Mangled Extremity Guidelines (Peds and Adults)

 Mangled Extremity 

 

Mangled Extremity Definition:  

      any major injury to the extremity from the shoulder to fingertips or hip to toes and 

      3 of the following 4 components:  

      

    Anatomic Structures            Service specific expertise overlap: 

  

1. Skin & Soft Tissue (Plastics, Hand) 

2. Skeletal (Ortho, Plastics, Hand) 

3. Neurologic Injury (Hand, Plastics, Neurosurgery) 

4. Vascular injury (Vascular, Hand, Plastics) 

  

  

      Requires a multidisciplinary approach  

      Attending to Attending communication optimal plus teamwork among services 

      Often Hand Surgery, Orthopedics, Plastics, Vascular, Neurosurgery, and General Surgery will be involved.  

      Areas of expertise may overlap and all services must coordinate care and work in a professional manner.   

      It is preferred that the first call for evaluation would be Trauma Surgery.  

      The Trauma Surgery Chief will then consult the Chief or Attending of the appropriate service(s) based on the level and type of injury.  

      In the event that another service is involved first, it is their duty to manage the patient appropriately and communicate with the other services for discussion as to whom needs to be appropriately involved.  

      A plan of management will be made among the Chiefs and Attending’s involved and the order and sequence of operative repair agreed upon. 

      Once a specific service has completed their acute management, the patient should be considered appropriate for transfer to whichever service still requires ongoing or further management of the patient’s injury 

  

PRINCIPLE RESPONSIBILITY: 

Upper Extremity 

1.     Trauma surgery is to be contacted first 

2.     Subsequently for injuries above or at the elbow, orthopaedic surgery should be the primary consult and team primarily responsible for coordinating care.   

3.     For mangled extremity injuries below the elbow, the hand team should be the primary consult and team primarily responsible for coordinating further care. 

  

Lower Extremity 

      Trauma Surgery is to be contacted as first consult.  

      Depending on the nature of the injury, Ortho, Plastics, Vascular may be the primary contact however for most lower extremity injuries, orthopaedic surgery should be the primary consult and team primarily responsible for coordinating further care. 

 ¹ Hard signs of vascular injury: A. Bruit/Thrill B. Active/Pulsatile hemorrhage C. Pulsatile/Expanding hematoma D. Signs of limb ischemia and or compartment syndrome including the 5 "P's" - pallor, paresthesias, pulse deficit, paralysis, and pain on passive extension of the compartment (pain on passive extension is the earliest and most sensitive physical finding) E. Diminished or absent pulses with + Doppler signals (this is not a sensitive prognostic finding, as up to 30% of patients with major vascular injuries requiring repair have normal pulses or Doppler signals distal to the injury due to collateral flow).  

² The Arterial Perfusion Index, API, is a validated tool for screening for peripheral vascular injury. This is performed by placing a blood pressure cuff above the ankle or on the bicep of the limb of concern. The systolic pressure is determined with a Doppler probe at the dorsalis pedis or brachial artery. Repeat this procedure on the ipsilateral uninjured limb. The API is calculated by dividing the systolic pressure in the injured limb by the systolic pressure in the uninjured limb. An API < 0.9 has a sensitivity of 95% and specificity of 97% for a major arterial extremity injury. In a study on blunt orthopedic extremity injuries the negative predictive value is 100% for an API > 0.9 to exclude an arterial injury.  

  

3 Fasciotomy: Consider fasciotomy if ischemia > 4hrs. Fasciotomy by operating revascularization service. Hand will provide for hand fasciotomies if requested. 

  

Disclaimer

These guidelines are not intended as a directive or to present a definitive statement of the applicable standard of patient care.  They are offered as an approach for quality assurance and risk management and are subject to (1) revision as warranted by the continuing evaluation of technology and practice; (2) the overall individual professional discretion and judgment of the treating provider in a given patient circumstance; and (3) the patient’s willingness to follow the recommended treatment. 

Draft 6/8/17—Talley/Xenos/Moghadamian  

Revised 11/7/17—Talley/Williams  

Revised 11/10/17—Talley/Bernard  

Revised 10/08/2020 Drake/Xenos/Bernard/Moghadamian 

Reviewed Feb 2024