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Reexamining Our Approach to Complex Traumatic Upper Extremity Reconstructions With a Multi-Specialty Approach
Ashley Nicole Flinn Patterson, Richard Walsh, Luke Perry,
Savannah Potter, Lori Pounds
The University of Texas Health Science Center at San Antonio, San Antonio, TX
INTRODUCTION: Upper extremity injuries have increased in frequency and the utility of scoring systems that are more suited to the legs have limited utility. The Mangled Extremity Severity Score (MESS) is a numeric calculation that accounts for the mechanism, degree and duration of ischemia, shock, and age to then guide the surgeon forward for limb salvage. Our case highlights a team approach for a high MESS injury with near complete return of function.
METHODS: A 28-year-old male presented as a transfer from an outside facility with a tourniquet in place approximately three hours after near-total amputation of his distal left forearm with a miter saw (MESS 7). He had no neuromuscular function, no arterial Doppler signals, transection of the radial and ulnar bones, and a volar skin bridge was the only tissue keeping the hand attached. Orthopedic Surgery performed a volar fixation of the radial and ulnar fractures while the greater saphenous vein was harvested by the Vascular Surgery team. A radial-radial artery bypass was then performed as this is where there was soft tissue coverage providing retrograde flow to the ulnar that was ligated. No identified venous outflow was seen. He returned to the OR for subsequent staged reconstructions of the tendons and nerves.
RESULTS: The multi-disciplinary trauma, orthopedic, and vascular surgery teams worked together along with rehab medicine. The patient is over one year post-injury and has been followed with duplex every 3 months. He takes 81mg of aspirin and a statin daily. He regained full composite fist formation in active and passive motion at approximately four months post injury and sensation in the median nerve distribution by 6 months.
CONCLUSIONS: A MESS score of 7 is a guideline for consideration of amputation, but these scoring platforms were originally designed for legs. The arms have a smaller muscle mass and a more robust collateral circulation that is more resistant to ischemia (12 hours in the arm versus 6 hours in the leg) secondary to the profunda brachii and high radial artery variants. With the poor results of prosthesis options for arms, despite the score, attempts at limb salvage should be attempted, even if ideal situations such as named venous drainage doesn't exist.
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