ora Management of the Mangled Upper Extremity Charalampos Zalavras, Lane Shepherd, Frances Sharpe, Milan Stevanovic Introduction ‘The human hand is characterized by its unique capabilities of detailed sensation and movement. The forearm and brachium facilitate these vital functions by stabi- lizing and positioning the hand in space. Major trauma to the hand and forearm involves a variety of structures and disrupts their integrity and interactions. The viability of distally intact structures may be compromised by mangling injuries to the arm, forearm, and hand. Although the evolution of repair and reconstruction techniques for each of the injured structures has helped to improve prognosis, the mangled upper extremity continues to challenge the treating surgeon and to have a severe impact upon the patient. Proper management is of utmost importance to reduce the disability result: ing from these injuries ‘The term “mangled” is commonly used to describe the hand and upper extrem- ity after major trauma. Gregory et al used the term “mangled” to describe a severe injury to at least three of the four organ/tissue systems of skin, bone, vessel and nerve. According to the Oxford English Dictionary to mangle is “to reduce by cut- ting, tearing or crushing to a mote or less unrecognizable condition” Each of these definitions imply a severe, high-energy injury, which involves multiple anatomical structures, usually over an extended topography. Mangling injuries are produced by high-energy forces. High-power equipment, either agricultural (corn picker, grain auger), industrial (punch press, power saw) or household (lawn mower, snow blower) may cause such an injury. In addition, gun shot wounds, explosives and motor vehicle accidents (especially with the arm of the patient being outside of the car window) account for many cases. The injury may have a combination of sharp, crushing, avulsive, and thermal components. The wound may be severely contaminated, depending on the location and mechanism of injury. Careful evaluation of both the patient and the injury, formulation of a treatment plan, meticulous operative treatment by an experienced team, and early, motivated rehabilitation reduce the morbidity associated with these injuries. Patient Evaluation Evaluation of the patient with a high-energy injury should include a thorough trauma evaluation, beginning with the basics of airway, breathing, and circulation Reconstructive Microsurgery, edited by Konstantinos N. Malizos. ©2003 Landes Bioscience.58 Reconstructive Microsurgery (ABC's). While the mangled extremity is often the most apparent injury, careful evaluation of the entire patient for potential life threatening or other associated injuries is critical to formulating a treatment plan. The patient history should focus on the time and mechanism of injury, and any associated chemical, electrical, or chermal components of the injury. The mecha- nism and the time from injury, when ischemia is present, are the most important factors in determining the zone of injury and predicting the ability to slvage the extremity. A medical history is taken to determine the patient's ability to tolerate a prolonged anesthesia with potential for significant blood loss, fluid shifts, and over- load of metabolic by-products. Medical conditions such as diabetes, hypertension, vasculitis or other inflammatory diseases, and smoking history can adversely affect outcome and should be considered in developing a treatment plan. Similarly, the occupational and social history are important in determining postoperative compli- ance and in addressing the reconstructive goals. The presence of one o several ad- verse factors is not an absolute contraindication to salvage of an extremity or to microvascular repair. However, these factors should be considered in selecting the type of reconstruction to be used and in berter predicting outcome Examination of the mangled extremity should be systematic and address the following: vascular status; skeletal stability; motor and sensory function; and soft- tissue loss. The vascular status is evaluated by assessment of peripheral pulses, color, temperature, and capillary refill time. Pulse oximetry is generally readily available in the emergency room and is very helpful in assessing ischemia. Doppler examination and angiography can also be used. Skeletal injury is assessed clinically by the pres- ence of deformity, crepitance or bone tenderness. Tangential radiographs should be taken of the entire extremity. A motor and sensory examination should be docu- mented. Motor and /or sensory loss can result from muscle, tendon, of nerve injury, as well as from ischemia. The ultimate assessment of the mangled extremity occurs in the operating room, after the debridement of nonviable tissue. Adjuvant studies of the extremity include detailed radiographs and angiography. In the case of limb threatening ischemia, some studies may best be obtained in the operating room. An intraoperative angiogram may aid in determining the level and extent of arterial injuries. Color Doppler may be alternatively used. Ic is accurate, less invasive, and may also be used intra-operatively. Radiographs taken in the oper- ating room are usually better quality than those taken in the emergency room, as the extremity can be positioned without causing the patient discomfort. ‘Iraction radio- graphs allow bercer delineation of the fracture pattern and number of fragments, especially in evaluating intra-articular fractures about the elbow. Photographic docu- mentation of the injury should be done in the operating room. Decision-Making and Planning Salvage vs. Amputation The surgeon may be confronted with the decision to attempt salvage or ampu- tate a mangled, nonviable extremity. The appropriate decision is difficult, since recovery of function in a salvaged extremity may be limited or absent. Thus, mul- tiple reconstructive procedures with associated morbidity, prolonged hospitalization, disability time, psychological distress and financial demands may be too expensive aManagement of the Mangled Upper Extremity 59 price to pay for the end result of a useless and painful limb. In contrast to prostheses for the leg, prostheses for the hand and forearm offer very limited restoration of function. Thus, most mangled upper extremities should be considered for salvage. Nevertheless, serious associated injuries or diseases, ischemia time greater than 6 hours and parts that are severely crushed, avulsed, contaminated or injured at mul- tiple levels, constitute unfavorable conditions for a replantation or revascularization attempt. In this setting, amputation is not a failure but rather a step towards stabili- zation of the patient and rehabilitation of the extremity. In deciding how to best treat the mangled extremity, a variety of factors should be considered. They can be broadly classified as patient and extremity factors. Perti- nent patient factors include the general condition, age, handedness, occupation, functional requirements and socio-economic background of the patient. Associated injuries resulting in cardiopulmonary or hemodynamic compromise, as well as pre- existing medical problems will be against a lengthy salvage procedure, especially in a patient of advanced age. Conditions adversely affecting the blood vessels, such as diabetes mellitus, vasculitis and smoking will increase the risk of anastomosis failure and should be taken into consideration. Psychiatric disorders may be a contraindi- cation to reconstruction, due to possible repeat suicide attempts or anticipated noncompliance with the rehabilitation program. A morose patient may be temporarily incompetent to participate in determining treatment. Since time is a critical factor in teeatment, it may be better to err in attempting to salvage an extremity than to perform a primary amputation. Important extremity factors comprise the time since the injury, the severity of the injury and the previous functional status of the extremity. Warm ischemia time greater than 6 hours results to irreversible changes in cellular structure of muscle. Even if vascularicy is reestablished, tissue necrosis will not be avoided. Systemic risks of revascularizing a limb with prolonged ischemia must also be considered and addressed. These include acidosis, hyperkalemia, and rhabdomyolysis. In amputa- tions of digits the delay until reperfusion may be extended to 20 hours. Finally, the previous condition of the extremity should be considered. A history of major trauma, neurological disease or congenital deformity resulting in impaired function may not justify a salvage attempt. “The multitude of factors and the complex interrelations among them make reach- ing a decision a difficult task, even for experienced surgeons. Specialized scoring systems have been developed based on lower extremity injuries. These may offer valuable guidelines for evaluating the lower extremity, but cannot be applied well to the upper extremity. Each case is unique. The final decision should be an individu- alized one, based on assessment of the patient and extremity parameters, as well as sound judgment. The patient's knowledge of the potential risks and benefits of sur- gery and the possibility of early or later amputation is important. Timing of Reconstruction Reconstruction of the mangled extremity may be undertaken either early or late. In both reconstructive plans, the initial treatment includes aggressive debridement, skeletal stabilization, revasculatization, and soft tissue coverage. Early soft tissue cov- erage is of paramount importance to limb salvage. This improves the vascularity to the traumatized area, limits exposure to hospital pathogens and reduces the risk of