Extremity Injury


How are open fractures calssified

Gustillo classification

· Type I: Wound <1cm. low energy. Clean, little contamination/crushing/muscle damage/comminution

· Type II Wound 1-10cm. Slight comminution. Can be closed.

· Type III: Any large wound (>10cm) or wound with severe contamination or tissue damage (high velocity GSW, crushing injury, farm yard injury

· Type IIIa: Enough local soft tissue for coverage of bone

· Type IIIb: not enough local soft tissue for coverage (requires flap)

· Distinction between IIIa and IIIb can only be made after debridemnet.

· Type IIIc: associated arterial injury.


How do you treat open fractures

· Abx (penicillin, gent, metro), tetanus prophylaxis, debridement.

· Debridement must be within 6 hours – radical muscle debridement and conservative bone debridement.

· Primary closure can only be achieved in type 1 injuries. Wounds >6 hours should not be closed.

· Cover bone, tendon, nerve and vessel with fat muscle or fascia and leave skin open

· Second look at 48 hours with delayed primary closure by 5 days

· Initial fracture stabilization: Ex fix or IM nail

· Definitive fracture treatment is undertaken at 4-8 weeks after soft tissue problems have resolved.


What is a mangled extremity

A limb injury combining soft tissue and ossesus damage +/- vascular injury to such a point that limb survival able is questionable.

The mangled extremity severity score (MESS) is used to objectively determine if a limb is amenable to reconstrcuction.

The MESS uses grading of severity of skeletal inury, limb ischaemia, age and shock to produce a numerical score. If MESS ≥7 then predictive of amputation.

 

 

Parameter

Points

Skeletal/soft tissue

 

Low energy

1

Medium energy

2

High  energy

3

Very high energy (above + contamination)

4

Limb ischaemia

 

Pusle reduced perfusion normal

1

Pulseless, parasthesia

2

Paralysed, insensate, numb

3

Shock

 

SBP>90

0

Transient hypotension

1

Persistent hypotension

2

Age

 

<30

0

30-50

1

>50

2

Even if a limb is salvaged the function and QoL may be inferior to amputation

Severe ipsilateral foot trauma is associated with poor outcome and should swy towards primary amputation.

Nerve disruption below knee level is associated with loss of protective sensation and poor outcome

The outcome of upper limb salvage is better than lower limb.