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Multidisciplinary Management of Severe Extremity Injuries

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Mitsuru Nemoto

Submitted: December 21st, 2018 Reviewed: February 28th, 2019 Published: April 1st, 2019

DOI: 10.5772/intechopen.85544

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Management of severe extremity injuries begins with controlling bleeding and stabilizing hemodynamics. There is no agreement regarding the selection of amputation or limb salvage for severe extremity injuries. The injury severity scoring system should be carefully and judiciously used. The important factor for the management of open fractures is how early the injured area of soft tissues is covered. Inappropriate management would increase complications and prolong the treatment period. Multidisciplinary management by specialists, in the emergency department, orthopedics, plastic surgery, vascular surgery, and rehabilitation, insisting on employing their own individual abilities as much as possible, would not only help to salvage limbs in severe extremity injuries but also provide highly satisfactory functional and aesthetic outcomes for patients.


  • severe extremity injury
  • management
  • reconstruction
  • salvage
  • amputation

1. Introduction

The goal of treatment for severe extremity injuries is limb salvage; however, complicated life-threatening injuries and mangled extremities may lead to indication of amputation. To achieve an optimal outcome in patients with severe extremity injuries requires multidisciplinary management that begins with resuscitation and evaluation of life-threatening injuries, following initial surgical management, definitive treatment, and postoperative care. Initial surgical management includes control of bleeding sites by vascular ligation and/or shunting, debridement of devitalized soft tissues and foreign materials, and stabilization of the fracture by external fixation. Definitive treatment includes internal fixation of long bones, vessel reconstruction with anastomosis and/or grafts, nerve repair, and soft tissue coverage within the appropriate time frame. This chapter describes the multidisciplinary management of severe extremity injuries based on the morphological and functional characteristics of upper and lower extremities.


2. Initial assessment and management

Initial assessment begins with the primary survey, in which the patients’ life-threatening injuries are evaluated based on the Advanced Trauma Life Support (ATLS) manual [1]. Establishment of an airway to avoid asphyxiation, maintenance and management of breathing, and circulation management by hemostatic procedure, and possibly transfusion, should be performed. Persistent bleeding should be detected early. Elastic or compression bandage or tourniquet is used when the bleeding cannot be stopped directly. Examination for bleeding sites in other regions than the extremities should be made. After the patient has been made hemodynamically stable, the next step is the secondary survey in which injuries are systematically surveyed to determine whether or not they require immediate medical treatment.


3. Extremity evaluation

The most important thing in the initial examination of extremity injuries is to evaluate whether or not the injuries are life-threatening and/or if they could cause dysfunctions. Meanwhile, if there are life-threatening complications, the initial diagnoses of minor injuries such as fractures with slight deformity or dislocation and/or ligament injuries are difficult and often likely to be missed. To preserve function of the extremities, the evaluation should be performed with careful attention to the maintenance of blood flow in the extremities, prevention of infection, proper treatment of surrounding skin and soft tissue injuries, and the prevention of secondary injuries. Tests of sensibility, motor function of and pulse in the bilateral extremities are periodically performed and recorded.

3.1 Peripheral nerve assessment

Systematic neurological assessment is essential. Sites exhibiting paresthesia, their distribution, and the ability of locomotor activity of muscles innervated by the peripheral nervous system should be examined. Muscle strength is evaluated by manual muscle testing. Definitive diagnosis can be made by examining the lesions in the operating room and confirming the presence or absence of any nerve injuries. However, in the case of blunt nerve injuries, often making a diagnosis is not easy, even when the lesion is open. In such cases, electrical nerve stimulation and observation of funiculus with an operating microscope would help in making a diagnosis. Especially in patients with multiple injuries, evaluation of nervous function is often initially difficult. Repetitive reevaluations should be made concurrently with the other surveys after the patient’s condition has been stabilized.

3.2 Vascular assessment

Extremity vascular injuries are classified into two groups depending on the type of causes: penetrating injuries made by knives and such, and blunt injuries due to fractures, dislocations, etc. Delay of diagnosis and treatment for extremity major arterial injuries influences the functional prognosis. Especially, blunt injuries of lower limb arteries often require fasciotomy and/or amputation and are associated with higher mortality [2]. Therefore, to avoid sequelae (e.g., residual disability) associated with extremity arterial injuries, early and accurate diagnosis is indispensable.

When right and left difference in peripheral artery pulsation or skin color, continuous bleeding, and/or the sign of an expanding hematoma are observed after an injury, extremity arterial injury is suspected. However, because there are some cases that in spite of the extremity major artery injury, apparent ischemic signs cannot be initially seen due to the presence of a collateral circulation, extra careful attention is required. For the diagnosis of extremity arterial injuries, examinations by Doppler-derived arterial pressure measurement [3, 4] and helical CT angiography [5, 6] are adopted. Diagnosis of the presence or absence of arterial injuries should not be made easily only by the evaluation of the capillary return sign and/or the Doppler-derived arterial pressure measurement. Suspected patients should undergo early angiography for a definitive diagnosis of the presence or absence of arterial injuries. However, revascularization should not be delayed due to putting a high priority on angiography. If ischemia due to arterial injury is suspected, early revascularization is necessary to save limbs, so it is also necessary to take surgery with information of the minimum contrast CT.

3.3 Soft tissue and bone assessment

When open injuries are found on the skin and soft tissues, diagnosis is easy from local findings. However, closed injuries of the skin and soft tissues are likely to be missed. When pulsation, mobility, dysesthesia, tire mark, and/or cutaneous abrasions are found on the skin, closed injuries are suspected. Open wounds should not be washed out before coming to the hospital or before debridement at the emergency department, because bacterial culture swabs are taken from the open wound. Then antibiotics are rapidly administered by infusion for the prevention of infection and a tetanus inoculation should be given. The administration of antibiotics from the prehospital period might help to lower the risk of infection at the site of a severe open fracture [7]. The confirmation procedure to determine whether or not the open wound, even if small, is in the communicating area of the fracture is performed under proper anesthesia in an operating room.

In the treatment of amputated extremities, tissues are wrapped with saline-soaked gauze, put into a plastic bag, and stored in ice water at 4°C.

3.4 Injury severity score

When we have to decide amputation or limb salvage depending on the degree of injury, the severity of extremity injury is evaluated based on the extremity assessment. Severity evaluation systems are the Gustilo-Anderson classification (Table 1) [8, 9], the Mangled Extremity Syndrome Index [10], the Predictive Salvage Index System [11], the Mangled Extremity Severe Score (MESS) (Table 2) [12], the Limb Salvage Index [13], and NISSSA (Nerve Injury, Ischemia, Soft Tissue Injury, Skeletal Injury, Shock, and Age of the patient) Score [14]. Among them, the Gustilo-Anderson classification and MESS are well-known severity evaluation systems. Although the Gustilo-Anderson classification is essentially designed to apply to intraoperative findings, it is actually often used from the initial evaluation. This classification method provides indices for the infection rate and the bone union period following the treatment of open fractures. MESS is composed of injury mechanism, severity and duration of limb ischemia, severity of shock, and patient’s age. When the score is ≥7, amputation is likely to be selected [15, 16, 17, 18].

Table 1.

Gustilo-Anderson classification.

Table 2.

Mangled Extremity Severity Score (MESS).


4. Surgical management

Surgical management for extremity injuries is performed under the condition of stable hemodynamics with controlled bleeding. The management procedures include damage control surgery, fracture management, revascularization, extremity fasciotomy, nerve repair, and soft tissue debridement and coverage. When the bleeding cannot be controlled in an unrepairable extremity injury, limb amputation is selected.

4.1 Damage control surgery

If bleeding from the extremities continues, it is stopped by compression. If the compression does not work, bleeding is controlled using tourniquet and damaged blood vessels are treated by ligation or vascular repair. Patients should undergo revascularization within 6 hours, and if the ischemic time is prolonged, vascular shunt should be constructed. If the arteries and veins are both damaged, shunting is required for each artery and vein. However, if it is impossible, veins are occluded by ligation.

4.2 Fracture management

When the open fracture of extremities is severe, debridement and skeletal stabilization are performed in the operating room after the evaluation and stabilization of concomitant injuries that could be life-threatening. For the initial skeletal stabilization, external fixation is useful.

4.2.1 Debridement and stabilization

At the initial surgery, thorough debridement of mangled tissues and foreign bodies is performed. Low-pressure irrigation is used for the lavage. A delay in the debridement is likely to lead to high rate of infection and/or amputation [19, 20, 21]. The grade of the Gustilo-Anderson classification is evaluated by the assessment of conditions of conserved soft tissues and fractures. It is difficult to accurately evaluate the grade of the soft tissue injuries and the presence or absence of infection at the initial surgery. In most cases, a second-look and/or third-look debridement is required. External fixation is often selected as the initial skeletal stabilization for severe open fractures. When there are major vessel injuries, prompt skeletal stabilization and revascularization should be required. If it takes a long time for skeletal stabilization, a vascular shunt should be made to shorten the ischemic time. The defect of the surrounding soft tissues is reevaluated within 72 hours in the operating room, and additional debridement or definitive fracture fixation and soft tissue coverage are performed.

4.2.2 Definitive fracture fixation

Definitive fracture fixation is performed when the patient’s condition, even with concomitant injuries, is stable. It is ideal that for the treatment of open fractures, external fixation has been changed to internal fixation, and soft tissue defects are promptly covered. For relatively low-grade open fractures of long bones, fixation with intramedullary nailing is considered preferable. However, because there is little difference in the outcomes between reamed and unreamed medullary nailing for long bone open fractures, the benefit of these procedures remains controversial [22, 23, 24]. External fixation of fractures offers a safe and effective management option for children (Figure 1) [25].

Figure 1.

(a) Open fracture of the left lower extremity was accompanied by a moderate soft tissue defect on the anterior lower extremity. (b) The fasciocutaneous flap was elevated from the lateral side. (c) Moderate soft tissue defect was covered by a fasciocutaneous flap, and skin grafting was applied to the donor site. (d) Intraoperative X-ray. (e) Postoperative view 84 months after surgery. (f) An X-ray of the leg 84 months after surgery, showing good bone union.

4.3 Revascularization

Factors influencing the functional prognosis after the main extremity artery injuries are proper treatment of the fracture and soft tissue injuries, including the nervous system, and the length of ischemic time. Because irreversible degeneration of muscle tissues is caused by ischemia of 6 hours or longer, the period between injury and revascularization should be as short as possible. The revascularization procedure includes vascular repair, vein grafting, inserting bypasses, stents, and/or shunts, which should be performed by surgeons with extensive experience in treating such injuries. When there are multiple levels of vessel injuries, revascularization should be started caudally from the most proximal vessel to the injury. If revascularization is likely to take up to 4 hours or longer, a temporary shunt should be constructed. In severe extremity injuries, revascularization after constructing a temporary shunt will decrease the amputation rates (Figure 2) [26]. When there is a defect of the vessels or the tension in the anastomotic site is strong, revascularization is performed after vein grafting (Figure 3). When there is a problem with venous return due to the injuries, revascularization of veins is performed.

Figure 2.

(a) Crush injury of the left forearm was accompanied by injuries to the radial and ulnar arteries. (b) Temporary vascular shunts (arrowheads) were placed into the radial and ulnar arteries before definitive vascular repair.

Figure 3.

(a) Preoperative X-ray. (b, c) The supracondylar fracture is accompanied by brachial vessel injuries. (d) The saphenous vein was harvested from the right thigh. (e) X-ray findings after Kirchner wire fixation, intraoperatively. (f) The saphenous vein was cut in half, and then the two veins were interposed in way of grafting to repair the defects in the brachial artery and vein.

4.4 Extremity fasciotomy

The fracture and bruising cause the muscles to swell, and the inner pressure of fascial compartments to rise. The compartment syndrome is the state that muscles are swollen further with lowered perfusion pressure, and the nervous system and muscles become ischemic. Diagnosis is determined from the present medical history and findings in physical examinations. Signs and symptoms are swelling in the overall area of the injury site, severe pain that cannot be alleviated by analgesics, increase of pain in the stretch test, and dysesthesia in the compartment region. Even though the compartment syndrome develops, peripheral arterial pulsation is usually palpable. During 48 hours after the injury, clinical signs and symptoms are periodically checked. Because clinical signs and symptoms cannot be checked if the patients have impaired consciousness or are under the effect of sedatives, inner pressure of the compartment is measured if the compartment syndrome is suspected. When the compartment inner pressure is ≥35–40 mmHg, a fasciotomy is performed (Figure 4). The open wound after a fasciotomy is treated by delayed primary closure and/or skin graft.

Figure 4.

(a) The left forearm was wringed by a industrial press machine, and the injury progressed to the compartment syndrome. (b) Fasciotomy was performed to alleviate the compartment pressure.

4.5 Nerve repair

Nerve injury that occurs concomitantly with fractures and/or dislocations is treated by repositioning and simple fixation. It is important that nerve repair is carefully performed using an operating microscope or surgical loupes. Factors other than surgery, such as the patient’s age, nerve injury at higher level, and the degree of injury, influence the recovery of nerve damage. In cases with life-threatening concomitant injuries and/or those with severe extremity injuries, nerve repair can be performed later, within 2 weeks, with good prognoses. If the torn nerve fiber can be identified, marking with a nylon suture at the end of the nerve fiber or fibers is recommended for later surgical repair. To treat a complete tear of nerve fibers, the nerve fibers are sutured together after the cut ends are reinnervated. When there is a high tension at the suture site or suturing is difficult or impossible because of nerve gaps, autologous nerve grafting [27] (Figure 5) or reconstruction with artificial nerve conduit [28] is incorporated into the treatment.

Figure 5.

(a) A penetrating wound was located in the middle of the right thigh. (b) The tibial nerve was ablated and crushed. (c) The sural nerve was divided in thirds and used as a cable graft to repair the severed tibial nerve.

4.6 Soft tissue debridement and definitive coverage

In open fractures, the degree of soft tissue injury is associated with prognosis [29]. Soft tissue wounds in severe extremity injuries have a high risk of infection and treatment should be begun immediately. There have been a few reports on immediate wound closure and primary wound closure [30, 31, 32]. However, because it is difficult to accurately evaluate the degree of soft tissue damage and the presence or absence of infection in severe extremity injuries, the number of cases in which immediate wound closure and primary wound closure are possible is limited. In most cases with severe extremity injuries, second-look and/or third-look debridement are required. Open wounds had been recommended to be treated with moist dressings after debridement. Recently, although NPWT (negative pressure wound therapy) is used for open fracture wounds during the period after the debridement until coverage [33], there has been no evidence that it is more useful than conventional moist dressing [34, 35].

Because the infection rate becomes higher with the passage of days after the injury of an open fracture, the open wound should be closed early if the patient’s general condition is stable and there is no local infection [36, 37]. For the coverage of the defect of soft tissues after the bone fixation, a flap is recommended [36, 37, 38, 39, 40, 41]. Even if wound coverage cannot be performed at the initial debridement, good functional prognosis can be expected when soft tissue coverage is performed within 72 hours after an injury [36, 38, 40]. For an extensive soft tissue defect, a free flap transfer is useful (Figure 6). A free flap transfer enables reconstruction of a soft tissue defect by an end to side or a flow-through type vascular anastomosis without sacrificing major vessels, even if the recipient vessels that can be anastomosed are limited [42].

Figure 6.

(a) An open fracture located in the distal third of the left lower extremity, accompanied by massive soft tissue defect. (b) Intraoperative X-ray after intramedullary nailing fixation. (c) The anterolateral thigh fasciocutaneous flap was harvested from the right thigh. (d) The anterolateral thigh fasciocutaneous flap was applied to the soft tissue defect. Six months after internal fixation, autogenous bone grafting and transposition of the fasciocutaneous flap was performed on the tibia defect. (e) Postoperative view 12 months after bone grafting. (f) X-ray at 12-month follow-up showing adequate bone union.


5. Complications

Complications associated with severe extremity injuries include infection and/or necrosis, pseudoarthrosis, osteomyelitis, venous thromboembolism, and rhabdomyolysis. If these complications occur, additional treatment is required and the treatment period would be prolonged.

5.1 Wound complications

Wound complications are caused by insufficient debridement and/or infection. The infection rate becomes higher with a higher grade of the Gustilo-Anderson classification. To prevent infection in severe extremity injuries, it is important to perform early and thorough debridement of necrotic tissues and construct coverage with tissues that have abundant blood flow.

5.2 Venous thromboembolism

Deep vein thrombosis (DVT) and pulmonary embolism (PE) occur in 2–58% of trauma patients [43, 44, 45]. Because severe extremity injuries have a high risk of DVT and PE, mechanical and pharmacologic prophylaxes are necessary [46].

5.3 Rhabdomyolysis and myoglobinuria

Rhabdomyolysis and myoglobinuria are observed in the crush syndrome, compartment syndrome, and reperfusion syndrome. Various substances released from necrotic striated muscle cells circulate throughout the body, causing hyperkalemia, metabolic acidosis, hypermyoglobinemia, and acute renal failure. Transfusion and correction of electrolytes are fundamental to preventing acute renal failure.


6. Amputation versus limb salvage

There is, as yet, no agreement on the selection criteria for amputation or limb salvage [47, 48, 49]. The injury severity scoring system is reported to be a good indictor in a few reports [50, 51, 52, 53] but considered negatively in others [54, 55, 56]. Because the indications for amputation differ depending on the patient’s age (whether an adult or a child), and occupation, the injury severity scoring system should be used carefully and judiciously [57, 58, 59, 60]. Indications for amputation are as follows: (1) life-threatening bleeding cannot be controlled, (2) preserving open injuries to the extremity is likely to cause the patients’ mortality, and (3) the injuries are so severe that a specialist judges the salvage of the extremity to be impossible (Figure 7). Ultimately, the decision regarding choosing limb salvage or amputation should be made in discussion with the patients themselves and their family members (Figure 8). Primary delayed amputation, if deemed necessary, should be performed within 72 hours after the injury.

Figure 7.

(a and b) The left upper extremity was avulsed by an industrial machine. This mangled limb was not salvageable.

Figure 8.

(a) The left upper extremity was ablated at the elbow, the median and ulnar nerves were preserved; however, the radial nerve was avulsed in the middle third of the upper arm. (b) Immediate revascularization to the brachial vessels was performed followed by external fixation. (c and d) Postoperative view 12 months after reconstruction and a modified Riordan operation was performed on the radial nerve to cure the palsy.


7. Conclusions

For the treatment of severe extremity injuries, multidisciplinary management is required from the primary survey through rehabilitation. Unless severe extremity injuries are treated properly within the proper time frames, complications may occur, resulting in severe sequelae. Multidisciplinary management by specialists, in the emergency department, orthopedics, plastic surgery, vascular surgery, and rehabilitation, insisting on employing their own individual abilities as much as possible, would not only help to salvage limbs in severe extremity injuries but also provide highly satisfactory functional and aesthetic outcomes for patients.


Conflict of interest

The author declares that there is no conflict of interest regarding the publication of this chapter.


  1. 1. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 9th ed. Chicago: American College of Surgeons; 2012
  2. 2. Tan TW, Joglar FL, Hamburg NM, et al. Limb outcome and mortality in lower and upper extremity arterial injury: A comparison using the National Trauma Data Bank. Vascular and Endovascular Surgery. 2011;45:592-597. DOI: 10.1177/1538574411415125
  3. 3. Lynch K, Johansen K. Can Doppler pressure measurement replace “exclusion” arteriography in the diagnosis of occult extremity arterial trauma? Annals of Surgery. 1991;214:737-741
  4. 4. Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: A prospective study. The Journal of Trauma. 2004;56:1261-1265
  5. 5. Soto JA, Munera F, Cardoso N, et al. Diagnostic performance of helical CT angiography in trauma to large arteries of the extremities. Journal of Computer Assisted Tomography. 1999;23:188-196
  6. 6. Busquets AR, Acosta JA, Colon E, et al. Helical computed tomographic angiography for the diagnosis of traumatic arterial injuries of the extremities. The Journal of Trauma. 2004;56:625-628
  7. 7. Lack WD, Karunakar MA, Angerame MR, et al. Type III open tibia fractures: Immediate antibiotic prophylaxis minimizes infection. Journal of Orthopaedic Trauma. 2015;29:1-6. DOI: 10.1097/BOT.0000000000000262
  8. 8. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. The Journal of Bone and Joint Surgery. 1976;58:453-458
  9. 9. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. The Journal of Trauma. 1984;24:742-746
  10. 10. Gregory RT, Gould RJ, Peclet M, et al. The mangled extremity syndrome (M.E.S.): A severity grading system for multisystem injury of the extremity. The Journal of Trauma. 1985;25:1147-1150
  11. 11. Howe HR Jr, Poole GV Jr, Hansen KJ, et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. The American Surgeon. 1987;53:205-208
  12. 12. Johansen K, Daines M, Howey T, et al. Objective criteria accurately predict amputation following lower extremity trauma. The Journal of Trauma. 1990;30:568-573
  13. 13. Russell WL, Sailors DM, Whittle TB, et al. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Annals of Surgery. 1991;213:473-480
  14. 14. McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective evaluation of the mangled extremity severity score (MESS). Journal of Orthopaedic Trauma. 1994;8:81-87
  15. 15. Behdad S, Rafiei MH, Taheri H, et al. Evaluation of mangled extremity severity score (MESS) as a predictor of lower limb amputation in children with trauma. European Journal of Pediatric Surgery. 2012;22:465-469. DOI: 10.1055/s-0032-1322541
  16. 16. Kumar MK, Badole C, Patond K. Salvage versus amputation: Utility of mangled extremity severity score in severely injured lower limbs. Indian Journal of Orthopaedics. 2007;41:183-187. DOI: 10.4103/0019-5413.33679
  17. 17. Rush RM Jr, Kjorstad R, Starnes BW, et al. Application of the mangled extremity severity score in a combat setting. Military Medicine. 2007;172:777-781
  18. 18. Robertson PA. Prediction of amputation after severe lower limb trauma. Journal of Bone and Joint Surgery. 1991;73:816-818
  19. 19. Sears ED, Davis MM, Chung KC. Relationship between timing of emergency procedures and limb amputation in patients with open tibia fracture in the United States, 2003 to 2009. Plastic and Reconstructive Surgery. 2012;130:369-378. DOI: 10.1097/PRS.0b013e3182589e2d
  20. 20. Hull PD, Johnson SC, Stephen DJ, et al. Delayed debridement of severe open fractures is associated with a higher rate of deep infection. The Bone & Joint Journal. 2014;96:379-384. DOI: 10.1302/0301-620x.96B3.32380
  21. 21. Malhotra AK, Goldberg S, Graham J, et al. Open extremity fractures: Impact of delay in operative debridement and irrigation. Journal of Trauma and Acute Care Surgery. 2014;76:1201-1207. DOI: 10.1097/TA.0000000000000205
  22. 22. Keating JF, O’Brien PJ, Blachut PA, et al. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. The Journal of Bone and Joint Surgery. 1997;79:334-341
  23. 23. Forster MC, Bruce AS, Aster AS. Should the tibia be reamed when nailing? Injury. 2005;36:439-444
  24. 24. Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures Investigators, Bhandari M, Guyatt G, Tornetta P 3rd, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. The Journal of Bone and Joint Surgery. 2008;90:2567-2578. DOI: 10.2106/JBJS.G.01694
  25. 25. Hull JB, Bell MJ. Modern trends for external fixation of fractures in children: A critical review. Journal of Pediatric Orthopaedics Part B. 1997;6:103-109
  26. 26. Desai P, Audige L, Suk M. Combined orthopedic and vascular lower extremity injuries: Sequence of care and outcomes. American Journal of Orthopedics. 2012;41:182-186
  27. 27. Stancic MF, Eskinja N, Bellinzona M, et al. The role of interfascular nerve grafting after gunshot wounds. A report of 44 cases. International Orthopaedics. 1996;20:87-91
  28. 28. Mackinnon SE, Dellon AL. Clinical nerve reconstruction with a bioabsorbable polyglycolic acid tube. Plastic and Reconstructive Surgery. 1990;85:419-424
  29. 29. MacKenzie EJ, Bosse MJ, Kellam JF, et al. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. The Journal of Trauma. 2002;52:641-649
  30. 30. Hertel R, Lambert SM, Muller S, et al. On the timing of soft-tissue reconstruction for open fractures of the lower leg. Archives of Orthopaedic and Trauma Surgery. 1999;119:7-12
  31. 31. Hohmann E, Tetsworth K, Radziejowski MJ, Wiesniewski TF. Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Archives of Orthopaedic and Trauma Surgery. 2007;127:131-136
  32. 32. Jenkinson RJ, Kiss A, Johnson S, et al. Delayed wound closure increases deep-infection rate associated with lower-grade open fractures: A propensity-matched cohort study. The Journal of Bone and Joint Surgery. 2014;96:380-386. DOI: 10.2106/JBJS.L.00545
  33. 33. Stannard JP, Volgas DA, Stewart R, et al. Negative pressure wound therapy after severe open fractures: A prospective randomized study. Journal of Orthopaedic Trauma. 2009;23:552-557. DOI: 10.1097/BOT.0b013e3181a2e2b6
  34. 34. Krug E, Berg L, Lee C, et al. Evidence-based recommendations for the use of negative pressure wound therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus. Injury. 2011;42(Suppl 1):S1-S12. DOI: 10.1016/S0020-1383(11)00041-6
  35. 35. Iheozor-Ejiofor Z, Newton K, Dumville JC, et al. Negative pressure wound therapy for open traumatic wounds. Cochrane Database of Systematic Reviews. 3 Jul 2018;7:CD012522. DOI: 10.1002/14651858.CD012522.pub2
  36. 36. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plastic and Reconstructive Surgery. 1986;78:285-292
  37. 37. D’Alleyrand JC, Manson TT, Dancy L, et al. Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications? Journal of Orthopaedic Trauma. 2014;28:288-293. DOI: 10.1097/BOT.0000000000000001
  38. 38. Gopal S, Majumder S, Batchelor AG, et al. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. Journal of Bone and Joint Surgery. 2000;82:959-966
  39. 39. Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. Journal of Bone and Joint Surgery. 2000;82:1681-1691
  40. 40. Gopal S, Giannoudis PV, Murray A, et al. The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage. Journal of Bone and Joint Surgery. 2004;86:861-867
  41. 41. Webb LX, Bosse MJ, Castillo RC, MacKenzie EJ, LEAP Study Group. Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. The Journal of Bone and Joint Surgery. 2007;89:923-928
  42. 42. Nemoto M, Ishikawa S, Kounoike N, et al. Free flap transfer to preserve main arterial flow in early reconstruction of open fracture in the lower extremity. Plastic Surgery International. 2015;2015:213892. DOI: 10.1155/2015/213892
  43. 43. Shackford SR, Davis JW, Hollingsworth-Fridlund P, et al. Venous thromboembolism in patients with major trauma. American Journal of Surgery. 1990;159:365-369
  44. 44. Geerts WH, Code KI, Jay RM, et al. A prospective study of venous thromboembolism after major trauma. The New England Journal of Medicine. 1994;331:1601-1606
  45. 45. Schultz DJ, Brasel KJ, Washington L, et al. Incidence of asymptomatic pulmonary embolism in moderately to severely injured trauma patients. The Journal of Trauma. 2004;56:727-731
  46. 46. Rogers FB, Cipolle MD, Velmahos G, et al. Practice management guidelines for the prevention of venous thromboembolism in trauma patients: The EAST practice management guidelines work group. The Journal of Trauma. 2002;53:142-164
  47. 47. Francel TJ, Vander Kolk CA, Hoopes JE, et al. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: Timing of coverage and long-term functional results. Plastic and Reconstructive Surgery. 1992;89:478-489
  48. 48. Hertel R, Strebel N, Ganz R. Amputation versus reconstruction in traumatic defects of the leg: Outcome and costs. Journal of Orthopaedic Trauma. 1996;10:223-229
  49. 49. Chung KC, Saddawi-Konefka D, Haase SC, Kaul G. A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plastic and Reconstructive Surgery. 2009;124:1965-1973. DOI: 10.1097/PRS.0b013e3181bcf156
  50. 50. Fagelman MF, Epps HR, Rang M. Mangled extremity severity score in children. Journal of Pediatric Orthopedics. 2002;22:182-184
  51. 51. Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation. Preliminary results of the Mangled Extremity Severity Score. Clinical Orthopaedics and Related Research. 1990;256:80-86
  52. 52. Mommsen P, Zeckey C, Hildebrand F, et al. Traumatic extremity arterial injury in children: Epidemiology, diagnostics, treatment and prognostic value of mangled extremity severity score. Journal of Orthopaedic Surgery and Research. 2010;5:25. DOI: 10.1186/1749-799X-5-25
  53. 53. Slauterbeck JR, Britton C, Moneim MS, Clevenger FW. Mangled extremity severity score: An accurate guide to treatment of the severely injured upper extremity. Journal of Orthopaedic Trauma. 1994;8:282-285
  54. 54. Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. The Journal of Trauma. 1993;34:99-104
  55. 55. Durham RM, Mistry BM, Mazuski JE, et al. Outcome and utility of scoring systems in the management of the mangled extremity. American Journal of Surgery. 1996;172:569-574
  56. 56. Sheean AJ, Krueger CA, Napierala MA Skeletal Trauma and Research Consortium (STReC), et al.. Evaluation of the mangled extremity severity score in combat-related type III open tibia fracture. Journal of Orthopaedic Trauma 2014;28:523-526. DOI: 10.1097/BOT.0000000000000054
  57. 57. Stewart DA, Coombs CJ, Graham HK. Application of lower extremity injury severity scores in children. Journal of Children’s Orthopaedics. 2012;6:427-431. DOI: 10.1007/s11832-012-0439-6
  58. 58. Brown KV, Ramasamy A, McLeod J, et al. Predicting the need for early amputation in ballistic mangled extremity injuries. The Journal of Trauma. 2009;66(4 Suppl):S93-S97. DOI: 10.1097/TA.0b013e31819cdcb0
  59. 59. Doucet JJ, Galarneau MR, Potenza BM, et al. Combat versus civilian open tibia fractures: The effect of blast mechanism on limb salvage. The Journal of Trauma. 2011;70:1241-1247. DOI: 10.1097/TA.0b013e3182095b52
  60. 60. Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. The Journal of Bone and Joint Surgery. 2001;83:3-14

Written By

Mitsuru Nemoto

Submitted: December 21st, 2018 Reviewed: February 28th, 2019 Published: April 1st, 2019