For centuries before the development of scoring systems, surgical indications for amputation were considered. Kirk, 3 in , noted indications for amputation included any injury or disease rendering limb salvage incompatible with function. Absolute and relative indications for amputation after open tibial fractures with vascular injury were described by Lange and colleagues 4 in Absolute indications included anatomically complete disruption of the posterior tibial nerve and a crush injury with a warm ischemic time greater than 6 hours.

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Children - civilian There are some reports on combat mangled extremities in children, but the articles did not make a clear separation between child and adult injuries. This category is discussed in section III. The English literature is poor in reporting on mangled extremity injuries in children.

Most of the studies involving children found good correlation between MESS and amputation. In his study on 44 children, Mommsen [ 27 ] reported good correlation between MESS and limb salvage or amputation. Most amputations were performed on young patients with an ischemic limb and with a general health status that precluded lengthy reconstructions [ 21 ]. In another study, Brown [ 29 ] encountered 77 military patients from Iraq and Afghanistan with 85 mangled extremities and also found good correlation between prolonged ischemia time, hypotension, unstable general condition, and amputation.

The authors concluded that MESS did not help in the decision as to whether or not to amputate. For primary amputation in combat situations, the results range from 3. In his study, Gifford [ 26 ] compared a group of patients who had a temporary vascular shunt TVS with a control group with similar characteristics but without temporary vascular shunts.

These results suggested the possible benefit of the TVS, although the results were not found to be statistically significant. The largest study reporting lower extremity injury severity score was reported by Bosse [ 30 ]. He evaluated lower extremities by using five scoring systems and found that The MESS had Discussion Because many mangled extremities are borderline cases with an unpredictable prognosis, the decision to amputate or to salvage a limb must be carefully assessed.

Unless the situation is life-threatening, the future of a limb should not be decided on the basis of the initial case evaluation alone. The mangled extremity scoring systems that are currently used were developed more than 15 years ago.

Since then, significant advances have been made in surgical techniques and devices, in the intensive care field, in stabilization methods and in reconstructions, all of which now permit limb salvage in the majority of lower limb trauma cases. Unfortunately, although the operation is usually deemed a success, there are cases that require secondary amputation.

Failed attempts at limb salvage result in prolonged hospitalization, along with multiple surgical procedures, pain, and psychological trauma. Although most recent studies agree that indications for limb amputation have diminished, there are authors who do not agree with performing a salvage operation for patients with an MESS higher than 7.

As the results revealed, there are major differences even among publications in the same year. For example, Elsharawy [ 16 ] saved This can be explained by the inclusion and exclusion criteria, as well as by the different type of studies prospective versus prospective plus retrospective. In almost all combat studies with a large number of cases, MESS is the most used scoring system, due to its simplicity.

Because most soldiers are under 30 years old, shock and ischemic time are the most important factors when calculating MESS in a combat casualty situation. In combat situations, lower limb injuries are frequently associated with other organ injuries, which are sometimes life-threatening. This may be explained by the fact that patients younger than 30 years of age receive no points on MESS. The literature has only a small number of studies referring to only a small number of cases of children with mangled extremities.

Children have a better outcome compared with adults and have a lower rate of delayed union or osteomyelitis [ 31 - 33 ] after lower limb injuries. In conclusion, we must note that the last two decades have seen advances in reconstructive techniques, combined with good collaboration between plastic surgeons, orthopedic surgeons, and vascular surgeons, that has made a difference in terms of limb salvage, as well as secondary reconstruction [ 24 , 34 ].

In his study on limbs, Bosse [ 30 ] did not validate the clinical utility of any of the lower-extremity injury-severity scores. We agree that it is better, as a first step, to attempt to salvage the limb; if it proves to be unsalvageable, a secondary amputation should be performed.

However, technical viability is not a sufficient criterion for limb salvage [ 35 ]. The growing enthusiasm for microvascular surgery may lead to death, sepsis, and preservation of dysfunctional limbs, as well as higher adjusted hospital charges. Those patients who underwent successful limb salvage procedures had more complications, more complex operations, more operative procedures, and longer hospitalizations than patients who underwent early amputation [ 36 ]. Unfortunately, a salvaged limb does not guarantee functionality, normal life, a pain-free extremity, or employability.

This is why a prediction score alone should not make the decision for amputation or salvage procedure. References 1. Adv Data. Wartime amputations. Mil Med. Injuries caused by antipersonnel mines in Croatian Army soldiers on the East Slavonia front during the war in Croatia. The impact of injuries below the knee joint on the long-term functional outcome following polytrauma.

The price of peace: the personal and financial cost of paramilitary punishments in Northern Ireland. Demographics, treatment, and early outcomes in penetrating vascular combat trauma. Arch Surg. Is staged external fixation a valuable strategy for war injuries to the limbs? Clin Orthop Relat Res. Prospective study of limb injuries in Calabar. J Orthop Surg. The Belfast approach to managing complex lower limb vascular injuries. Eur J Vasc Endovasc Surg.

The value of shunting in complex vascular trauma of the lower limb. In Evidence for Vascular Surgery. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg. Elsharawy MA. Arterial reconstruction after mangled extremity: injury severity scoring systems are not predictive of limb salvage.

Extremity vascular trauma in civilian population: a seven-year review from North India. A comparison of two predictive indices. J Bone Joint Surg Br. Cannada LK, Cooper C. The mangled extremity: limb salvage versus amputation. Curr Surg. Salvage versus amputation: Utility of mangled extremity severity score in severely injured lower limbs. Indian J Orthop. Critical evaluation of mangled extremity severity scoring system in Indian patients. Application of the Mangled Extremity Severity Score in a combat setting.

The mangled extremity and attempt for limb salvage. J Orthop Surg Res. Outcome and utility of scoring systems in the management of the mangled extremity.

Am J Surg. Effect of temporary shunting on extremity vascular injury: an outcome analysis from the Global War on Terror vascular injury initiative. J Vasc Surg. Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score.

J OrthopSurg Res. Mangled extremity severity score in children. J Pediatr Orthop. Predicting the need for early amputation in ballistic mangled extremity injuries. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am. J Orthop Trauma. Age as a prognostic factor in open tibial fractures in children. Open fracture of the tibia in children.


Mangled lower extremity: can we trust the amputation scores?

Models that predict the risk of lower limb trauma patients are designed to provide an estimation of the probability of limb salvage. Materials and Methods From September to , we collected the hospital records of all children who presented with lower extremity long bone open fractures. The inclusion criteria were I grade, II B, III C open fractures, severe injury to three of four organ systems, and severe injury to two of four organ systems with minor injury to two of four systems that require surgical interventions. Severity of limb injury was measured using MESS. Patients were followed up for 1 year. The discrimination of MESS model in differentiating of outcome in patients was assessed by calculating the area under the receiver operator characteristic plot. Results We evaluated children referred consecutively to our center.


Mangled Extremity Severity Score (MESS)

In case the answer is yes, regardless of the answer to limb ischemia question, the points are doubled. Simple fractures, stabbings or gunshots are considered low, dislocations or multiple fractures have medium energy while high spend MVA, rifle shots and in general most high speed trauma are at the high end, usually resulting in gross contamination from the exposure to the environment. It is most often used for lower extremity trauma in the emergency department during the initial evaluation in the trauma assessment centre. During that, the clinician might also use the Gustilo Classification of injury, stating whether the wound is grade I, II or III while observing the bone puncture and tissue and vascularisation damage. The cut off is set at 7, with score below presenting a better prognosis while score above 7 presenting a higher risk of amputation and negative outcome.

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