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Mangled Extremity Severity Score ( MESS )

INTRODUCTION
Mangled Extremity
Defined as significant injury to three or four major organs or tissues system, namely, soft tissues , bones , nerves, or vessel

Blunt Trauma : Industrial / Motor


Accidents

CLASSIFICATION SYSTEMS
Lange et al (1985) : Absolute
& Relative indications of amputation of open tibial fractures with vascular injury.

Mangled extremity syndrome index (MESI) 1985


Gregory et al : First scoring system for severly injured extremity Drawback : some elements are subjective & score varies from observer to observer

Mangled extremity severity score (MESS) 1990 Limb Salvage Index (1991) Russel et al NISSSA (1994) Mc Namara et al
Modification of MESS

WHAT IS MESS ?
HISTORY
1990 JOHANSEN et al proposed Mangled Extremity scroring system based on 4 clinical criteria : 1) 2) 3) 4) Skeletal & Soft tissue injury Limb Ischemia Shock Age

Numeric grading system to assist

between Limb salvage & amputation

A DECISION- MAKING PROTOCOL Easy To Apply

WHY MESS ?
Help in deciding on limb salvage versus amputation Based on retrospective review of 26 mangled Lower extremities

Validated in prospective trial involving 26

patient treated at separate trauma centers In both trials mess score of <7 predicted Salvage with 100% accuracy

WHEN TO AMPUTE ?
Mc Namara et al Retrospective studies
A MESS SCORE OF 4 IS 100% SENSITIVE A VALUE OF 7 IS 100 % SPECIFIC & A VALUE OF 7 OR MORE IS 100 % PREDICTIVE OF AMPUTATION

SLAUTERBACK et al : UPPER EXTREMITY

Both concluded that MESS is accurate

predictor of amputation of both upper & lower extremity

DRAWBACKS
The differentiation between high

energy & very high energy injuries is based in part on presence of gross contamination which is largely subjective determination There can be interobserver variations

NISSSA SCORING SYSTEM


1994 Mc Namara et al ( Modification of MESS)

Nerve injury Ischemia Soft tissue contamination Shock Age

Skeletal & soft tissue

components are separate & score of nerve injury has been added

More sensetive & specific than


MESS

RECOMMENDATIONS
To obtain & maintain medical records in
the form of Photographs of limb in each stage of treatment protocol If amputation is to be undertaken A written concerning second opinion of qualified orthopedician , general surgeon, or vascular surgeon should be taken. This may save the surgeon from legal involvement in some situations

CONCLUSION
The attitude that amputation of mangled
limb represents theraputic failure can lead to costly , high morbid , demoralising & sometimes lethal attempts at recostruction of functionless extremeties All scoring systems have their own limitations Attempts should be directed at guidelines that will assist in early identification of salvaged limbs with poor functional potential that may be best treated with secondary amputation

Thank you !