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The Mangled Digit Severity Score: Determining Salvageability of Severe Digital Injuries
Anna Luan, MD, MS
1,2; Jeffrey B. Friedrich, MD
3; Aviram M. Giladi, MD, MS
4; Suhail K. Mithani, MD
5; Peter C Rhee, MD
6; Bauback Safa, MD
7; Adam B. Strohl, M.D.
8; Kyle R. Eberlin, MD
91Massachusetts General Hospital/Harvard, Boston, MA; 2Stanford University, Palo Alto, CA; 3University of Washington, Seattle, WA; 4The Curtis National Hand Center, Baltimore, MD; 5Plastics and Reconstructive Surgery, Duke University Medical Center, Durham, NC; 6Orthopaedic Surgery, Mayo Clinic, Rochester, MN; 7The Buncke Clinic, San Francisco, CA; 8Philadelphia Hand to Shoulder Center - Thomas Jefferson University, Philadelphia, PA; 9Massachusetts General Hospital/Harvard Medical School, Boston, MA
Introduction: The assessment, prognostication, and decision making for mangled digital injuries can be challenging, even for experienced surgeons. This study aims to develop a Mangled Digit Severity Score (MDSS) to predict whether a mangled digit should be salvaged. Materials & Methods: An anonymous questionnaire was sent to 67 hand surgeons at seven level I trauma centers as an initial survey panel. Participants were provided a list of factors influencing outcomes following a mangled digital injury and were asked to assign weights from 0-10 for each factor reflecting its relative importance in determining likelihood of functional salvage versus failure or secondary amputation. Using the modified Delphi method, iterative questionnaire rounds were then performed with seven expert panelists and consensus determined. Central tendency and dispersion of responses were calculated. The final ratings were then used to develop a weighted scoring system to assess mangled digits. A retrospective single-center review of patients with a mangled digit injury was then conducted to validate the scoring system. The sensitivity and specificity for amputation at different MDSS prognostic thresholds were evaluated, and a receiver operating characteristic curve and area under the curve (AUC) were calculated.Results: From initial surgeon responses (36/67 responded) and two subsequent rating rounds among expert panelists, consensus was achieved on 14 factors, including crush/avulsion mechanism, intraarticular fracture, and zone II flexor tendon injury. Final weights for all factors ranged between 3-9. Among 54 mangled digits reviewed, digits that were salvaged had a significantly lower MDSS than those that underwent amputation. The MDSS demonstrated an AUC of 0.87. At a threshold of 35, the MDSS achieved a sensitivity of 60% and specificity of 88% in predicting amputation, reflecting a false positive rate of 12%. At a threshold of 25, the MDSS achieved a sensitivity of 85% and specificity of 65% in predicting amputation.Conclusions: The MDSS was developed through a consensus of experts and is a useful tool for identifying mangled digits that may not be salvageable.
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