this strategy drove a few creators to endeavor to measure the seriousness of injury and to propose scores in order to build up mathematical rules .The Mangled Extremity Severity Score (MESS) is presumably the most widely recognized scoring framework utilized. Point revalidation of Mangled Extremity Severity Score (MESS) in lower appendage awful vascular injury. Techniques This is an imminent non randomized investigation, led on 33 patients with serious furthest points wounds that met the measures of the Mangled Extremity Severity Scoring (MESS score at or close to edge (score 7 and score 8) taking care of the Emergency Department (ED) at Benha University Hospital. Result this investigation showed that the most regular influenced vessel was popliteal supply route (54.5%) trailed by PTA (24.2%) at that point ATA and SFA (18.2% for each) and CFA (3.0%) This examination showed that 54.5% showed breaks, 21.2% showed disengagement, 18.2% showed nerve injury and 42.4% showed muscle injury, Mean length of emergency clinic stay was 10 days with standard deviation of 3 days, just 27.3% of study populace went through 2ry removal. Ends the MESS was not prescient of removal Overall with the need of additional revalidation and the chance of appendage rescue for MESS score over the edge in the present of new period in remaking methods.

A STUDY OF USE OF COMPUTED TOMOGRAPHY ANGIOGRAPHY AND MANGLED EXTREMITY SEVERITY SCORE AS PREDICTORS OF LIMB SALVAGE IN EXTREMITY VASCULAR TRAUMA

Back Ground:Major loss of limb and life remains as an increasing importance as the occurances of arterial injuries are increasing . The prevention of such events and accurate identification of the limbs at risk, remains our serious concern. Introduction: There has been a longtime search for definitive score or test for evaluation of patients with vascular injuries. Mangled Extremity Severity Score (MESS) has been proved as predictor of viable limbs and Computed tomography Angiography (CTA) as an essential tool in diagnosing arterial injury. We did this study in India , combining MESS and CTA for predicting outcomes of arterial injury of extremity trauma victims in our hospital . Methods: A prospective,observational study of limb injuries between 2016 and 2018 in trauma unit was performed.We examined the clinical signs, operative findings using Mangled Extremity Severity Score and Computed tomography Angiography at presentation and compared with resultant limb salvage outcome. Results:Out of 100 people , 70 people fulfilled the inclusion criteria . Our study resulted an accuracy of 94.3% indicating perfect predictive ability of limb salvage by using the MESS score. CT angiography as the predictable variable and limb salvage as outcome variable showed an accuracy of prediction was 92.9% and excellent predictable accuracy of 97.1% when combining MESS with CTA. Conclusions:Combining clinical assessment using MESS and CTA improves the diagnostic accuracy of vascular injury and the need for immediate intervention for limb salvage procedures, and prevents amputation by delay.

Guided growth surgery for genu valgum in mucopolysaccharidosis type VI: Timing is everything

Open injuries in children are rare compared to adults. In children with major open injuries, there is no specific scoring system to guide when to amputate or salvage the limb. The use of available adult scoring systems may lead to errors in management. The role of Ganga Hospital Open Injury Severity Scoring (GHOISS) for open injuries in adults is well established and its applicability for pediatric open injuries has not been studied. This study was done to analyse the usefulness of GHOISS in pediatric open injuries and to compare it with MESS(Mangled Extremity Severity Score).All children (0–18 years) who were admitted with Open type IIIB injuries of lower limbs between January 2008 and March 2015 were included. MESS and GHOISS were calculated for all the patients. There were 50 children with 52 type IIIB Open injuries of which 39 had open tibial fractures and 13 had open femur fractures.Out of 52 type IIIB open injuries, 48 were salvaged and 4 were amputated. A MESS score of 7 and above had sensitivity of 25% for amputation while GHOISS of 17 and above was found to be more accurate for determining amputation with sensitivity of 75% and specificity of 93.75%.GHOISS is a reliable predictor of injury severity in type IIIB open fractures in children and can be used as a guide for decision-making. The use of MESS score in children has a lower predictive value compared to GHOISS in deciding amputation versus salvage. A GHOISS of 17 or more has the highest sensitivity and specificity to predict amputation.

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

Introduction and aimsOpen injuries in children are rare compared to adults. In children with major open injuries, there is no specific scoring system to guide when to amputate or salvage the limb. The use of available adult scoring systems may lead to errors in management. The role of Ganga Hospital Open Injury Severity Scoring (GHOISS) for open injuries in adults is well established and its applicability for pediatric open injuries has not been studied. This study was done to analyse the usefulness of GHOISS in pediatric open injuries and to compare it with MESS(Mangled Extremity Severity Score). MethodsAll children (0–18 years) who were admitted with Open type IIIB injuries of lower limbs between January 2008 and March 2015 were included. MESS and GHOISS were calculated for all the patients. There were 50 children with 52 type IIIB Open injuries of which 39 had open tibial fractures and 13 had open femur fractures. ResultsOut of 52 type IIIB open injuries, 48 were salvaged and 4 were amputated. A MESS score of 7 and above had sensitivity of 25% for amputation while GHOISS of 17 and above was found to be more accurate for determining amputation with sensitivity of 75% and specificity of 93.75%. ConclusionGHOISS is a reliable predictor of injury severity in type IIIB open fractures in children and can be used as a guide for decision-making. The use of MESS score in children has a lower predictive value compared to GHOISS in deciding amputation versus salvage. A GHOISS of 17 or more has the highest sensitivity and specificity to predict amputation.

Is amputation a viable treatment option in lower extremity trauma?

IntroductionThere is currently no consensus on how to treat patients with lower extremity trauma. Should amputation be performed early on to avoid complications or should the limb be saved at any price? The goal of this study was to show that early amputation is a viable treatment option in lower extremity trauma cases. Material and methodsTwenty patients who underwent early amputation and 16 patients who underwent limb-salvage were included with a minimum follow-up of 1year. The main endpoints were the Mangled Extremity Severity Score (MESS) used to predict amputation, complications, sequelae, bone union and functional outcomes. ResultsThe amputees had a higher MESS score than those treated conservatively (7.8 vs. 4.9, P<0.00001), had a shorter hospital stay (P<0.022) and had fewer postoperative complications (P<0.003), especially infection-related (P<0.001). The prevalence of infection in limb-salvage patients was 61%. There was no significant difference between the two groups in terms of quality of life. DiscussionIn cases of lower extremity trauma, early amputation and limb-sparing treatment each have their advantages and disadvantages. Early amputation seems to be better in cases of complications, despite similar quality of life in the two groups in the long-term. It is a viable treatment option in cases of lower extremity trauma. Amputation must not be considered as a failure, but a deliberate choice due to the functional impact of complications that occur after limb-salvage. Level of evidenceLevel IV study.

Validation of mangled extremity severity score in assessing the need for extremity amputation

INTRODUCTION: The decision to either salvage or amputate a mangled extremity poses great challenge to a surgeon.Different scoring systems were therefore developed to aid orthopaedic surgeons in this decision,eitherto contemplate amputation or proceed to salvage a mangled extremity. Of these scoring systems, the mangled extremity severity score (MESS) is mostly used.However,the high predictive accuracy reported by its developers has not been replicated by other authors. This study was carried out to validate the use of this scoring system in Nigeria and by extension, Africa.PATIENTS MATERIALS AND METHOD:The study was a hospital based prospective descriptive one which studied all patients with mangled extremities that were admitted into the Accident and Emergency room of the Lagos University Teaching Hospital (LUTH), Idi- Araba, from April 2014 to March 2015. Injured patients with mangled extremities were resuscitated and relevant investigations conducted. The MESS was calculated at presentation in the emergency room by two senior doctors in orthopaedic and trauma units (not lower than senior registrar cadres) independently and an average score calculated, rounded up to the nearest positive integer and documented.Type of treatment offered was based on the experience of the managing consultants. Patients' progresses were monitored and functional outcomes documented. All data generated during the study were analysed using Statistical Package for the Social Sciences (SPSS inc. Chicago, Illinois. version 21.0.Year of release - 2012).RESULTS: Twenty-nine mangled extremities in 27 patients were studied.The male: female ratio was 3.5:1.Age of patients ranged between 21-70 years with a mean age of 39.9 ±12.3years. Nineteen (65.5%) extremities were salvaged while 10(34.5%) were primarily amputated. Average MESS of all mangled limbs reviewed was 8.1+ 2.6 with scores that ranged from 3 to 13. The mean MESS for limb salvage was 7.0 +2.2while that for primary amputation was 10.1+2.0(P value- 0.01).MESS in this study had a sensitivity of 90%,specificity of 47.4%,positive predictive value of 47.4%, negative predictive value of 90%.AUROC in this study was 0.853.The cost of treatment, number of surgeries, and duration of hospital stay were higher in those with Salvaged limbs.The functional outcome for salvaged upper and lower extremities were better than for those whose limbs were amputated.Level of satisfaction was better in the limbs salvaged group than for those who had ablative surgery with statistical significance (P value- .000).CONCLUSION: This study validated the clinical utility of MESS in predicting the need for amputation in patients with mangled extremity injuries but it had a low predictive accuracy for extremities that would eventually enter the limb salvage pathway.Therefore,when contemplating limb salvage for a patient with mangled extremity,in addition to the result of the MESS score,the surgeons experience cannot be overemphasized.KEY WORDS: Open fracture,mangled limb,amputation,MESS score,classification

Fractures ouvertes Gustilo 3 et amputations sub-totales ou totales du membre supérieur : résultats et pertinence du MESS « Mangled Extremity Severity Score »

IntroductionThird degree open fractures and traumatic sub-/total amputations of the upper extremity represent severe injuries and are associated with a high rate of functional impairment of the affected extremity. More than 20years ago, the Mangled Extremity Severity Score (MESS) was introduced to predict amputation following severe lower extremity trauma. However, there have been few studies evaluating MESS in connection with the mangled upper limb. Material and methodsA retrospective medical chart review was performed of all patients diagnosed with the aforementioned fractures of the upper extremity treated at the Department of Trauma Surgery (Level I Trauma Center) and the Clinical Division of Plastic and Reconstructive Surgery at the General Hospital of Vienna between 1994 and 2014. ResultsFifty-four out of 606 (9%) patients suffered from a total of 61 third degree open fractures or traumatic sub-/total amputations of the upper extremity (Gustilo-Anderson type IIIA n=30; Gustilo-Anderson type IIIB n=15; Gustilo-Anderson type IIIC n=9; traumatic sub-/total amputations n=7). Thirty-seven out of 54 (69%) patients suffered fractures of the forearm, 10/54 (19%) patients of the humerus and 7/54 (13%) patients of the forearm and the humerus. The median MESS and Injury Severity Score (ISS) for all patients was 5 (range, 3–10) and 9 (range, 4–50), respectively. Seventeen out of 54 (31%) patients were diagnosed with a MESS≥7. Twenty-one out of 54 (39%) patients suffered severe vascular injuries and 22/54 (41%) patients suffered injuries of neural structures. Throughout the therapy process, 6/54 (11%) patients died. Definite limb salvage was achieved in 45 (94%) of the 48 survivors, of whom 9/45 (20%) subjects had a MESS≥7. DiscussionIt became apparent that definite limb salvage could be achieved in the mangled upper extremity regardless of MESS. It should be noted that in the current study limb functionality was not assessed. However, without a standardized scoring system, there might be significant risk of salving dysfunctional upper limbs. Level of evidenceIV: retrospective or historical series.

The effect of systemic injury score on the decision making of mangled lower extremities

PurposeMangled lower extremity with Mangled extremity severity score (MESS) more than 7 are considered unsalvageable. We are looking for a factor helps us predicting the salvage potential in the patient with MESS score between 7 and 9. Materials and methodsWe reviewed the patients with lower extremities open fracture type IIIB or IIIC and received salvaged procedure or amputation in CGMH between 2002/01 and 2010/09. The patients are subgroup according to their MESS score. ISS score, Gustilo open fracture classification were compared between patient with successful salvage and patient with delay amputation. Logistic regression and stepwise modeling were used to determine the effect of each covariate. Results242 patients were enrolled in the study. 33 patients had primary amputation, 160 patients had successfully salvaged limbs and 49 patients received delay amputation. Among patients with MESS score less than 7, 116 patients had successful salvage limbs and 7 patients received delay amputation. Among patient with MESS between 7 and 9, 44 patients discharged with salvaged limbs and 39 patients were failed to salvage their limbs. Successful salvaged patients in this group had significant lower ISS score in compare to delay amputated patients. Patients with ISS score more than 18 in this group has higher delay amputated rate (P value=0.01). ConclusionSystemic injury severity score can help us tell potentially salvaged patient from potentially amputated patient. In patients with MESS score between 7 and 9 concurrently have ISS score less then 17 are potentially salvageable. Level of Evidence & Study Type: Level 3 Retrospective cohort study/prognostic study

Third degree open fractures and traumatic sub-/total amputations of the upper extremity: Outcome and relevance of the Mangled Extremity Severity Score

IntroductionThird degree open fractures and traumatic sub-/total amputations of the upper extremity represent severe injuries and are associated with a high rate of functional impairment of the affected extremity. More than 20 years ago, the Mangled Extremity Severity Score (MESS) was introduced to predict amputation following severe lower extremity trauma. However, there have been few studies evaluating MESS in connection with the mangled upper limb. Material and methodsA retrospective medical chart review was performed of all patients diagnosed with the aforementioned fractures of the upper extremity treated at the Department of trauma surgery (level I trauma center) and the Clinical division of plastic and reconstructive surgery at the general hospital of Vienna between 1994 and 2014. ResultsFifty-four out of 606 patients (9%) suffered from a total of 61 third degree open fractures or traumatic sub-/total amputations of the upper extremity (Gustilo-Anderson, type IIIA, n=30; Gustilo-Anderson, type IIIB, n=15; Gustilo-Anderson, type IIIC, n=9; traumatic sub-/total amputations, n=7). Thirty-seven out of 54 patients (69%) suffered fractures of the forearm, 10/54 (19%) patients of the humerus and 7/54 (13%) patients of the forearm and the humerus. The median MESS and Injury Severity Score (ISS) for all patients was 5 (range: 3–10) and 9 (range: 4–50), respectively. Seventeen out of 54 patients (31%) were diagnosed with a MESS≥7. Twenty-one out of 54 patients (39%) suffered severe vascular injuries and 22/54 (41%) patients suffered injuries of neural structures. Throughout the therapy process, 6/54 (11%) patients died. Definite limb salvage was achieved in 45 (94%) of the 48 survivors, of whom 9/45 (20%) subjects had a MESS≥7. DiscussionIt became apparent that definite limb salvage could be achieved in the mangled upper extremity regardless of MESS. It should be noted that in the current study, limb functionality was not assessed. However, without a standardized scoring system, there might be significant risk of salving dysfunctional upper limbs. Level of evidenceIV: retrospective or historical series.

Factors Associated with Amputation after Popliteal Vascular Injuries

Popliteal artery trauma has the highest rate of limb loss of all peripheral vascular injuries. The objectives of this study were to evaluate outcomes after popliteal vascular injury and to identify predictors of amputation. Retrospective data over a 14-year period were collected for patients with popliteal artery with or without vein injuries. Patient demographics, mechanism of injury, Injury Severity Score (ISS), Mangled Extremity Severity Score (MESS), and physiologic parameters were extracted. Time to operative intervention, operative time, type of vascular repair, need for concomitant orthopedic procedures, and outcomes including amputation rate, and in-hospital mortality were recorded. Fifty-one patients were found to have popliteal artery injuries, with a median age of 25 (range 10-70years). The median ISS was 9, and the mean extremity Abbreviated Injury Severity score was 3. The mechanism of injury was blunt for 43% and penetrating for 57%. Fasciotomies were performed in 74% of patients and 64% of patients underwent combined orthopedic and vascular procedures. Overall, 66% of these patients had their vascular procedure performed first. Ten patients required amputation: 1 immediate and 9 after attempted limb salvage (20%). We found that those patients requiring amputation had a higher incidence of blunt trauma (80% vs. 35%, P=0.014) and higher MESS score (7.1 vs. 4.7, P=0.02). There was no difference in the incidence of amputation for those who underwent orthopedic fixation before vascular repair (P=0.68). Popliteal vascular injuries continue to be associated with a high risk of amputation. Those patients undergoing attempted limb salvage should be revascularized expediently, but selected patients may undergo orthopedic stabilization before vascular repair without increased risk of limb loss.

Reliability of the mangled extremity severity score in combat-related upper and lower extremity injuries.

Background:Decision of limb salvage or amputation is generally aided with several trauma scoring systems such as the mangled extremity severity score (MESS). However, the reliability of the injury scores in the settling of open fractures due to explosives and missiles is challenging. Mortality and morbidity of the extremity trauma due to firearms are generally associated with time delay in revascularization, injury mechanism, anatomy of the injured site, associated injuries, age and the environmental circumstance. The purpose of the retrospective study was to evaluate the extent of extremity injuries due to ballistic missiles and to detect the reliability of mangled extremity severity score (MESS) in both upper and lower extremities.Materials and Methods:Between 2004 and 2014, 139 Gustillo Anderson Type III open fractures of both the upper and lower extremities were enrolled in the study. Data for patient age, fire arm type, transporting time from the field to the hospital (and the method), injury severity scores, MESS scores, fracture types, amputation levels, bone fixation methods and postoperative infections and complications retrieved from the two level-2 trauma center's data base. Sensitivity, specificity, positive and negative predictive values of the MESS were calculated to detect the ability in deciding amputation in the mangled limb.Results:Amputation was performed in 39 extremities and limb salvage attempted in 100 extremities. The mean followup time was 14.6 months (range 6–32 months). In the amputated group, the mean MESS scores for upper and lower extremity were 8.8 (range 6–11) and 9.24 (range 6–11), respectively. In the limb salvage group, the mean MESS scores for upper and lower extremities were 5.29 (range 4–7) and 5.19 (range 3–8), respectively. Sensitivity of MESS in upper and lower extremities were calculated as 80% and 79.4% and positive predictive values detected as 55.55% and 83.3%, respectively. Specificity of MESS score for upper and lower extremities was 84% and 86.6%; negative predictive values were calculated as 95.45% and 90.2%, respectively.Conclusion:MESS is not predictive in combat related extremity injuries especially if between a score of 6–8. Limb ischemia and presence or absence of shock can be used in initial decision-making for amputation.

Combat Versus Civilian Open Tibia Fractures: The Effect of Blast Mechanism on Limb Salvage

This study compares open tibia fractures in US Navy and US Marine Corps casualties from the current conflicts with those from a civilian Level I trauma center to analyze the effect of blast mechanism on limb-salvage rates. Data from the 28,646 records in the University of California San Diego Trauma Registry from 1985 to 2006 was compared with 2,282 records from the US Navy and US Marine Corps Combat Trauma Registry Expeditionary Medical Encounter Database for the period of March 2004 to August 2007. Injuries were categorized by Gustilo-Anderson (G-A) open fracture classification. Independent variables included age, gender, mechanism of injury including blast mechanisms, shock, blood loss, prehospital time, procedures, Injury Severity Score, length of stay, and Mangled Extremity Severity Score (MESS). Dependent variables included early or late amputation and mortality. The civilian group had 850 open tibia fractures with 45 amputations; the military group had 21 amputation patients (3 bilateral) in 115 open tibia fractures. Military group patients were more severely injured, more likely have hypotension, and had a higher amputation rate for G-A IIIB and IIIC fractures then civilian group patients. Blast mechanism was seen in the majority of military group patients and was rare in the civilian group. MESS scores had poor sensitivity (0.46, 95% confidence interval: 0.29-0.64) in predicting the need for amputation in the civilian group; in the military group sensitivity was better (0.67, 95% confidence interval: 0.43-0.85), but successful limb salvage was still possible in most cases with an MESS score of ≥7 when attempted. Despite current therapy, limb salvage for G-A IIIB and IIIC grades are significantly worse for open tibia fractures as a result of blast injury when compared with typical civilian mechanisms. MESS scores do not adequately predict likelihood of limb salvage in combat or civilian open tibia fractures.

Brachial Artery Injuries in a Rural Catchment Trauma Center: Are the Upper and Lower Extremity the Same?

The predictors of amputation for patients with lower extremity vascular trauma are well described in the literature, but the predictors of amputation in the upper extremity are not so well defined. We hypothesize that the predictors of amputation in the lower extremity are much different when compared with the upper extremity. Retrospective chart review of all brachial artery traumatic injuries presenting to a rural-state university trauma center. In a 6-year period, 41 patients presented with brachial artery injuries. Operative management was performed in 38 (93%) patients which included 23 reversed saphenous vein grafts, 13 primary repairs, and 2 synthetic grafts. There were four deaths (9.8%) and four (9.8%) amputations. Comparing the amputation and limb salvage groups, the Injury Severity Score (ISS) was 32 versus 12, whereas the Mangled Extremity Severity Score (MESS) was 7 versus 4.3. Five patients had a MESS score greater than 7; four of whom had an amputation or died. Amputation was performed in only 4 of 23 patients with neurologic deficits. Limb salvage was successful in 24 of 28 patients without a palpable pulse on arrival. Predictors of amputation in brachial artery injuries differ from lower extremity vascular injuries. Delayed presentation greater than 6 hours, MESS, open fracture, nerve deficits, and diminished capillary refill were not predictive of amputation for patients with brachial artery injuries. These data suggest that the vast majority of upper extremity injuries should have attempted salvage regardless of the severity scoring systems.