The Mangled Extremity: An Update
- 2 Downloads
Purpose of Review
The purpose of this article is to explore the changes over the last 10 years related to limb salvage for even the most complex cases of limb trauma and describe a thoughtful approach to the mangled extremity.
CT angiography has replaced formal angiography around the country with promising results for evaluating the vascular network of a limb. While concepts in skeletal fixation and vascular reconstruction have remained generally unchanged, advances in nerve grafting and conduit use will guide future directions for limb salvage and improve functional outcomes for patients.
The surgeon should consider the analogies of home building and limb salvage when planning their reconstructive steps: image review as blueprints, debridement as foundation excavation, skeletal fixation as the foundation and framework, plumbing and electric as vessel and nerve repair, and soft tissue coverage as the roof above the reconstruction.
KeywordsMangled extremity Reconstruction Freeflap Trauma
Compliance with Ethical Guidelines
Conflict of interest
Alexander J. Kish and Raymond A. Pensy declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 3.Galanakos SP, Bot AG, Zoubos AB, et al. Psychological and social consequences after reconstruction of upper extremity trauma: methods of detection and management. J Reconstr Microsurg. 2014;30(3):193–206.Google Scholar
- 7.Sasser S, Hunt R, Faul M, Sugerman D, Pearson W, Dulski T, et al. Guidelines for field triage of injured patients: recommendations of the national expert panel on field triage. CDC Morb Mortal Wkl Rep (MMWR). 2011;61:1–20.Google Scholar
- 9.Pensy, RA. The mangled extremity: chapter 1. Springer Publishing. In Press.Google Scholar
- 10.Peng PD, Spain DA, Tataria M, et al. CT angiography effectively evaluates extremity vascular trauma. Am Surg. 2008;74(2):103–7.Google Scholar
- 21.• Nagpal P, Maller V, Garg G, et al., Upper extremity runoff: pearls and pitfalls in computed tomography angiography and magnetic resonance angiography. Curr Probl Diagn Radiol. 2017;46(2):115–129. This reference provides good evidence for the use of CTA in traumatic mangling upper extremity injuries. Google Scholar
- 26.Murovic JA. Upper extremity peripheral nerve injuries: a Louisiana State University Health Sciences Center literature review with comparison of the operative outcomes of 1837 Louisiana State University Health Sciences Center edian, radial, and ulnar nerve lesions. Neurosurgery. 2009;65(4 Suppl):A11–7.CrossRefGoogle Scholar
- 27.Millesi H. Techniques for nerve grafting. Hand Clin. 2000;16(1):73–91.Google Scholar
- 28.•• Boeckstyns ME, Sorensen AI, Vineta JF, et al. Collagen conduit versus microsurgical neurorrhaphy: 2 year follow- up of a prospective, blinded clinical and electrophysilogical multicentered randomized, controlled. Trial. J Hand Surg Am. 2013;38(12):2405–11. This article demonstrates good clinical results of collagen conduits compared to microsurgical neurorrhaphy at 2 year follow up. Google Scholar
- 30.Rasmussen TE, Tai NRM. Rich’s vascular trauma. 3rd ed. New York: Elsevier Health Sciences; 2015. p. 405.Google Scholar
- 31.Badash ID, Burt KA. Outcomes of soft tissue reconstruction for traumatic lower Extremity fractures with compromised vascularity. Am Surg. 2017;83(10):1161–5.Google Scholar