LIMB SALVAGE

Dr. Rahadyan Magetsari, Sp.OT., Ph.D., FICS

Definition of limb salvage
 Limb : extremity
 Salvage : save/ rescue

 Limb salvage procedure :

Medical procedure taken to preserve the limb
and avoid amputation
ALL can be …. Life threatening
or… LIMB THREATENING
Limb Threatening Conditions
 Traumatic amputation :
 Sharp instrument injury
 Crushed injury

 Compartment syndrome
 Others :
 Tumour

 Infection

 Peripheral vascular disease (DM, Buerger disease, etc)

 What must you
do as an
Emergency (ER) Doctor??
ALL MEDICAL PERSONEL (doctors, nurse, coAss and medical students)
must able to ASSESS and TREAT ABCD
LIMB SALVAGE VS AMPUTATION

Depend’s on

Do FIRST THINGS FIRST  Prioritize

6  After ABCD

 Stabilize the
fracture
 (to elicit PAIN

and FURTHER
SOFT TISSUE
injury

6 HOURS of
(After the trauma)
Warm Ischemia (Anoxic) Time  6 HOURS

 Because irreversible necrotic changes begin

in muscle after 6 hours of ischemia without
cooling (at 20°C to 25°C)

 it is preferable to begin the replantation of parts

amputated proximal to the palm within this time.
 Musculoskeletal Examination
 Assess the neurovascular status
 Look : Redness / Pale
 Feel : Warm / Cold,

Capillary Refill test < 2 seconds

Palpation for PULSE of the DISTAL artery
MOTORIC and SENSORY function of the nerve
distal to the injured side
KNOW your
Management of Amputee
 Need GOOD team of specialist
 Need good and supporting facilities
 Microsurgery
 Need GOOD orthopaedic specialist
 NEED GOOD AMPUTEE Management
(material handling before reaching the hospital)

It is
Management for Amputee
 Major injuries should take precedence
 Life >> Limb
 Patient's condition should be stabilized
 Found the amputee
 Rinsed gently with sterile saline, lactated Ringer, or
other physiological solutions   contamination is
removed
 DO NOT clamp, dissect, ligate, or cannulate vessels
on the amputated part
Management for Amputee
 It may be wrapped with sterile gauze or other clean
material, soaked in sterile lactated Ringer or saline,
and placed in a plastic bag without fluid and then
put in the a cold fluid

 DO NOT use Nonphysiological solutions such as

alcohol and formaldehyde should not be used on the
amputated part.
11/3/2012
 COMPARTMENT SYNDROME

Definition:
An increased pressure within enclosed
osteofascial space
  DECREASE capillary perfusion
below level necessary for tissue
Viability : can lead to AMPUTATION

MAY RESULTED from

Demographics
 Incidence:
 Men7.3/100,000
 Women 0.7/100,000

 69% due to trauma

 36% fx tibia
 9.8% distal radius
 23% soft tissue injury without fx
 10% on anticoagulants
 High energy = low energy incidence
Etiology
 Trauma with
bleeding/swelling
 Bleeding disorders
 Burns
 Tight wraps, tight cast
 Traction
 Surgical positioning
 Pneumatic antishock
garment
 Reprefusion swelling
Diagnosis
 History
 Clinical exam: the 5 Ps
 Measurement of Compartment pressures
 Laboratory tests
 CPK

 Urine myoglobin
Compartment syndrome:
Clincal signs:
5P
- Pain
- Pale
- Pulseless Compartment Syndrome
pada fraktur supracondyler
- Paresthesia If Possible : humerus

- Paralysis Measurement the Compartment

Pressures
Stryker Stic System
 Easy to use
 Can check multiple compartments
 Different areas in one compartment
Treatment
 Lower the involved extremity to level of the heart
 Remove the cast
 Split all dressings down to skin
 Fasciotomy if continued clinical findings and/or
elevated compartment pressure

WHAT YOU
Casting & Wraps
 Casting increases pressure 3-7 times
 Watch out for TIGHT Plaster cast
 Positioning may effect pressure
 Elevation of extremity changes A-V gradient
Fasciotomy
 TRAUMA to the EXTREMITY

LIMB SALVAGE

Compartment syndrome

Depend’s on

Do FIRST THINGS FIRST  Prioritize

Volkmann Ischemic Contracture
 Limb Salvage in Chronic condition
 Peripheral vascular disease (Diabetes, Buergers, etc)
Limb salvage :
1. Treat the primary disease
(e.g : control blood glucose level !!)
2. Protect the foot (e.g : use sandals around the house)
3. Daily inspection of the foot

 Malignancy (bone tumour): Excision, amputation or

Reconstruction with BONE REPLACEMENT or MEGAPROSTHESES
Diabetic Foot
Prevention
Level of resection in musculoskeletal Tumour
Autograft
GCT Distal Tibia
Allograft
Bone scaffold

 To cover large bone defect

 Natural : Bovine hyrdroxyapatite

 Synthetic : Coral, gypsum, calcit (batu
kapur) material
 Bone scaffold
 Recent RESEARCH :
 Mega scaffold + mesenchymal stem cell
 Megaprostheses
in musculoskeletal
Malignancy