A truly Collaborative Approach to Care

Ginger Mars CCRN, MSN, NP-CNurse Practitioner Department of Reconstructive Plastic SurgeryNYU Langone Medical CenterNew York

Trauma

1. A serious injury or shock to the body, as from violence or an accident.2. An emotional wound or shock that creates substantial, lasting damage to the psychological development of a person, often leading to neurosis.3. An event or situation that causes great distress and disruption.

Management of Mangled Extremity

Combined expertise of:Trauma SurgeonVascular SurgeonOrthopedic SurgeonPlastic/Reconstructive SurgeonNursing staff

Priorities

Priority of multi‐system injury:                      “Life over limb”.

ATLS guidelinesABC’s

If other life‐threatening injuries treatment of extremity limited toStabilization of injured extremityControl of bleeding

Is the limb salvageable?

Visual & Manual ExaminationExamination of wound:Vascular

Pulses, color, temperature, turgorAngiography

BoneInspection, xrays, CT scans

Soft‐tissueSkin, subcutaneous tissue, muscle and periosteum

Nerve Motor & Sensory 

Questions the Surgeon Asks

Does the extremity require revascularization?Is it technically possible?

Is the soft tissue defect treatable with local or free tissue transfer?Is there bone loss? 

Is bone loss reconstructible?

Is there nerve injury? Is it reparable?

Decisions

Gustilo Fracture ScorePredictive Salvage Index (PSI)Mangled extremity severity score (MESS)Nerve Injury,Ischemia, soft‐tissue injury, skeletal injury, shock & age of patient score (NISSSA)Limb Salvage Index (LSI)Hemodynamic instability

Gustilo Fracture Score

Developed 1976Grades open fractures based on degree of soft tissue injury.Gustilo found that infection rates increased as amount of soft tissue coverage decreased.Amputation  rates were highest for type IIIC injuries.  

Gustilo Fracture Score

i – open fx w wound <1cmii – open fx w wound >1cm/no soft tissue damageiii – open fx w extensive soft tissue damageiiiA – iii w adequate soft tissue coverageiiiB – iii w soft tissue loss/periosteal stripping/bone exposureiiiC – iii w arterial injury requiring repair

Mangled Extremity Severity Score

Developed in 1990Provides objective criteria for choosing limb salvage or amputationValidated by multiple studiesScore of 7 or > was 100% predictive of eventual amputation.

MESS Skeletal soft tissue injury

Low 1Medium 2High 3V. High energy 4

Limb ischemia Near normal 1No pulse/dec cap refill   2Cool, insensate, paralyzed                         3

Double if >6 hours

ShockSBP always >90            0Transient hypoT            1Persistent HypoT          2

Age (year)<30                                      030‐50 1>50                                       2

Primary Operative Exploration

Fracture fixation

Repair vesselsTendons, nerves

DebridementWound assessment

Definitive wound closureNon-definitive wound closureTemporary closure

Second Look

Soft tissue reconstruction within48-72 hours

Serial debridements

Wound closure

Major issues with LE reconstruction

Full force of body weight is transposed thru the legs

Tibia provides 85% of WB of LE

Hydrostatic pressure on legs increases incidence of edema, deep vein thrombosis and venous stasis problems.  LE much more prone to atherosclerosis than upper extremity.  

Principles of Lower Extremity  Reconstruction

Mechanism of Injury

Tissue damage is proportional to the energy transferred

MVATransfers 50x the energy of bullet

GSWTransfers 20x the energy of a fall

FallsProportional to height of fall & body weight

Wounds appearing similar on presentation progress differently depending on mechanism of injury.Areas of soft tissue injury may initially appear viable

Wounds appearing similar on presentation progress differently depending on mechanism of injury.Areas of soft tissue injury may initially appear viable

Fracture Management

Stable framework must be constructed prior to soft tissue repairFracture fixation comes first

TractionCasting/splintingIntramedullary pinning/nailingInternal or EXTERNAL FIXATION

Internal Fixator

External Fixator

External Fixator with frame

Lower Extremity Reconstruction

Goal:

To salvage the threatened limb which will be more favorable/functional than a prosthesis

If extremity cannot be salvaged, goal is to maintain maximum functional length of stump.

Lower Extremity Salvage

Long, complicated processPts must be aware of expected course, anticipated functional outcomePsychosocial factors must be addressed prior to attempted limb salvage

Although normal function rarely achieved, most patients are grateful for salvaged limb.

No long‐term study comparing

Why are distal leg wounds problematic?

Poor skin elasticityFrequent severe edemaVenous congestionHigh rate of osteomyelitisFoot/ankle requires good flap durability due to friction/shear by walking and footwear.

Challenges of LE Reconstruction

Lengthy recoveryCost $$$$$Abnormal ambulationPatient/Family ExpectationChronic Pain

Ideal Outcome of extremity salvage is full return to functioning society.Path to full recovery is slow and may result in delayed amputation.LEAP (Lower Extremity Assessment Project)

Multicenter comparison on complex LE injuriesMore likely be re‐hospitalizedMore likely to undergo multiple operations

An event or situation that causes great distress and disruption

How can we help our patients cope with the trauma?

Issues Patients Must Deal With

MedicalPainNutritionMultiple surgeriesWound careRehabilitationInsurance

Psycho‐SocialLoss of IncomeLack of ControlDrug/ETOH abuseLegal IssuesHome/Family IssuesMobilityBody Image

Members of the Team

SurgeonsTraumaVascularOrthopedicReconstructive

Medical DoctorsInfectious DiseasePsychiatryInternal MedicinePhysiatry

Residents/NP’s/PA’sNursesPT/OTSocial WorkHome CareNutritionFamily/Friends

Case Study25 y/o female, no PMHPassenger mini‐bike struck by car 

Injury occurred 4 years prior to presentation @ NYUNo fracture, all soft tissue injuryPrevious skin graft x 2Recent osteomyelitis on IV antibiotics

Single, from Bermuda; no family in NYWorks as model & bartender + smoker (both tobacco & marijuana)

Prior to admission at outside hospital

Purulent drainage

Surgery at outside hospital- debridement- attempted closure

Leeches

Dangling begins

Prior to discharge home

Case Study

54 y/o male without reported PMHDignosed with DM following injury 

Employed, marriedCrush injury with 200lb metal weight  at work

Open R 1st metatarsal fx2nd metatarsal base fx3rd metatarsal neck fxDegloving injury to dorsum of foot

2 years post op

Great toe amputationDue to Osteomyelitis

Ambulatory, but notback to work

Case Study15 y/o male with no PMH

Jehovah’s witness

Pedestrian struck by busCrush injury right footMultiple fractures/degloving injuryNerve injury

Multiple organism + wound culturesDeveloped post‐injury depression

Major weight loss, anxiety

Wound upon transfer

Multiple debridementsMRSA/VRE from outside hospital culturesEnterobacter, MRSA, alpha‐hemolytic strep from NYU cultures

After serial debridements

Ready for microvascular free flap

Case Study

57 y/o male without significant PMHEmployed, married with 2 children (15 & 18)Pedestrian struck by carFractures: RLE comminuted tibial fractureDegloving RLE injury

2 failed free flaps prior to transfer to NYU

Incidental finding: GIST tumor

Two months after surgery at NYU

Almost 7 months after the initial accident

Case Study

24 yr old female, No PMHMVA – motorbike – taxi collisionSingle, family lives out of stateAvulsion injury right footAbsent sensation heelDP, PT pulses intactFx of the calcaneum, lat cuneiform & cuboidNo other injuries

External Fixator Placed

Post‐debridement

The defect

Heel reconstruction

Latissimus Flap&Skin Graft

Ambulating in 2 months

Several Years later:

Returns with open wound toheel