1 Introduction

Over the last two decades, considerable advances have taken place in the management of soft tissues following extremity trauma. Several factors have contributed to this evolution, including:

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  Concentration of clinical expertise in trauma centers

  
  
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  Improvement in stabilization techniques and implant devices

  
  
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  Development and refinement of procedures for reconstructing soft-tissue defects

However, the treatment of these injuries remains a surgical challenge and injury to the soft tissues is a key component of extremity trauma (particularly if associated with high energy) dictating both the initial, and sometimes the definitive, management of the injury, as well as being essential for bone healing [1].

Increased awareness of the importance of the soft-tissue injury and its impact on the final outcome has raised a series of questions about the assessment of the lesion, classification schemes, predictive indices, stabilization of the fracture, and the management of bone defects. Definitive answers to these questions should promote an optimal combination of techniques for bone repair and/or reconstruction and soft-tissue management.

The variation in injury patterns makes it difficult to devise a standard decision-making algorithm: every injury with a significant soft-tissue defect is unique and requires a personalized solution taking into account local factors at the injury site (the soft tissue and fracture), patient factors, and healthcare facilities [2].

Improved understanding of the blood supply to the muscles and skin, with its clinical application for wound coverage by using customized flaps of various tissues, has increased the reconstructive options available for the treatment of soft-tissue loss ( Fig 4.3-1 ).

2 Evaluation of soft-tissue defects

The following description details the clinical, radiographic, and laboratory assessment of the patient and the soft-tissue injury.

2.1 The patient

A systematic examination is essential to assess the injury correctly. A thorough case history is combined with a detailed examination of the injured limb and a general examination of the patient, which must be clearly recorded. The aim is to rapidly obtain a diagnosis that is as accurate as possible ( Fig 4.3-2 ). However, clinical priorities may sometimes delay assessment, since life-threatening conditions need to be handled first. The evaluation of an unconscious patient will often be incomplete as certain aspects of the injury, such as nerve damage, cannot be assessed.

The history should include the mechanism, energy, and time of injury. General factors that influence decision making must also be evaluated. These include age, gender, head injury, vascular disease, diabetes, tetanus immunization, viral infection (eg, HIV, hepatitis B or C), and psychosocial factors, such as cognitive status, compliance, as well as addiction to drugs, nicotine, or alcohol.

2.2 The soft tissues

The value of the assessment of injured soft tissues and the classification of their severity greatly depends on the examiner′s experience. Therefore, senior surgeons should be involved in this process. Often, full assessment of the extent of soft-tissue injury can only be carried out in the operating room during irrigation and debridement and/or primary fixation. The examination will allow the surgeon to evaluate the severity of the soft-tissue injury and define the “zone of injury.” Photographs can be helpful for communication and reduce the need for repeated exposure of any wounds.

The assessment of soft-tissue injuries must address the following issues:

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  Site, size, extent, and character of the wound (eg, crush, abrasion, defect, degloving)

  
  
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  Wound contamination and/or presence of foreign bodies

  
  
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  Condition of the skin (color, capillary refill, turgor, and temperature)

  
  
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  Systematic evaluation of surrounding structures (eg, nerves, vessels, muscles, tendons, bone, cartilage)

  
  
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  Condition of the adjacent tissues including joints above and below the injury

Capillary refill is examined by applying light pressure on the skin with a finger or instrument, which is then quickly released ( Fig 4.3-3 ). Scarification of the skin with a sharp needle or a scalpel may sometimes be helpful to judge dermal bleeding. Perfusion is then evaluated by judging color (eg, light red or bluish) and flow of dermal bleeding. Absent capillary bleeding is suggestive of nonviable tissue. Nevertheless, skin may reperfuse after trauma.

Bluish discoloration will indicate some injury to the skin, which may survive, whereas greyish discoloration of the skin will indicate changes beyond the skin′s ischemic tolerance. All these clinical signs should be used to assess perfusion of normal skin or of a flap ( Table 4.3-1 ). Muscle viability may be determined by assessing the four “C”s:

Table 4.3-1 Clinical signs indicating compromised skin perfusion.

	Bruise	Inflammation/infection	Arterial insufficiency	Venous congestion
Color	Purple	Red	Pale	Dark red, purple
Capillary refill	Normal	Accelerated	Slow to absent	Accelerated
Turgescence	Increased	Increased	Decreased	Increased
Surface temperature	Normal	Increased	Decreased	Normal to increased

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  Color

  
  
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  Contractility (by mechanical or electrical) stimulation

  
  
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  Consistency

  
  
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  Capacity of the muscle to bleed

Absent pulses may suggest a severely injured artery proximal to the region of interest. This clinical finding cannot be ignored and must be acted on immediately. The presence of a pulse more distally does not guarantee intact vascularity because collateral vessels may maintain a palpable pulse. When a wound is situated over a tendon, the examination should include testing the tendon′s function actively and passively. If in doubt, wound exploration must be carried out in the operating room and the surgeon must be prepared to repair the tendon. The viability of muscle and tendons cannot always be judged in a freshly injured patient. Necrotic tendons that are exposed over a period of days will macerate and develop a greenish discoloration. Deformity of the limb and crepitation are typical for a fractured bone, which must be verified by radiography. The following clinical signs may indicate significant injury to nerves and must be assessed immediately:

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  Severe pain and dysesthesia may be due to compartment syndrome or an expanding hematoma causing nerve compression

  
  
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  Massive contusion or transection of a nerve resulting in paralysis and functional deficit of a limb, foot, or hand, eg, drop foot (common peroneal nerve), wrist drop (radial nerve), claw hand (ulnar nerve), monkey hand (median nerve), or traumatic paresis of the brachial plexus

  
  
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  Absence of 2-point discrimination to touch

  
  
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  Lack of response to strong and painful stimuli and absence of peripheral reflexes

  
  
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  Absence of sweating in the sensory distribution of the nerve

Full assessment of a soft-tissue injury often requires further investigations. Several nonclinical techniques are available to assess the injury and viability of skin ( Table 4.3-2 ).

Table 4.3-2 Advantages and disadvantages of nonclinical techniques to assess skin blood flow.

	Invasiveness	Reliability	Quantification	Ease of handling
Temperature	No	Some	Some	Yes
Tissue oxygenation	Yes	Yes	Yes	Some
Acoustic Doppler	No	Some	No	Yes
Laser Doppler flowmetry	No	Some	Some	Some
Duplex, color Doppler	No	Yes	Yes	No
CT imaging	Yes	Yes	No	No
Fluorescent dyes	Yes	Yes	Some	No

Once assessed, the soft-tissue injury must be classified using a system that includes the soft tissues such as the Gustilo-Anderson classification or the AO soft-tissue classification.

3 Limb salvage versus early amputation

In recent years, rescue times have decreased and neurovascular repair techniques have improved so that limb salvage of severely injured limbs with critical ischemia has become a more frequent option. A number of classification and scoring systems have been developed to help define whether limbs are salvageable or not. These include the mangled extremity severity score (MESS) [3], the limb salvage index (LSI) [4], the nerve injury, ischemia, soft-tissue injury, skeletal injury, shock, and age of the patient score (NISSSA) [5], and the Hanover fracture scale [6]. The scores emphasize the technical capability of salvaging limbs, but do not address functional outcomes or quality of life after limb salvage or amputation. The lower extremity assessment project (LEAP) is the only large study to do so [7]. Therefore, the various scoring systems have often been of limited value in the treatment of an individual patient.

In clinical practice there are clear cases that cannot be salvaged ( Fig 4.3-4 ). However, the trauma surgeon is commonly confronted with severe limb injuries that technically can be salvaged. However, limitations of skill, timing or resources preclude this. When limb salvage is not possible, the key is to plan the level of amputation to preserve as much function as possible and guarantee the best possible prosthetic rehabilitation. If the limb is technically salvageable, the question confronting the surgeon is whether the patient will be functionally better off following reconstruction and limb salvage than following amputation.

Upper extremity: The prevailing opinion is that in the upper extremity every attempt should be made to salvage the limb ( Fig 4.3-5 ). Unfortunately, there are cases when amputation is still the best option. Some cases are clearly not salvageable, including massive crush injuries with segmental bone and soft-tissue loss as well as extensive neurovascular injury. Other situations are more questionable, such as when there is traumatic loss of both the flexor and extensor compartments of the forearm. Most patients prefer a nonfunctional limb to a prosthesis in the upper extremity, thus reconstruction is more often attempted. During the initial assessment of an injured upper extremity, the surgeon should make a thorough inventory of the intact muscles, vessels, and nerves to facilitate the decision-making process.

There has been tremendous technical progress in advanced prostheses in recent years. Consequently, a poorly functioning or nonfunctional hand, or a hand that causes chronic pain and has no sensation is often not as good as a good stump, especially if it is on the nondominant side. Such conditions, most often in young men, hinder reintegration into the workplace and myoelectric prostheses (ie, an “intelligent” replacement of the arm or of the hand that can be controlled by selective muscle contraction), could be a valuable option in the near future. The role of hand or arm allotransplantation has not yet been established routinely and remains a procedure to be performed in very rare and highly selected cases.

Lower extremity: The surgeon should approach severe trauma to the lower extremity with a different set of criteria than for the upper extremity because of the differences in perception of body image and the function of available reconstructive options. In some cultures, the integrity of the body and especially of the limbs may be even more important than function and this fact should not be ignored. Function should be considered from a broad perspective. Prosthetic function must be compared with the potential functional outcome of a salvaged limb. In the upper extremity, a variety of tendon or muscle transfers are possible, which may restore the function of the hand. In contrast, in the lower extremity, there are fewer options. Moreover, many good foot or ankle prosthetic replacements are available, which can replicate different functions of the foot.

The absolute indications for amputation are:

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  Unstable polytrauma patient where prolonged attempts at limb salvage will put their life at risk

  
  
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  Nonreconstructible vascular injury with critical ischemia

  
  
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  Crush injury comprising a wide zone of the extremity, such as hydraulic press injury

  
  
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  Overwhelming infection or necrotizing fasciitis

  
  
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  Severe muscle, nerve and/or tendon loss over multiple compartments

  
  
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  Resource issues in a country with compromised health care facilities

The patient′s age, comorbidities, and general state of health at the time of the injury should be considered as relative indications for amputation and discussed on an individual base.

If a lower extremity is considered to be technically salvageable, then a decision must be reached whether salvage should be attempted or not. In most situations, the functional outcome should be the primary determinant of salvage or amputation.

Surgeons should carefully assess the entire environment and circumstances in which the patient lives. They must, whenever possible, present the likely outcome of salvage versus amputation to the patient and his/her relatives, and allow them to participate in the decision-making process. Surgeons should consider the following when presenting options to the patient and/or family [7]:

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  Occupation and activity of the patient

  
  
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  Availability of suitable prosthetics and rehabilitation facilities

  
  
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  General health, psychosocial factors, compliance, and expectations of the patient who may have to undergo multiple procedures to reconstruct the limb (eg, age, smoking, medication, diabetes, nutritional state)

  
  
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  Risks associated with limb salvage procedure(s): anesthetic risks, bleeding, vascular occlusion, infection, wound breakdown, malunion, nonunion, persistent pain, multiple surgeries, long rehabilitation time, possibility of secondary amputation, long process of professional, and/or social reintegration

  
  
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  Risks associated with amputation: wound breakdown, phantom sensation, phantom pain, and/or replacement costs of prosthetics

  
  
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  Time it may take to reconstruct a limb versus recovery time from an amputation

  
  
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  Function of the limb if all reconstructive efforts (fracture healing, soft-tissue coverage, etc) are successful

  
  
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  Function of the prosthesis in the context of the patient′s occupation and activities, as well as the social and cultural environment of the patient (eg, in some cultures, amputees are ostracized from society)

Patients must be made to feel that there is no right or wrong choice, only alternative ways of restoring function. Some patients and physicians will view amputation as a failure. This should be discouraged. Restoration of preinjury activities is the goal. By carefully considering the path to this goal, both patient and physician can reach the best decision.