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Mangled Upper Extremity Injuries: Trends in Demographics, Injury Patterns and Outcomes at a Metropolitan Level 1 Trauma Center
Ira L. Savetsky, MD; Ara A. Salibian, MD; Jordan D. Frey, MD; John T. Stranix, MD; Z-Hye Lee, MD; Joshua Mirrer, MD; Spiros G. Frangos, MD; Vishal D. Thanik, MD
New York University, New York, NY
Introduction: The mangled upper extremity is a complicated and challenging problem due to injury to multiple tissue components (soft tissue, muscle/tendon, bone, nerves, and vessels). The complexity of these injuries has hindered the development of accurate scoring systems and treatment algorithms, with subsequent management individualized by patient and injury pattern. The purpose of this study was to define our center’s experience with mangled upper extremities and analyze for trends in patient characteristics, mechanisms, patterns of injury, and outcomes.
Material & Methods: Patients with traumatic mangled upper extremities presenting to a metropolitan level 1 trauma center in New York City over a five-year period were identified. A mangled upper extremity was defined as any injury to three or more tissue components involving the extremity proximal to the digit. Patient demographics, mechanism and severity of injury, and outcomes were analyzed.
Results: Thirty mangled upper extremities (29 patients) were identified over the study period. 80% of patients were male and 20% were female; the average age was 38. The majority of patients (55%) were manual laborers. 63% of injuries were to the non-dominant extremity and 90% were multi-level injuries. Injury mechanisms included crush (67%), degloving/avulsion (53%), and sharp (23%). Defect coverage required skin grafting in 50% of cases, pedicled flaps in 10% and microvascular free flaps in 27%. The majority of cases (67%) had multi-level bony injury with the radius fractured most commonly (50%) followed by the ulna (47%). 67% of cases involved injury to flexor tendons, and 53% injury to extensor tendons, most commonly in zones V and VII, respectively. Major arterial and nerve injury was present in 47% of cases. 86% required multiple debridements with an average of four operative procedures. Of 25 cases where limb salvage was attempted, 20 (80%) were successful. Average hospital length of stay was 19.8 days. The most common complication was contracture (37%) followed by tissue necrosis (33%). At follow-up, 70% of salvaged limbs had decreased active range of motion, while 63% had decreased passive range of motion.
Conclusion: Mangled upper extremities were most likely to be crush and avulsion multi-level injuries in the non-dominant extremity of young male manual laborers. Most injuries involved multi-level fractures, often with major arterial & nerve injury, and many required more complex means of defect coverage. Though salvage rates were high, functionality of those limbs was often compromised.
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