Mangled Upper Extremity Salvage

A mangled upper extremity can look unsalvageable before resuscitation, perfusion, and debridement reveal what function remains. In this episode of Plastics in Practice, we build a practical limb-salvage sequence—from life-threatening priorities and early antibiotics to revascularization, compartment assessment, reconstruction, and rehabilitation. Key takeaways: • Put life before limb. Complete trauma resuscitation, control hemorrhage, and document perfusion, motor function, and sensation before committing to salvage or amputation. • A MESS of seven is a risk signal, not an upper-extremity amputation verdict. A 2024 meta-analysis suggested that at least one in five patients above the included studies’ MESS amputation thresholds underwent limb salvage.[1] • For an open long-bone fracture within BOAST's scope, give intravenous prophylactic antibiotics as soon as possible, ideally within one hour of injury. Hand, wrist, and digit injuries are outside this BOAST’s scope and may be managed locally using similar principles.[2] • If the limb is ischemic, restore flow as soon as possible. When timely definitive vascular repair is not feasible because of patient physiology or skeletal instability, a temporary vascular shunt can rapidly restore perfusion while stabilization proceeds.[6] • In adults with traumatic extremity injury, on repeated or continuous monitoring, delta pressure equals diastolic blood pressure minus intracompartmental pressure. A value above thirty millimeters of mercury may assist in ruling out acute compartment syndrome; thirty or less is concerning but not diagnostic and must be integrated with serial examination.[3] • Functional salvage requires meticulous debridement, stable bone, vascular repair, coordinated tendon and nerve reconstruction, durable soft-tissue coverage, and rehabilitation planned from the beginning.[4,5] This content is for educational purposes only and is not medical advice. 🎧 Full episodes available now: Instagram: https://www.instagram.com/plasticsinpractice/ Spotify: https://open.spotify.com/show/4Ct8jOgYXP9QJin7QOuG3Z?si=JNcBxQmwT2mfz1LSJZEFKA Apple: https://podcasts.apple.com/us/podcast/plastics-in-practice-resident-review/id1835564216 YouTube: https://youtube.com/@plasticsinpractice?si=tqLInp5vvsJFKlRO Amazon: https://music.amazon.com/podcasts/8bef056e-7c87-4224-978e-7e691b04554a/ 📘 Free Study Guides: → https://drive.google.com/drive/u/0/folders/12BUldPbCmihG-ndZh6992WqhRYyxw8ZZ #MangledUpperExtremity #LimbSalvage #OpenFracture #Revascularization #CompartmentSyndrome #HandTrauma #HandSurgery #PlasticSurgeryEducation #PlasticsInPractice References: 1. Yoneda H, Takeda S, Saeki M, et al. Utility of severity scoring systems for mangled upper limb salvage: a systematic review and meta-analysis. Injury. 2024;55(4):111447. doi:10.1016/j.injury.2024.111447 2. British Orthopaedic Association. BOAST - Open Fractures. Published December 2017. https://www.boa.ac.uk/resource/boast-4-pdf.html 3. American Academy of Orthopaedic Surgeons. Management of Acute Compartment Syndrome Evidence-Based Clinical Practice Guideline. 2025. https://www.aaos.org/acscpg2025 4. Macrì M, Pugliese P, Accardo G, et al. Current principles in the management of a mangled hand. J Hand Surg Glob Online. Published online August 21, 2024. doi:10.1016/j.jhsg.2024.07.009 5. Nayar SK, Alcock HMF, Edwards DS. Primary amputation versus limb salvage in upper limb major trauma: a systematic review. Eur J Orthop Surg Traumatol. 2022;32(3):395-403. doi:10.1007/s00590-021-03008-x 6. Wahlgren CM, Aylwin C, Davenport RA, et al. European Society for Vascular Surgery 2025 Clinical Practice Guidelines on the Management of Vascular Trauma. Eur J Vasc Endovasc Surg. 2025;69(2):179-237. doi:10.1016/j.ejvs.2024.12.018