Surgical management of severe extremity injury

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All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2016. | This topic last updated: Jul 11, 2016.

INTRODUCTION — Trauma to the extremities represents one of the most common injury patterns seen in emergency medical and surgical practice. Achieving an optimal outcome in patients with severe extremity injuries requires a multidisciplinary approach with oversight by the general or trauma surgeon and commitment from other specialists including orthopedic, vascular, and plastic surgeons, and rehabilitation specialists. In most instances, a course of limb salvage can be attempted even if the patient has a mangled extremity; however, occasionally, the injury to the extremity is so severe that primary amputation at the initial operation is required to save the patient’s life. Complications of surgical treatment for severe extremity injury are common; early recognition and treatment are important to minimize morbidity and mortality. 

The surgical management of severe extremity injuries will be reviewed here. The initial management of severe extremity injury is discussed elsewhere. (See "Severe extremity injury in the adult patient".)

EXTREMITY EVALUATION — The extremity evaluation is structured around the four functional components of the extremity (nerves, vessels, bones, soft tissues). Injury to three of these four elements constitutes a “mangled extremity.” The evaluation and radiologic evaluation of the severely injured extremity is discussed elsewhere. (See "Severe extremity injury in the adult patient", section on 'Initial evaluation and management' and "Severe extremity injury in the adult patient", section on 'Extremity evaluation'.)

EXTREMITY ANATOMY — Knowledge of extremity anatomy and functional physiology is important for proper preoperative and postoperative extremity assessment.

Lower extremity anatomy — The bony structures of the lower extremity include the femur, tibia and fibula. The musculature is contained within defined compartments including the anterior, posterior and medial compartments of the thigh (figure 1), and the anterior, lateral, posterior, and deep posterior compartments of the leg (figure 2). 

The nerves of the lower extremity are derived from the lumbar plexus (figure 3) and include the sciatic, femoral, saphenous, tibial and peroneal (fibular) nerves (figure 4). The femoral nerve (L2 through L4) is lateral to the common femoral artery (figure 5). The femoral nerve provides motor branches to hip and knee extensors, and sensation to the anterior thigh, femur, knee joint, and medial leg (figure 6). The saphenous nerve is the extension of the femoral nerve and is purely sensory.

The sciatic nerve (L4 through S3) runs posteriorly down the thigh, continuing below the knee after dividing into the tibial and common fibular nerves (figure 7). It supplies the hip flexors, motor function of the lower leg, and nearly all the sensory function of the lower extremity (figure 6). The superficial and deep peroneal (fibular) nerves are derived from the common fibular nerve. The deep peroneal (fibular) nerve passes distally with the anterior tibial artery while the tibial nerve accompanies the posterior tibial artery.

The lower extremity is perfused by the common femoral artery (figure 8). The common femoral artery branches into the superficial and deep femoral vessels. The superficial femoral artery runs anteriorly down the thigh between the adductor and quadriceps muscles within the anterior compartment (figure 9). In the distal third of the femur, the superficial femoral artery is in close proximity to the femur. The superficial femoral artery passes through the adductor canal to become the popliteal artery (picture 1) which divides at the level of the tibial tuberosity into the anterior tibial artery and tibioperoneal trunk, which further divides into the posterior tibial and peroneal arteries (picture 2A-B). The anterior tibial artery accompanies the deep peroneal (fibular) nerve along the posterior margin of the tibia (figure 2). The peroneal artery passes adjacent the medial margin of the fibula throughout its course distally. The posterior tibial artery is accompanied by the tibial nerve within the deep posterior compartment.  

Collateral circulation — The collateral circulation in the lower extremity is derived from the deep femoral artery (profunda femoris) (figure 9). Collaterals are poorly developed in younger patients who tend to develop severe acute ischemia with arterial disruption. 

Upper extremity anatomy — The bones of the upper extremity include the humerus, radius and ulna. The musculature is contained within defined anterior and posterior compartments (figure 10). 

The brachial plexus is formed by the ventral rami of the lower cervical and upper thoracic nerve roots (figure 11A-B). It supplies cutaneous (figure 12) and muscular innervation to the upper extremity. The cords of the brachial plexus contribute to each of the five major nerves of the upper extremity (axillary, musculocutaneous, radial, median, and ulnar). The axillary nerve is purely sensory. The radial nerve is vulnerable to injury with humeral fracture since it winds around the humerus between the medial and lateral heads of the triceps. 

The upper extremity is perfused by the axillary artery which is a continuation of the subclavian artery. Near the head of the humerus, the axillary artery gives off the circumflex humeral artery and continues as the brachial artery (figure 13). The brachial artery passes between the biceps and triceps muscles accompanied by the ulnar and median nerves adjacent to the humerus. The ulnar nerve deviates to pass around the lateral condyle while the brachial artery and median nerve pass to the antecubital fossa where the artery divides into the radial, interosseus, and ulnar arteries (figure 14). Distally at the wrist, the ulnar artery and nerve and the radial nerve are closely apposed to the ulna and radius, respectively (figure 15).

Collateral circulation — The collateral circulation in the upper extremity is robust around the shoulder (figure 16) and elbow, and the upper extremity is generally more tolerant of acute focal arterial occlusion compared with the lower extremity. Multiple injuries or involvement of the collateral vessels lower the level of tolerance.

LIMB SALVAGE VERSUS AMPUTATION — A decision to salvage a limb versus amputation is always difficult. A management algorithm from the Western Trauma Association illustrates the complexity of this decision in patients with severe extremity trauma as well as the lack of high-quality evidence to guide this critical decision (algorithm 1) [1]. Primary amputation may need to be considered in patients who have no options for limb salvage that would lead to meaningful functional recovery of the limb [2]. However, based on our experience with combat injuries, there are very few absolute indications for primary amputation.

If limb salvage can be accomplished at the index operation without threatening the patient’s life, we suggest making the effort even if the patient has multiple risk factors for limb loss. This strategy allows time for the patient and family to accept amputation if it becomes necessary. Provided there is some chance for functional recovery of the limb, initial limb salvage is cost effective [3].

Patients with a severely crushed extremity, or patients with traumatic amputation or near-amputation who have destruction of the tissues distal to the injury, a mangled stump, excess intervening tissue loss, or the amputated extremity is missing should undergo a formalized amputation. 

If there is a fracture in the same extremity proximal to the amputation, stabilizing the fracture preserves residual limb length, which, for the lower extremity, may improve the ability to ambulate [4]. Other generally accepted principles of open fracture management should be followed. (See 'Fracture management' below.)

SURGICAL MANAGEMENT — The goal of surgical management is limb salvage. Patients with life-threatening injuries should undergo a damage control approach and a small number of patients with devastating injuries will require amputation.

Damage control surgery — When emergent surgery is indicated to control life-threatening bleeding in the abdomen or chest, extremity fractures should be quickly reduced and stabilized with splinting or in-line traction. Damage control torso surgery takes priority over extremity trauma as long as sites of extremity bleeding remain controlled. Tourniquets and dressings may need to remain in place on the extremity until life-threatening hemorrhage is controlled. 

After life-threatening torso injuries are addressed, the extremity injury can be assessed. Priorities include definitive control of bleeding sites with vascular ligation or placement of a vascular shunt, debridement of devitalized or grossly contaminated tissue, and quick stabilization of any fractures, if possible. Following these measures, the soft tissue wound can be managed with temporary closure using gauze dressings or negative pressure wound dressings. Further plans are made for repeat evaluation once the patient has been stabilized in the intensive care unit.

Vascular ligation — In general, ligation (arterial or venous) is best tolerated with distal or minor vascular injury. There is some degree of redundancy of circulation in the forearm and leg. Specifically, the radial or ulnar artery of the forearm can often be ligated when the other is not damaged. Similarly, ligation of any one of the three vessels of the leg (anterior tibial, peroneal, posterior tibial) is a damage-control option provided either the anterior or posterior tibial vessel is patent to provide in-line flow to the foot.

Whenever possible, we prefer vascular shunting over arterial ligation as a damage-control technique for managing injuries to more major arterial structures. Arterial ligation of major vessels should be undertaken with caution only after options for reconstruction have been carefully considered, since ligation risks the development of limb-threatening ischemia. If the vascular injury needs to be ligated, the patient should be closely monitored in the postoperative period for evidence of progressive ischemia that may indicate a need for revascularization or amputation depending upon the patient’s other injuries and clinical status. 

Similarly, ligation of major veins can cause venous hypertension. This can increase the rate of arterial graft failure in the acute setting and can also increase the incidence of long-term complications such as limb swelling and skin breakdown from venous stasis. 

Vascular shunting — A less morbid damage-control approach (compared with ligation) for patients with extremity vascular injury is vascular shunting, a technique that has been available for over 50 years [5]. A vascular shunt is a synthetic tube that is inserted into the vessel and secured proximally and distally. 

The effectiveness of temporary vascular shunting in patients with severe extremity injury has been shown in studies of combat casualties and in high-volume civilian practice [6-9]. In one retrospective review, the use of temporary intravascular shunts over a 10-year period in 786 patients was reviewed [9]. Shunts were placed in the context of damage control, to allow for reconstruction of Gustilo IIIc fractures or limb replantation. In this series of patients at high risk for limb loss, the limb salvage rate was 82 percent.

Vascular shunts are typically used for larger, more proximal arteries and veins such as the femoral, popliteal, and brachial vessels [6-8,10,11]. Prolonged disruption of flow proximally is associated with increased morbidity due to a greater burden of tissue ischemia compared with injury to more distal vessels. In the setting of shock, the time to the onset of neuromuscular ischemia may be shortened. Studies in a hypotensive animal model suggest that neuromuscular ischemia can occur in as little as one hour [12]. In this model, shunting expedited reperfusion and improved nerve and muscle recovery. Vascular shunting may also be more crucial for injuries in which collateral circulation has been disrupted, such as when associated soft tissue wounds are sizable. 

Temporary vascular shunting is preferred in the presence of the following clinical circumstances:

●Life-threatening non-extremity injuries 

●Hemodynamic instability, coagulopathy, acidosis, hypothermia

●Unstable skeleton

●Major wound contamination/infection or wound deficits that preclude soft tissue coverage

●Vascular injury requiring a repair more complicated than a primary repair

●Resource-limited environment 

 

Shunts can remain in place up to six hours, but definitive vascular reconstruction should be performed as soon as the patient is sufficiently stable to undergo the procedure. Systemic anticoagulation is not typically used to maintain shunt patency due to the potential for bleeding from other injuries.

Fracture management — Once a fracture is identified, it is reduced as much as possible and splinted. If an open fracture is suspected, the patient should be taken to the operating room to debride and stabilize the fracture (usually with external fixation) either after life-threatening injuries have been managed or concurrently while less emergent chest, abdominal, or head injuries are being addressed [13]. 

The timing of definitive stabilization of fractures depends upon the nature and severity of the fracture and the presence of significant vascular or soft tissue injury. 

Debridement and stabilization — At the initial operation, devitalized tissue and foreign material are surgically debrided from the wound. The location and extent of any soft tissue injury and its communication with the skeletal injury are evaluated. Open fractures should then be graded using the Gustilo-Anderson grading system [13]. (See "Severe extremity injury in the adult patient", section on 'Open fracture grading'.)

The wound is then copiously irrigated with 6 to 9 liters of normal saline. We use a low pressure irrigation system because higher pressure (≥50 psi) has the potential to drive foreign debris and bacteria into the deeper tissues, disrupt intact tissues, and inhibit bone formation [14-18]. A multicenter trial aimed at clarifying the optimal approach to managing open fracture investigated the outcomes of castile soap compared with normal saline irrigation delivered by means of high (>20 psi), low (5 to 10 psi), or very low irrigation pressure (1 to 2 psi) [17]. Patients with traumatic fractures were randomly assigned to one of six groups (2551 randomized; 2447 included in final analysis). Primary endpoints included reoperation within 12 months of the index surgery for the promotion of wound or bone healing or treatment of a wound infection. Secondary endpoints included nonoperatively managed infection, and wound or bone healing problems within 12 months of the index surgery. There were no significant differences for primary or secondary end points when comparing level of pressure. Reoperation occurred in 109 of 826 patients (13.2 percent) in the high-pressure group, 103 of 809 (12.7 percent) in the low-pressure group, and 111 of 812 (13.7 percent) in the very-low-pressure group. For type of irrigation, reoperation occurred in significantly more patients in the soap compared with saline group (14.8 versus 11.6 percent). We agree with the study authors’ conclusion that very low pressure saline irrigation (performed with a bulb syringe) is an acceptable, low-cost strategy for the irrigation of open fractures. 

The skeletal stabilization procedure of choice is external fixation, which can be performed in any surgical environment (including resource-limited) with infrequent need for modification and few complications [19]. Initial internal fixation is preferred if extensive soft tissue destruction, associated vascular injury, or significant contamination of an open fracture wound are not present. (See 'Definitive fracture fixation' below.)

External fixation or splinting of the skeleton is used until the wound is clean enough to perform definitive internal stabilization. The soft tissue defect is evaluated every 24 to 96 hours in the operating room depending upon the appearance of the wound at the last assessment. 

If a vascular injury is diagnosed in the setting of associated orthopedic injuries, the operative sequence may have a bearing on the success of revascularization [20]. In general, achieving bony stabilization greatly facilitates the vascular reconstruction. External fixation is usually performed quickly; however, if any problems are foreseen, a vascular shunt can be placed prior to external fixation to limit warm ischemia time to the distal limb. (See 'Vascular shunting' above.)

Once the limb has been brought out to length and stabilized, vascular reconstruction can then proceed without fear of disrupting the anastomosis during subsequent bone manipulation. (See 'Revascularization' below.)

Some surgeons advocate placement of cement beads with impregnated antibiotic solution into the wound bed adjacent to the fracture. Although this approach delivers high concentrations of antibiotics locally, a randomized trial comparing systemic antibiotics alone to antibiotic beads alone showed no significant difference in infection rates [21]. (See "Treatment and prevention of osteomyelitis following trauma in adults".)

Definitive fracture fixation — Definitive stabilization of complex open orthopedic injuries depends upon the degree of bone lost, extent of soft tissue injury and the nature and severity of associated injuries. Definitive fracture fixation is not performed until the patient is hemodynamically stable and other life-threatening injuries have been managed. Patients with isolated extremity injuries and patients with minimal associated non-extremity injuries can undergo definitive fracture stabilization without delay. 

Early stabilization of fractures improves pain control, protects the surrounding soft tissues, and facilitates mobilization of the patient. If the patient is well resuscitated with a mild to moderate disease burden and has a low-grade open fracture, intramedullary (IM) nailing of long bone fractures is the preferred approach. 

For patients who are initially managed with external fixation, conversion to IM nailing within 28 days of external fixation results in a lower incidence of infection (3.7 versus 22 percent) [22]. Some clinicians prefer to allow fixation sites to heal during a “safety interval” by casting the patient prior to definitive IM nailing. Others employ this technique only when pin site infections have occurred, but otherwise convert directly from external fixation to IM nailing once the patient is stable and soft tissue coverage of open fractures has been achieved [23]. 

A multicenter trial randomly assigned 1319 patients to reamed IM nailing versus unreamed IM nail stabilization [24]. Patients undergoing reamed IM nailing of closed fractures were significantly less likely to undergo reoperation (relative risk [RR] 0.67, 95% CI 0.47-0.96), less likely to undergo fasciotomy for intraoperative compartment syndrome (RR 0.15, 95% CI 0.02-1.25) and less likely to experience fracture dynamization from a broken or bent screw (RR 0.42, 95% CI 0.22-0.80). These benefits were not observed in the open fracture group. Several other small studies have suggested that reamed IM nailing is safe and beneficial in patients with low-grade open fractures [25,26].  

The adjunctive use of bone morphogenetic protein (BMP) added to the fracture bed during definitive stabilization has been evaluated to improve bony union. Although a systematic review and metaanalysis of 11 trials found no significant difference in healing rates with BMP [27]. However, fewer secondary procedures were required in patients treated with BMP (RR 0.65, 95% CI 0.50-0.83, three studies). Because of considerable industry involvement in these studies, these findings should be viewed with caution. 

Distraction osteogenesis using computer-based protocols has been used in cases of segmental bone loss [28].

Revascularization — Ischemia due to vascular injury is a major risk factor for amputation and, ideally, the injury will be identified and treated within six hours to minimize ischemic nerve and muscle damage [12,29,30]. (See "Severe extremity injury in the adult patient", section on 'Predicting limb loss'.)

The neuromuscular ischemic threshold may be less than the traditionally quoted six hours [12]; however, in addition to duration of ischemia, an individual’s ischemic threshold also depends upon the nature of the injury, age of the patient, medical comorbidities (eg, peripheral artery disease), and the adequacy of the collateral circulation. The pathophysiology of ischemia-reperfusion is discussed in detail elsewhere. (See "Patient management following extremity fasciotomy", section on 'Ischemia-reperfusion'.)

Bony stabilization of orthopedic fractures prior to vascular reconstruction facilitates the creation of an appropriate length of interposition graft and limits motion, thereby reducing the potential for anastomotic disruption [20]. If external fixation will result in an excess duration of ischemic time, a vascular shunt should be placed. (See 'Vascular shunting' above and 'Debridement and stabilization' above.)

Injuries to the tibial vessels may not require repair depending upon the degree of perfusion to the foot. If the anterior or posterior tibial artery remains intact and the foot is warm, immediate vascular reconstruction may not be needed. However, if the peroneal artery is the only intact vessel, perfusion of the foot through collaterals may be inadequate and distal bypass to the anterior or posterior tibial artery should be performed if the foot is in jeopardy. One study confirmed this selective approach, emphasizing the importance of Doppler examination in deciding which distal vascular injuries could be safely ligated and which required reconstruction [31]. In this study, the need for immediate vascular reconstruction increased significantly as the number of involved tibial vessels increased. 

In stabilized patients following initial shunt placement for damage control, or patients with few other injuries, we suggest the following approach at the index operation for definitive vascular reconstruction:

●The patient should be systemically anticoagulated if there are no known contraindications (eg, intracranial bleeding). 

 

●Regional anticoagulation should be used with heparinized saline (1 to 10 Units heparin per mL 0.9% normal saline) injected in the proximal and distal arterial segments. 

 

●Once the injured vessel (artery or vein) has been identified, the devitalized vessel wall should be debrided back to healthy tissue. 

 

●Thrombus should be removed from the proximal and distal artery using a Fogarty embolectomy catheter.

 

●Whenever possible, the vessel (artery or vein) should be brought together (primary end-to-end anastomosis). However, more typically, reconstruction with an interposition or bypass graft is needed due to an intervening defect.

 

●The interposition graft should ideally be reversed autologous saphenous vein taken from an uninjured leg. If both lower extremities are injured, the saphenous vein from the least injured extremity can be used, or arm vein can be considered. Prosthetic graft material (eg, polytetrafluoroethylene [PTFE]) is an option for the extremities, if no autologous conduit is available [32,33]. In a small retrospective review of combat vascular injuries reconstructed with PTFE compared with matched injuries reconstructed with autologous vein, PTFE had good long-term patency and freedom from infection in axillosubclavian region, but long-term outcomes for brachial, common femoral, and superficial femoral reconstruction were sub-optimal [32].

 

●At the conclusion of the reconstruction, we confirm the adequacy of arterial repair using Doppler, repeat injured extremity index (IEI), ankle-brachial index (ABI), or completion arteriogram depending upon available time and resources. 

 

●Whenever possible, we repair proximal venous injuries, particularly if the adjacent paired vein is also injured [34,35]. Venous ligation is appropriate for distal veins and proximal injuries associated with other life-threatening injuries. Extremity injury causing vascular injury is often associated with soft tissue injury that disrupts collateral venous flow, and although the patency rates of venous reconstruction are lower than arterial reconstruction, vein repair provides outflow and limits extremity swelling in the short term. Preserving venous outflow also decreases the likelihood of early arterial graft failure, especially with injuries to the popliteal vessels [34-36], which may ultimately decrease the incidence of secondary amputation as compared with venous ligation [29]

 

Role of endovascular repair — Endovascular techniques have less of a role in the management of extremity vascular injuries given that most of these are readily accessed with an open surgical approach, and experience with endovascular techniques in this setting remains limited. The use of covered stents may have the most potential for the management of larger, more proximal vessels at difficult-to-access junctional regions (eg, axillary, common femoral) [37-39]. In a review of the National Trauma Data Bank, endovascular treatment of axillosubclavian injuries increased significantly from 2010 to 2012 (11.3 versus 17.2). The long-term patency of these stents remains unknown, however [37]. 

Extremity fasciotomy — Prophylactic fasciotomy should be performed in all high-risk extremities which can include patients with significant crush injury, and those patients with an ischemic time greater than six hours, which includes prehospital and operative time. The diagnosis and treatment of acute compartment syndrome is discussed in detail elsewhere. (See "Acute compartment syndrome of the extremities".)

In the lower extremity, the standard approach is a two-incision four compartment release through medial and lateral lower leg incisions. Thigh compartment syndrome is rare but is similarly managed by opening the anterior and posterior fascia of the thigh. (See "Lower extremity fasciotomy techniques".)

In the upper extremity, forearm compartment syndrome is decompressed through a single volar incision.

Following decompression, the extremity wound is initially dressed with moist sterile gauze. As the swelling in the extremity decreases, the wound edges can be gradually reapproximated. In some cases, the skin edges can eventually be closed, but many of these wounds require skin grafting. Complications related to the need for fasciotomy, including rhabdomyolysis and wound-related issues, are discussed in detail elsewhere. (See "Patient management following extremity fasciotomy".)

Nerve repair — At the index operation, providing the patient’s condition permits, the nerve ends can be identified and marked with fine suture for later repair. Definitive management options include nerve decompression, repair, or nerve transfer, the choice of which depends upon the nature of the nerve injury.

Although repair can be performed at the index operation, nerve repair is often delayed to allow for debridement of contaminated wounds and resolution of other concomitant injuries. Repair of peripheral nerve injuries can be performed up to two weeks following injury.

If the nerve was transected, direct epineural repair with fine monofilament sutures can be performed. If a tension-free repair is not possible, an artificial or autologous nerve conduit (eg, the sural nerve) is used. 

For brachial plexus and certain median nerve injuries, a technique called nerve transfer may restore key extremity functionality [40]. In this procedure, an in-situ proximal segment of a less important nerve is anastomosed to the distal portion of an injured nerve with more essential function.

Soft tissue debridement/coverage — Open wounds are initially packed using moist dressings. Following debridement, which is usually performed in conjunction with open fracture management, negative pressure wound dressings can be used to provide coverage between operations. Negative pressure wound therapy has the advantages of reducing wound edema, maintaining skin integrity and limiting bedside wound manipulation [41-43]. The basic principles and use of negative pressure wound devices are discussed in detail elsewhere. (See "Negative pressure wound therapy".)

Fasciotomy wounds and many soft tissue defects can be managed with delayed primary closure or skin grafts, but more extensive wounds may require a combination of rotation flaps and free tissue transfer [44,45]. The functional outcomes of these various techniques are the subject of ongoing research [46].

(See "Principles of grafts and flaps for reconstructive surgery".)

The timing of closure of any residual tissue defect depends upon the availability of donor tissues and the level of contamination within the wound. It is generally accepted that immediate coverage can be performed for uncontaminated wounds when good quality soft tissue is available to cover the defect [47,48].

For wounds that don’t meet these criteria, the timing of coverage is controversial.

●One study found an increased incidence in infection for soft tissue coverage (1.5 versus 17.5 percent) and free flap failure (0.75 versus 12 percent) for wounds that were managed after 72 hours as compared with before [49].

 

●A retrospective review found that the incidence of infection was lower if soft tissue coverage was provided <10 days (18 versus 69 percent) compared with >10 days. Wounds that were allowed to heal by secondary intention had a 53 percent incidence of infection [50].

 

●The authors’ experience using local rotational or free flap at a mean of 20 days following the initial operation resulted in infection in 5 to 18 percent of patients [45].

 

Degloving injuries — Rotational injuries to the extremities can avulse the skin and subcutaneous fat off the underlying tissues. These free-floating segments of skin and soft tissue can become ischemic and slough completely resulting in large areas of soft tissue loss that must then be skin grafted

Once a degloving injury has been identified, systemic antibiotics should be administered to cover skin flora (eg, cefazolin) to minimize the development of infection, which significantly increases the patient’s morbidity and mortality.

If the patient has no underlying fractures or vascular injuries, the patient can be taken to the operating room and the soft tissue managed first by debriding obviously devitalized tissue. The free-floating subcutaneous tissues can then be tacked down to the underlying fascia and closed suction drains or a negative pressure dressing placed to evacuate serous fluid. 

A bulky overlying dressing and a splint should be applied to immobilize the extremity. The injury should then be reassessed in the operating room in 24 to 48 hours to identify any additional devitalized tissue. 

POSTOPERATIVE CARE AND FOLLOW UP — The postoperative course for patients with lower extremity injury is highly variable depending on the nature and severity of extremity injury, associated injuries, and the patient’s comorbidities. General issues related to inpatient management of injured patients are discussed in detail elsewhere. (See "Overview of inpatient management in the adult trauma patient".)

Activity — Early mobilization should be achieved as soon as feasible in patients with multiple injuries. Generally, the patient activity will be limited more by the orthopedic injury than by vascular reconstruction. 

For above-knee vascular reconstruction, the patient can bear weight as tolerated the day after surgery. For below-knee bypass grafts, ambulation is delayed 24 to 48 hours. To limit lower extremity swelling, the revascularized extremity should be elevated when the patient is not ambulating. 

Patients with extremity fractures benefit from physical therapy once or twice daily beginning in the intensive care unit. The goals of therapy should be graduated and tailored to the patient’s pre-injured physical activity status. However, patients with badly comminuted fractures, even after internal fixation, will need to limit weight-bearing for a period that ranges from weeks to months, but they should participate in physical therapy to the extent they are able. 

Antithrombotic therapy — Antithrombotic therapy is indicated to prevent venous thromboembolism and following revascularization.

VTE prophylaxis — Patients with severe extremity injury, particularly lower extremity injuries, are at high risk for venous thromboembolism (VTE). (See 'Venous thromboembolism' below.)

Patients should receive both mechanical and pharmacologic prophylaxis for venous thromboembolism, as soon as feasible [51]. With rare exception, anticoagulation should be continued perioperatively during subsequent procedures given the high risk of thromboembolic complications in this population. Pharmacologic agents and dosing regimens for VTE prophylaxis are discussed in detail elsewhere. (See "Prevention of venous thromboembolic disease in surgical patients", section on 'Pharmacologic agents for VTE prevention'.)

The risk of thromboembolic complications rises sharply if treatment is delayed beyond 72 to 96 hours [51]. If pharmacologic therapy is contraindicated for a period that will extend beyond this time frame, an inferior vena cava filter may be indicated [52]. The trauma team should ensure that a protocol is in place to ensure that follow-up has been arranged for patients who receive a temporary inferior vena cava filter [53]. (See "Placement of vena cava filters and their complications".)

Antiplatelet therapy — Patients with vascular injuries should be maintained on an antiplatelet medication (eg, aspirin, 325 mg daily) for 6 to 12 weeks following revascularization until the intima heals at the anastomotic sites. Although there is no literature on the need for or effectiveness of antiplatelet therapy following extremity vascular injury and repair, the use of antiplatelet therapy following repair of vascular injury is based on known mechanism of action of these medications and extrapolation from similar regimens in patients having undergone vascular procedures for age-related vascular disease. (See "Surgical management of claudication", section on 'Antithrombotic therapy'.)

Although systemic anticoagulation has no proven role in maintaining vascular graft patency, it may be used transiently in the postoperative period if there is concern for residual distal thrombus. Dextran has been used in the setting of venous reconstruction although the benefits of this approach have not been rigorously studied [54]. 

Surveillance of the vascular repair — As with any vascular reconstruction, surveillance of the vascular reconstruction, ideally with duplex ultrasonography, should be performed at 3, 6, and 12 months postoperatively, and then annually thereafter. (See "Surgical management of claudication", section on 'Duplex ultrasound surveillance'.)

COMPLICATIONS — Patients with severe lower extremity injuries have a high incidence of complications, including wound complications (infection, necrosis, nonunion, osteomyelitis), venous thromboembolism, rhabdomyolysis, and late complications including amputation and heterotopic ossification in residual limbs. Most of these complications require or prolong hospitalization, or require additional operative treatment [55]. 

Amputation as a primary treatment or secondary to failed revascularization or infection is discussed separately. (See 'Amputation and functional outcomes' below.)

Wound complications — Wound problems, due to ischemia or infection, are the most common complications of severe extremity injury and can result in wound breakdown, exposure of bone or vascular grafts, and secondary infection. 

The incidence of infection correlates with increasing injury severity as defined by the Gustilo-Anderson score [56]. Representative infection rates (wound infection and/or osteomyelitis) are as follows [56-60]: 

●Infection rate: percent

 

•Grade I: 0 to 2 

•Grade II: 2 to 5 

•Grade IIIA: 5 to 10 

•Grade IIIB: 10 to 50 

•Grade IIIC: 25 to 50 

 

The presence of infection affects the type and timing of soft tissue wound closure, the progress of bony union, and increases the risk for late amputation [61]. Preventive measures include prophylactic antibiotics and early wound debridement. (See "Severe extremity injury in the adult patient", section on 'Antibiotics' and 'Soft tissue debridement/coverage' above.)

Established infections are treated with antibiotics based upon antibiotic sensitivities and ongoing debridement of devitalized soft tissue and bone, as needed. (See "Treatment and prevention of osteomyelitis following trauma in adults", section on 'Treatment'.)

Venous thromboembolism — Deep venous thrombosis (DVT) and pulmonary embolism (PE) occur in up to 40 and 20 percent of injured patients, respectively. [62-64]. The most important risk factors are likely related directly to the extremity injury and immobilization. Up to half of documented deep vein thromboses affect the proximal lower extremity veins. Venous repair does not appear to increase the incidence of venous thromboembolic complications based on a recent review of 103 venous injuries [34]. In this study, DVT occurred at 10 sites remote from the vascular injury site in 82 total patients. There were 3 vein thromboses in 34 repairs. The treatment of DVT and PE are discussed in detail elsewhere. (See "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Overview of the treatment, prognosis, and follow-up of acute pulmonary embolism in adults".)

Rhabdomyolysis and myoglobinuria — Muscle cell death (rhabdomyolysis) and myoglobinuria can result from severe extremity trauma, crush injury, compartment syndrome and revascularization. Rhabdomyolysis presents with elevated serum muscle enzymes (including creatine kinase), red to brown urine due to myoglobinuria if there is persistent renal function, and electrolyte abnormalities. Peak serum creatine kinase levels depend upon the volume of muscle breakdown and the muscle mass of the patient. Patients with extremity injury and risk factors for rhabdomyolysis should have serial serum CK levels measured twice daily until decreasing levels are observed. (See "Clinical manifestations and diagnosis of rhabdomyolysis".)

Aggressive saline hydration is the primary initial therapy of myoglobinuria, lowering the risk of induction of acute kidney injury. The prevention and general management of heme pigment-induced acute kidney injury is discussed in detail elsewhere. (See "Prevention and treatment of heme pigment-induced acute kidney injury (acute renal failure)".)

Heterotopic ossification — Bone healing can be complicated by the formation of ectopic bone within skeletal soft tissues (heterotopic ossification) in patients with severe extremity injuries. Risk factors for heterotopic ossification (image 1) include increasing burden of disease (increasing injury severity score), traumatic brain injury, and severe extremity trauma which are associated with a heightened inflammatory response. As a result, mesenchymal osteogenic progenitor cells are activated and deposit mineralized bone within the soft tissues [65]. 

High-risk patients have been prophylactically treated with nonsteroidal antiinflammatory drugs, biphosphate therapy and external beam radiation therapy. Of these, radiation therapy is possibly more effective but is much more expensive than other available preventative measures [66,67]. 

Surgical resection is indicated when the ectopic bone causes breakdown of the overlying skin, interferes with prosthetic fitting, or limits mobility of the extremity. In a series that included 373 limbs with combat-related amputations, 235 limbs had formed clinically-detectable heterotopic ossification. Of these, 25 required excision [68]. 

Excision of heterotopic calcification is associated with a risk of injury to the surrounding muscles and adjacent vessels and nerves. However, the benefits of excision, which improves functional outcomes, probably exceed the risk in severe cases. Recurrence rates are low with perioperative prophylaxis for secondary prevention. 

Future research is needed to determine the specific mechanisms that produce heterotopic ossification, define early biomarkers and prospectively evaluate primary prevention strategies in a controlled manner in patients with severe extremity injuries [65].

AMPUTATION AND FUNCTIONAL OUTCOMES — The presence of extremity injury is a significant determinant in the patient’s long-term functional recovery after major trauma [69]. In one longitudinal study of patients with severe lower extremity trauma, 50 percent had persistent severe disability over the seven-year study period [70]. Patient characteristics that are associated with poorer outcomes include older age, female gender, nonwhite race, lower education level, living in a poor household, current or previous smoking, and poor health status before the injury [70]. Functional recovery depends greatly upon the social and economic resources available to the patient, which can be more of a factor than the severity of the initial injury [71-73].

Blunt extremity injuries are associated with a higher rate of amputation. In a retrospective review of 62 patients with 93 blunt vascular injuries, the rate of amputation was 18 percent [74]. In contrast, a series of 204 patients, of which 86 percent were penetrating femoral arterial injuries, there were 6 (3 percent) acute amputations and 1 delayed amputation at nine months [75]. In a review of 152 patients who presented with upper or lower extremity injuries requiring a vein interposition graft (91 percent blunt mechanism), secondary amputation during the index hospital stay was greater in the lower extremity than the upper extremity (13.3 versus 2.9 percent), and early graft occlusion was often followed by limb loss, particularly in the lower limb [76]. 

Functional recovery is more likely with an isolated amputation. One review of 395 patients found that 20 percent of patients had multiple amputations, 22 percent had isolated upper extremity amputations, and 59 percent had isolated lower extremity amputations. Following amputation, 17 percent returned to military duty, the majority of whom had a single extremity amputation [77]. 

Comparing outcomes for different levels of lower extremity amputation, a systematic review evaluated 3105 patients and found significantly lower physical component scores for progressively shorter residual limb lengths (below-knee, through-knee, and above-knee amputation) [78]. A significantly greater proportion of patients with a below-knee (72 versus 55 percent) or through-knee amputation (78 versus 55 percent) were able to walk 500 meters compared with an above-knee amputation or bilateral amputations (72 and 78 versus 50 percent, respectively). However, patients with a through-knee amputation wore their prosthesis less, and had significantly more pain (85 versus 58 percent) compared with those with an above-knee amputation.

There is no single risk factor that increases the likelihood of delayed amputation [29], but the combination of complex pain symptoms and neurologic dysfunction appears to increase the risk, particularly if the initial injury was a severe hindfoot injury or distal tibial fracture [79]. In civilian studies, long-term functional outcomes for severe extremity injuries are not significantly different in patients with limb salvage versus amputation, although most patients prefer limb salvage initially.

●A retrospective review of 93 civilian patients with open lower extremity fractures from blunt trauma from 1994 to 2012 included seven patients who underwent primary amputation and four patients who expired within one month of injury [80]. Of the remaining 82 patients, 10 (12 percent) underwent secondary amputation after a median follow-up of 22 months. Factors that were significantly different between the limb salvage group and the secondary amputation group were Gustilo-Anderson fracture grade, high-energy injury mechanism, mangled extremity severity score, AO fracture classification, vascular injury, and fasciotomy.

 

●A retrospective comparison of 850 civilian and 115 military open tibia fractures found a higher overall injury severity and limb injury severity in combat casualties [81]. There were 45 amputations in the civilian group (5.3 percent) and 24 amputations in 21 military patients (18.3 percent). There was no difference in the civilian versus military amputation rate for Gustilo-Anderson grade I through IIIA fractures (1.2 versus 0 percent) or Gustilo-Anderson grade IIIB fractures (6.9 versus 10 percent). However, amputation rates were significantly higher in the military population (28.8 percent versus 69 percent). In both groups, limb ischemia was predictive of failed limb salvage although many patients with ischemia on initial evaluation had successful limb salvage. In this study, follow-up was limited to the index hospital stay for the civilian group and up to 60 days in the military group.

 

●In a detailed review of 104 distal combat-related lower extremity injuries, 20 percent were managed with vascular reconstruction and were compared with 80 percent managed without [31]. The overall amputation rate (primary and secondary) was not different (23 versus 19 percent) between revascularized and nonrevascularized patients. There was a trend toward less chronic pain in the bypass group (10 versus 30 percent). 

 

●An outcomes assessment was performed in 569 patients evaluated after limb salvage (n = 384) or primary/early secondary (within three months) amputation (n = 161) [82]. Limb salvage and amputation had similar degrees of disability. Of 330 limb salvage patients with 24 months of follow-up, 4 percent underwent late secondary amputation (after three months). 

 

Ultimately, limb salvage commits the patient to a prolonged recovery with an increased risk of complications and potentially additional surgery. The patient and their social supports often experience significant stress, which may lead the patient who initially preferred limb salvage to opt for amputation [83].

MORTALITY — In blunt civilian extremity injury, mortality ranges from 5 to 10 percent and is greater with blunt compared with penetrating injuries [74,84]. Mortality is a reflection of the severity of extremity injury, overall injury severity, and the development of complications (eg, venous thromboembolism). Mortality correlates to the volume of blood lost as a result of the extremity injury, which can be significant with junctional vascular injuries [85]. Isolated extremity injuries have lower rates of mortality. 

SUMMARY AND RECOMMENDATIONS

●Trauma to the extremities represents one of the most common injury patterns seen in emergency medical and surgical practice. About 400,000 extremity injuries were reported in 2010 to the National Trauma Databank resulting in an estimated 3700 major civilian amputations annually. (See "Severe extremity injury in the adult patient", section on 'Introduction'.)

 

●A brief extremity examination is performed during the initial trauma assessment but should be repeated in detail once life-threatening injuries have been addressed. Injury to three of the four functional elements (nerves, vessels, bones, soft tissues) constitutes a “mangled extremity” (calculator 1). (See 'Extremity evaluation' above and "Severe extremity injury in the adult patient", section on 'Initial evaluation and management' and "Severe extremity injury in the adult patient", section on 'Extremity evaluation'.)

 

●Damage control techniques are used to manage the extremity injury in patients with concomitant life-threatening torso or head injuries. Damage control torso surgery takes priority over the extremity injury as long as sites of extremity bleeding remain controlled. Fractures are managed with traction, splinting, or external fixation; vascular injuries with shunting of larger injured vessels or ligation of smaller vessels; injured nerves are rapidly identified and tagged if time permits; and soft tissues are irrigated and debrided to remove gross contamination, foreign material, and devitalized soft tissues. (See 'Damage control surgery' above.)

 

●Achieving an optimal outcome in patients with severe extremity injuries requires a multidisciplinary approach with oversight by the general or trauma surgeon and commitment from other specialist surgeons. Definitive treatment includes internal fixation with intramedullary nailing of long bones; arterial and venous reconstruction with autologous vein interposition graft(s); decompression or repair of peripheral nerves; and immediate or interval coverage of soft tissues. (See 'Fracture management' above and 'Revascularization' above and 'Nerve repair' above and 'Soft tissue debridement/coverage' above.)

 

●The postoperative course for patients with lower extremity injury is highly variable depending on the nature and severity of extremity injury, associated injuries, and the patient’s comorbidities. Patients should receive mechanical and pharmacologic prophylaxis for venous thromboembolism as soon as feasible given the high risk for deep venous thrombosis (DVT) and pulmonary embolism (PE) in this population. The risk of thromboembolic complications rises sharply if pharmacologic prophylaxis is delayed beyond three days. (See 'VTE prophylaxis' above and 'Venous thromboembolism' above and "Prevention of venous thromboembolic disease in surgical patients", section on 'High risk general and abdominal-pelvic surgery patients'.)

 

●Complications from severe extremity injury are common and can be life- or limb-threatening, and, thus, early recognition and treatment are important to minimize morbidity and mortality. Complications include wound complications (wound breakdown, infection), venous thromboembolism, rhabdomyolysis and myoglobinuria (crush injury, ischemia-reperfusion, extremity compartment syndrome), and heterotopic ossification. The threshold for performing extremity fasciotomy is low in patients with severe extremity injury. (See 'Complications' above and 'Extremity fasciotomy' above.)

 

●In civilian studies, functional outcomes for severe extremity injuries are not significantly different in patients who have undergone limb salvage compared with amputation, although most patients prefer limb salvage initially. Long-term functionality is more dependent upon patient social factors than upon the severity of the injury. Mortality for civilian extremity injury ranges from 5 to 10 percent. (See 'Amputation and functional outcomes' above and 'Mortality' above.)

 

 

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