Maxime Coles, MD, FICS, FRCS, FAANOS Orthopedist and Traumatologist, 2011

We did not need a Jan 12, 2010 Earthquake with 222,570 dead, 300,572 injured, and more than one million of homeless in our country to discuss this topic. Thousand were crushed under collapsing ceilings and falling walls but near 4,000 underwent emergency amputation under the form of “Guillotine” for dysvascular and mangled extre- mities (fig.1)

Fig.1: Mangled extremitie under evaluation

Many of us, Surgeons,  were  confronted  in  situa- tions where salvation becomes questionable. It is always unpleasant to perform such operations creating devastating effects on the victim itself. Multiple attempts at saving a highly morbid limb can become costly and as well a menace for the life of the patient. There is always a dilemma: Reconstruct or Amputate.

The evaluation of a Mangled extremity begin on the site of the injury and require consideration to the extend and the severity of the vascular injury, the  bone  and  the  soft  tissues  destruction,  the duration  of  the  limb  ischemia  with  the  present health   status      of       the          victim.           All            taken    in consideration,  the  goal  of  the  treatment  is  to produce a functional and painless residual limb. Many methods have allowed trauma surgeons to evaluate those extremities at risk but two practical guides are presently the most common used: The Mangled   Extremity   Syndrome Index   (MESI)   or (PSI) and  the  Mangled  Extremity  Severity  Score (MESS). The         MESS,       developed        by          Johansen, is more practical and more refined. Those guide are  used  to supplement  the  clinical  judgment  of the surgeon and look at the injury severity (Energy of Transfer), ischemia, Shock and Age. The MESS is highly specific for an extremity that should not undergo amputation. The MESI or the PSI (Predictive  Salvage  Index) developed  by  Howe  in 1987 look mainly at the level of the vascular injury, the degree of osseous and muscular trauma and the  warm  ischemia  time.   Other  scores  like  the Limb Salvage Index (LSI) popularized by Russel in 1991 is similar to the PSI while finally the Hannover Fracture Scale (HFS) considers the viability of the extremity on the degree of the open fracture with vascular injury (Gustillo Type 3C).

More than a year has passed but the journey of many of our disabled compatriots is at a begin- ning. If they are lucky to have a stump at any level of amputation that has healed without infections or revisions, you will realize that that a stump will undergo changes in shape and size demanding constant evaluation and adjustment to assure proper fitting with a prosthetic de vice (fig.2)

Fig. 2:  Arm Stump after amputation

Many  companies are on site around the country like Hanger, Handicap International and many countries have provided help. Many hospitals have initiated set up for fabrication of prosthetics on the spot.  Many  have   claimed   success  stories   and miracle in Haiti allowing some to play football and others to dance professionally. They are certainly rendering life easier for these amputees who can benefit from the care but the rate of stump infection is alarming. We will need more time to appreciate the consequences of so many wounds dehiscence, Osteomylitis, etc… before claiming victory…..

1-,  Management of  Complex Extremity
Trauma East Practice Management Guidelines.
2- M. Jeminez, Assistant Professor Lutherian General Hospital-University of Chicago Medical School, The Mangled Extremity Limb Salvage vs Amputation.
3- Dr. Dirschl and LE Dahners, The Mangled Extremity: When Should it be Amputated Journal Am academy of Orth. Surg.
4- E Book, Amputations in Emergency War Surgery
3rd United States Revision, Chapter 25, 2004
5- Durham RM, Mistry BM, Mazuzki JE et AL, Outcome   and   Utility   in   Scoring   Systems   in   the management of  the  Mangled Extremity, Am.  J.  Surg. 172:569:1996 6- Russell WL, Sailors DM, Whittle TB, Fisher DF Jr, Burns RP. Limb Salvage vs Traumatic Amputation. A Decision based on a seven-part predictive Index Ann Surg. 1991; 213:47 7- Howe HR Jr, Poole GV, Hansen KJ, Clark T et AL, Salvage Extremities following combined orthopedic and vascular Trauma. A predictive salvage  index. AM Surg. 1987; 53:205-8.

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