[Skip to Content]
Access to paid content on this site is currently suspended due to excessive activity being detected from your IP address Please contact the publisher to request reinstatement.
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
[Skip to Content Landing]
October 1991

The Mangled ExtremityWhen to Amputate?

Author Affiliations

From the Department of Surgery, University of California, Davis, Medical Center, Sacramento.

Arch Surg. 1991;126(10):1243-1249. doi:10.1001/archsurg.1991.01410340085012

• To determine indications for immediate or delayed amputation of the mangled lower extremity, we reviewed the cases of 80 patients. Vascular, neurologic, bone, and soft-tissue status were reviewed, as were postoperative complications, requirements for mechanical ventilation, fluid balance, delayed amputation, and survival. Although neurologic, bone, and soft-tissue status did influence decisions regarding immediate amputation, they had little to do with delayed loss of limb or life. The circulation, as determined by the presence or absence of a palpable or Doppler-detected pulse, however, was critical. Of six patients in whom salvage was attempted and in whom fluid balances of greater than 3 L were detected in the first 24 hours postoperatively, five eventually required amputation. Salvage should usually be attempted if a distal pulse is present. If no distal pulse is present, the decision for immediate amputation should be based on functional prognosis. In cases in which salvage is attempted, amputation should be performed at 24 hours if the patient's condition, including a markedly positive fluid balance, indicates systemic compromise. In the absence of a distal pulse on presentation, the eventual amputation rate is high.

(Arch Surg. 1991;126:1243-1249)

Gregory RT, Gould RJ, Peclet M, et al.  The mangled extremity syndrome (M.E.S.): a severity grading system for multisystem injury of the extremity . J Trauma . 1985;25:1147-1150.Article
Johansen K, Daines M, Howey T, Helfet D, Hansen T.  Objective criteria accurately predict amputation following lower extremity trauma . J Trauma . 1990;30:568-573.Article
Howe HR, Poole GV, Hansen KJ, et al.  Salvage of lower extremities following combined orthopedic and vascular trauma: a predictive salvage index . Am Surg . 1987;53:205-208.
Gustilo RB, Mendoza RM, Williams DN.  Problems in the management of type III (severe) open fractures: a new classification of type III open fractures . J Trauma . 1984;24:742-746.Article
Seiler JG, Richardson JD.  Amputation after extremity injury . Am J Surg . 1986;152:260-264.Article
Drost TF, Rosemurgy AS, Proctor D, Kearney R.  Outcome of treatment of combined orthopedic and arterial trauma to the lower extremity . J Trauma . 1989;29:1331-1334.Article
Lange RH, Johansen K.  Limb reconstruction versus amputation decision making in massive lower extremity trauma . Clin Orthop . 1989;243:92-99.
Lange RH, Bach AW, Hansen ST Jr, et al.  Open tibial fractures with associated vascular injuries: prognosis for limb salvage . J Trauma . 1985;25:203-208.Article
Caudle RJ, Stern PJ.  Severe open fractures of the tibia . J Bone Joint Surg Am . 1987;69:801-807.
Moore TJ, Green SA, Garland DE.  Severe trauma to the lower extremity: long-term sequelae . South Med J . 1989; 82:843-844.Article
Bondurant FJ, Cotler HB, Buckle R, Miller-Crotchett P, Browner B.  The medical and economic impact of severely injured lower extremities . J Trauma . 1988;28:1270-1273.Article
Klausner JM, Paterson IS, Valeri CR, Shepro D, Hechtman H.  Limb ischemia-induced increase in permeability is mediated by leukocytes and leukotrienes . Ann Surg . 1988;208:755-760.Article
Klausner JM, Anner H, Paterson IS, et al.  Lower torso ischemia-induced lung injury is leukocyte dependent . Ann Surg . 1988;208:761-767.Article
Baker SP, O'Neill B, Haddon W, Long W.  The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care . J Trauma . 1974;14:187-196.Article
 Association for the Advancement of Automotive Medicine . The Abbreviated Injury Scale . Des Plaines, Ill: Association for the Advancement of Automotive Medicine; 1990.
Hansen ST Jr.  Overview of the severely traumatized lower limb: reconstruction versus amputation . Clin Orthop . 1989;243:17-19.
Shah PM, Ivatury RR, Babu SC, Nauathambi M, Clauss R, Stahl W.  Is limb loss avoidable in civilian vascular injuries? Am J Surg . 1987;154:202-205.Article
Vassar MJ, Moore J, Perry CA, Spisso J, Holcroft J.  Early fluid requirements in trauma patients: a predictor of pulmonary failure and mortality . Arch Surg . 1988;123:1149-1157.Article