Mangled Extremity Protocol

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1. Mangled Extremity Definition: Any extremity sustaining sufficiently severe injury to a combination of vascular, bony, soft tissue and/or nerve structures that results in subsequent concern for viability of the limb should be considered a mangled extremity and evaluated appropriately to optimize the potential for functional outcome.
2. Service Response for Mangled and/or Amputated Extremity (Attending presence is required):
   • Trauma Surgery – Class I Activation
   • Plastic Surgery
   • Vascular Surgery
   • Orthopedic Surgery
   • It is important to examine the patient for associated injuries that may be of higher priority.  Hemostasis must be ensured.  Intravenous resuscitation and the need for tetanus prophylaxis must be assessed.  In the case of incomplete amputation, splint the extremity in a physiologic position.
   • The decision whether to attempt limb salvage or amputate a mangled extremity is very challenging, and requires the multidisciplinary input of vascular, plastic, orthopedic, and general trauma surgery.  This is particularly true when multiple extremities are involved.  This is best accomplished in the operating room, where optimal lighting, magnification, and anesthesia are optimal.  Review of pictures of the injury and/or a report of a vascular exam by a resident or fellow is not sufficient for this complex decision-making.
   • For traumatic extremity amputations, the replantation team is activated, and decision regarding replantation is made with multidisciplinary input of plastic, vascular, orthopedic and general trauma surgery.  
3. Service Admission
   • If the patient has multiple injuries, other than the mangled/amputated extremity, the patient will be admitted to the ACS/Trauma Burn Service with the other services following as consult services.  If the patient requires repair or replantation of the mangled or amputated extremity, and no other traumatic injuries have been identified, the patient will be admitted to the surgical service that performed the operative procedure.