Management of Mutilating Injuries of the Upper Extremity

Jaimie T. Shores

Andrew W. P. Lee

“Mangled” or “mutilating” injuries to the upper extremity are uncommon but devastating. A “mangled” extremity injury has injuries to at least three of the four following tissue groups: Integument/soft tissue, nerve, vasculature, and bone.1

Although this definition was created to define mangled lower extremity injuries, the same definition can be used for the upper extremity,2 though the incidence is less frequent than lower extremity injuries. Civilian studies have shown 23 mangled upper extremities versus 51 mangled lower extremities during a 10-year period at a tertiary care trauma center in the United States.3 In Japan, a study of 1,024 trauma center patients revealed 5 severe upper extremity injuries that demonstrated arterial involvement, with 3 patients qualifying as mangled.4 In recent U.S. military combat theaters, 23 patients with mangled upper extremity wounds over a 3-year period receiving complex reconstruction at a single institution represented the largest case series reported.5

The Mangled Extremity Severity Score (MESS) can be applied to the upper extremity, though it is done so infrequently. Originally described in 1990 as a lower extremity injury tool to predict amputation, it has not found widespread acceptance in application to the upper extremity.6 The MESS is a cumulative score with points given for skeletal/soft tissue injury, limb ischemia, shock, and age (Table 82.1). Commonly, a MESS ≥ 7 has been used as an indication for amputation in the lower extremity. However, it does not mandate or predict on an individual basis whether or not amputation should be performed. In addition, it is a score developed for the prediction of lower extremity salvage/amputation, which has functional implications that differ from those for the upper extremity. Lower extremity injuries carry a lower threshold for amputation due to the life-threatening consequences of large, nonviable muscles and because the loss can be adequately replaced with modern prosthetics. In a review from Walter Reed Army Medical Center in 2010, of the 750 lower extremity trauma-related amputations performed in the previous 10 years, 15% were due to unsatisfactory or “failed” limb salvage. In contrast, only two patients voluntarily requested late hand or upper extremity amputation following initial limb salvage,7 indicating the importance of the upper limb to patients, even when there is limited function. In another study of 52 patients with upper extremity vascular injuries, none of the 33 patients with a MESS < 7 underwent amputation. Interestingly, 63% of 19 patients with a MESS ≥ 7 also had limb salvage, with only 37% progressing to amputation.8 Thus, in its application to the upper extremity, the MESS seems to be a better predictor of limbs that will not require amputation than of those that will.

CLINICAL PRESENTATION

Mangled upper extremities may be life-threatening injuries themselves or may be associated with other life-threatening injuries. In combat populations, the etiologies include ballistic missiles, blast injuries (such as improvised explosive devices), and traditional mechanisms such as motor vehicle accidents (MVAs). Civilian populations may encounter devastating upper extremity injuries due to all mechanisms of trauma, with MVAs predominating. Industrial and agricultural injuries tend to be isolated upper extremity injuries. Civilian injuries also include firearm- and blast-related trauma.

Evaluation of the patient begins with standard ATLS protocols. Control of hemorrhage may require tourniquet placement. A secondary survey to determine the presence of more specific injuries should be performed efficiently. If possible, a full neurologic evaluation is performed prior to patient intubation. Standard pulse examination may be aided by the use of a hand-held Doppler. Function is ideally tested but may be hampered by pain and patient cooperation. Observations of gross deformity and digital cascade are documented. X-ray studies involving the affected portion of the extremity as well as the joints proximal and distal, and any region that is deemed clinically necessary, are obtained.

TABLE 82.1 MANGLED EXTREMITY SEVERITY SCORE (MESS) VARIABLES

▪	VARIABLE		▪	POINTS
	Skeletal/soft tissue injury
		Low energy (stab wound, simple fracture, low velocity GSW)		1
		Medium energy (open or multiple fractures, dislocations)		2
		High energy (shotgun, high-velocity GSW, crush injury)		3
		Very high energy (above + gross contamination, soft tissue avulsion, massive crush injury)		4
	Limb Ischemia
		No Ischemia		0
		Pulse absent, perfusion normal		1
		Pulse absent plus paresthesias		2
		Pulse absent, limb cool and insensate		3
	(Multiply all limb ischemia scores × 2 for warm ischemia > 6 h)			0
		Shock		1
		Systolic BP > 90 mm Hg		2
		Transient hypotension < 90 mm Hg		0
		Persistent hypotension < 90 mm Hg		1
	Age (years)			2
	<30
	30-50
	>50
Adapted from Slauterbeck JR, Briggon C, Moneim MS, Clevenger FW. Mangled extremity severity score: an accurate guide to treatment of the severely injured upper extremity. J Ortho Trauma. 1994;8(4):282-285.

INITIAL MANAGEMENT

During primary and secondary survey, bleeding is controlled. In many instances this is as simple as gauze packing and a pressure dressing with extremity elevation; however, application of a tourniquet may be required. Clamping of vessels is discouraged because other structures, such as nerves, are easily injured. The affected extremity should be closely examined and radiographs of any traumatized region, in addition to the joints proximal and distal, are obtained.

PHYSICAL EXAMINATION

Observations of the digital cascade and the position of the limb are noted, because this may help identify tendon injuries, joint dislocations, and fractures. Exposed tissues and the nature of contaminants are noted. Vascular and neurologic exams are performed, and pulses palpated and compared with the uninjured arm and correlated with the patient’s mean arterial pressure. The absence of palpable pulses should be confirmed with a hand-held Doppler probe. Color, warmth, and capillary refill are documented. If perfusion to an extremity is compromised in the setting of a joint dislocation or fracture, attempts to reduce the anatomic deformity are made to see if this restores perfusion. Any indication of compartment syndrome warrants an immediate compartment pressure evaluation. A neurological examination should be performed to evaluate sensory and motor function in all nerve distributions. If the patient has a head injury and is intubated or sedated, then neurological examination is difficult. Reflexes and protective responses to pain such as withdrawal may be obtained, but these may not be reliable in diagnosing compartment syndrome may not be reliable in diagnosing compartment syndrome or other conditions and injuries in this setting.

RADIOGRAPHIC EXAMINATION

Any suspicion of injury to an extremity warrants X-ray evaluation. Three views of the hand and/or wrist, two views of the forearm, and two views of the elbow are standard examinations. Radiographic evaluation utilizing thin-slice computed tomography scanning may provide added information regarding complex injuries involving the wrist or elbow. Any patient with suspected major vascular injury due to mechanism of trauma or who has clinical evidence of vascular insufficiency should receive angiographic evaluation.

In all cases of severe upper extremity trauma, immunization for tetanus is administered immediately. Antibiotic prophylaxis is initiated as soon as possible in the patient’s treatment course. In a prospective study of 1,104 open fractures, Patzakis et al. demonstrated that the single most effective intervention in decreasing the wound infection rate in open fractures was beginning treatment with intravenous antibiotics within 3 hours of injury (not presentation to the emergency department).9

If the patient is not stable or suitable for definitive treatment of the upper extremity wound in the operating room (OR), a preliminary washout-debridement and wound packing should be performed in the emergency department. Antimicrobial agents can also be added to the solutions used for washout, but these agents have not been demonstrated to decrease infection rates.10^,11 In fact, many of these agents have been shown to be toxic to host cells such as fibroblasts and may even impair host cell function.11 The use of saline and tap water was found to have similar outcomes for wound irrigation in the emergency department, including open fractures.12

OPERATIVE MANAGEMENT

Patients who have been physiologically stabilized and who do not have life-threatening injuries should have debridement, stabilization, and at least temporization of their wounds in the OR as soon as possible. Those patients with other life-threatening injuries or conditions that require direct admission to an intensive care unit (ICU) may be able to have some debridement and wound management even in the ICU setting.

Patients taken to the OR emergently for other injuries may be able to have their extremity injuries managed simultaneously. Care for the multiply injured or critically ill requires excellent communication across all teams involved in the patient’s care. Patients who are able to have their injuries managed operatively are to be addressed as soon as possible. However, the commonly held belief that management of open fractures requires operative debridement and stabilization within 6 hours has not been substantiated. Although most data for open fracture management have been derived from the more common lower extremity fractures, this dictum has been disproven more often than supported by evidence,9^,13^,14^,15^,16 even in children.17 Nonetheless, earlier wound debridement should be the goal for all mangled upper limb injuries.

Initial management in the OR is dictated by the extent of vascular compromise. Critical warm ischemia times vary from tissue to tissue (Table 82.2). Extremities with warm ischemia require expedient vascular reconstruction with concomitant fasciotomies. This may be in the form of an arterial repair, arterial reconstruction, or temporary shunt. Temporary shunts are synthetic conduits used for restoring flow in arteries, veins, or both and are used commonly for carotid bypass operations. Materials such as standard sterile IV tubing or pediatric feeding tubes may also be used.18 Shunts have been used in extremity revascularization and replantation since the 1970s with good results.19^,20

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