Limb Salvage after a Traumatic Injury

If a person has sustained an open fracture with a crush injury that is severe enough to prevent healing of the wound, the use of an amputation must be considered.  Traumatic injuries resulting in amputation tend to do better because they happen to young people who have good circulation to the remaining stump.

As time has gone on through the various wars the US and Europe has engaged in in the last few centuries, newer techniques were developed that allowed for microvascular repair to tiny blood vessels and a greater chance for recovery of an injured limb.  Mortality rates following an amputation have gone down considerably as doctors discovered sterile techniques to perform amputation surgeries.

While it may seem like common sense to salvage a limb that has been traumatized, it costs a great deal more time and money than simply amputating the limb.  In at least one research study, patients who had an amputation and prosthesis considered themselves less disabled than those who underwent salvation of the affected limb.  Many surgeons, while taking into the accounts of patients who underwent limb salvage, felt that more people would benefit from amputation than the costly and ineffectual methods of trying to save a mangled limb.  Certain severe crush injuries to the lower extremities alone did not heal well even when the limb was technically saved and most later had an amputation to improve functional capabilities with a prosthetic device.

Doctors have developed simple scoring techniques to decide whether or not to try and save the extremity.  One such tool is called the Mangled Extremity Syndrome Index, which looks at the severity of the damage of the limb, the nerve disruption, the state of the skin on the extremity, the patient age, the state of the bony injury and the lag time from the time of the injury until restoration of the circulation.  Depending on how the person scores on this index, an amputation or salvage is attempted.
 
Managing the Salvaged Limb
 
If the limb is to be salvaged, the person needs a tetanus shot and measures must be taken to keep the mangled area as sterile and clean as possible.  Antibiotics are given to prevent infection every 4-6 hours and the patient must go into surgery for restoration of blood supply to the affected area as soon as possible.
Dead tissue must still be removed while attempting to save the rest of the limb.  This might need to be able to be done in multiple different surgeries as some areas will heal and some will continue to degenerate after the initial surgery.

Sometimes, there can be a situation where the bone has lost its blood supply and must be removed as well.  In such cases, the surgeons use rods and other techniques to connect healthy areas of bone to more distal healthy areas of bone.   Sterile beads of a plastic-like material are introduced into the bony defect left by removing bone.  These sterile beads take the place of bone during the healing process.  Antibiotics are impregnated into the beads to further sterilize the bone and to prepare it for receiving a bone graft at a later date.

Because it may be necessary to go back and debride more tissue every 24-48 hours, the wound may need to be left open until it can be definitively closed at about one week following the injury.  The wound can be closed primarily or treated with a skin graft or flap repair.
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