The mangled extremity severity score (MESS) is a scoring system that can be applied to mangled extremities and help one determine which mangled limbs will . Mangled Extremity Severity Score (MESS). Introduction. used to predict necessity of amputation after lower extremity trauma. Variables. skeletal. fractures, soft tissue damage, vascular, nerve and tendon lesions. The Mangled Extremity Severity Score (MESS) is probably the most common scoring system.

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The purpose of the present study was to evaluate the clinical utility of Mangled extremity severity score MESS in severely injured lower limbs. Retrospectively 25 and prospectively 36 lower limbs in 58 patients with high-energy injuries were evaluated with the use of MESS, to assist in the decision-making process for the care of patients with such injuries. Difference between the mean MESS scores for amputated and salvaged limbs was analyzed. In the retrospective study 4.

In the prospective study 4.

There was a significant difference in the mean scores for salvaged and amputated limbs. MESS is a simple and relatively easy and readily available scoring system which can help the surgeon to decide the fate of the lower extremity with a high-energy injury. Massive lower extremity trauma, in particular open tibial fractures with associated vascular injuries, presents immediate and complex decision-making challenges between a limb salvage attempt and primary amputation.

The management of massive lower extremity trauma is a subject of considerable interest and controversy. While the evolution of sophisticated microsurgical reconstruction technique has created the possibility of successful limb salvage in even the most extreme cases, it has become painfully obvious that the technical possibilities are double-edged swords.

Hansen 2 in analyzing his vast personal experience with managing open fractures, noted that protracted limb salvage attempts may destroy a person physically, psychologically, socially and financially, with adverse consequences for the entire family as well. In spite of best attempts, severiy functional sverity are sevverity worse than an amputation. Thus, enthusiasm for limb salvage techniques must be tempered by a realistic assessment of the results, not just for the injured part but for the patient as a whole.

The aim of limb salvage procedures following severe lower limb trauma is the preservation of a sevsrity and fully functional limb. Unfortunately, while limb preservation is frequently possible, the salvaged limb may have significant functional deficits and may have ultimately required secondary ablation. In an attempt to identify those scoe injured lower limbs, which could be successfully salvaged and those, which should proceed to primary amputation, a number of predictive indices were devised.

This study was carried out from January to June The study group comprised all the patients of either sex and any age, who had presented in emergency. The study includes a total of 58 patients with 61 limbs. Cases extrrmity selected as per the following inclusion criteria:. On admission to emergency ward all resuscitative measures according to the advanced trauma life support ATLS protocol were followed.

Once the general condition of the patient was stabilized, a detailed case history was recorded with particular importance to mode of injury, treatment taken if any, interval between injury and admission and associated medical or surgical illnesses if any.

Radiographs of the mangled extremity were taken. For all the mangled extremities pulse oximeter reading was noted and monitored till improvement of vascularity. Color Doppler of mangled extremity was carried out whenever peripheral pulses were absent and perfusion was in doubt.

Patients severiity shifted to the operation room and initial management of the mangled extremity was started in the form of thorough irrigation with copious normal saline, meticulous debridement, pressure bandage, antibiotics and fracture stabilization with external fixator.

Mangled Extremity Severity Score (MESS) | Calculate by QxMD

MESS was done at the time of admission or seveity the operation table, according to Table 1. Mangled extremity severity score 4. Vascular repair, if indicated, and primary fracture alignment and stabilization were carried out. Serial debridements were carried out every two to four days when required.


The second look debridement under anesthesia was undertaken 48 to 72 hrs following the injury. Serial wound cultures were done and appropriate antibiotics were given. Adequate physiotherapy was carried edtremity depending upon the circumstances.

This salvage protocol was severitu if the general condition of the patient deteriorated or once the severe infection of injured limb was observed or renal failure set in making amputation inevitable. Iliac bone grafting was undertaken in patients with bone loss or lack of healing process at the fracture site. Once adequate soft tissue coverage had been obtained, patient was discharged and extreemity up at regular intervals of two weeks for progression of fracture healing.

External fixator was replaced with a cast when there was no sign of infection, adequate soft tissue coverage was obtained and the fracture healing was progressing satisfactorily. External fixator or cast was removed once the fracture was soundly united and adequate physiotherapy was advised.

In the retrospective study, all the attempted salvage patients were followed mamgled for a period of two and mamgled half years. Maximum follow-up in the study period was done at the end of six and a half years, with minimum follow-up done at the end of two and half years. Three patients had not reported for follow-up and two patients had died before complete follow-up.

In the prospective study all the attempted salvage patients were followed up for a minimum period of six months. A successful salvage limb was defined as an extremity that remained in the limb salvage and reconstruction pathway six months after injury. Six months were selected as the end point because patients who had amputation after that time scoe be most likely to have had major complications or intolerance to additional reconstruction efforts or both. Average duration of follow-up was six months.

Trauma Scoring Systems – Trauma – Orthobullets

No patient died within the follow-up period. The present study comprised 58 patients with 61 injured lower limbs.

The retrospective study group comprised 24 patients with 25 injured limbs and the prospective severuty group comprised 34 patients with 36 injured limbs. The most common mechanism of injury was high-energy trauma.

Trauma Scoring Systems

Road traffic accidents accounted for The mean hospitalization for primary amputation was There were 15 In the prospective study, out of six Out of the remaining 30 injured limbs The mean score for salvaged limbs was 4. In the prospective study of 36 injured limbs, three limbs 8.

In the prospective study, maximum period of follow-up was 28 months and minimum period was two months. In the retrospective study, maximum period of follow-up was done at the end of six and half years and minimum period of follow up was done at the end of two and half years.

Out of a total of 61 injured lower limbs, 11 limbs The management of severe lower limb injury remains one of the most controversial subjects in Orthopedic surgery. Advances in surgical technology of fracture fixation, infrapopliteal vascular reconstruction and free micro vascular tissue transfer now permit limb salvage in the majority of lower limb trauma cases.

Unfortunately, while most attempts of limb salvage are successful, many are not. Failed attempts at limb salvage result in prolonged hospitalization including multiple surgical procedures, pain and psychological trauma, as well as economic hardship to the patient.

Frequently, overzealous attempts at limb salvage with prolonged unsuccessful attempts at rehabilitation result in a functionally useless limb, chronic disability and pain and may be followed later by delayed amputation. In contrast, correct application of surgical salvage technique may successfully rescue a limb, which might otherwise have been amputated.

The ideal situation is one which allows identification of those patients who will benefit from early and aggressive attempts at limb salvage and those for whom primary amputation is the correct choice. An attempt to quantify the severity of the trauma and to establish numerical guidelines for the decision to amputate or salvage the limb has been proposed by many authors.


A point system was developed to grade the severity of each of the four criteria. The MESS was based on retrospective review of 26 limbs. They also reported a prospective trial validating by index with 26 patients at a separate trauma center. The occurrence of just one of two absolute indications complete posterior tibial nerve disruption in adults; crush injuries with longer than six hours of warm ischemia time warrants primary amputation, while at least two of three relative indications serious associated polytrauma, severe ipsilateral foot trauma or projected long course to full recovery must be present to reach that decision.

LSI was formulated based on the degree of injury to the arterial, nerve, bone, muscle, skin, venous and warm ischemia time. LSI score of less than 6 predicts successful limb salvage whereas LSI score of 6 or more than six predicts amputations. They concluded that the MESS was an early and accurate predictor for identifying the extremities that may be treated by amputation.

However, when the limbs which required delayed amputation were analyzed, the LSI was slightly more accurate in predicting amputation. They concluded that MESS is not sufficiently precise to allow the decision regarding amputation to be made at the initial operation. In India, Sharma et al. Similar results are also found by Lin et al. Results of both these studies suggest that many limbs with MESS score of equal to or more than 7 may be salvaged.

The high sensitivity suggests that almost all limbs requiring an amputation will have MESS equal to or more than seven. The clinical utility of MESS has been extensively evaluated with varying results. There was a significant difference in the mean MESS scores in the prospective study, 4. Similarly there was a significant difference in the mean MESS score in the retrospective study, 4.

The high sensitivity suggests that almost all limbs requiring an amputation will have MESS equal to or more than 7. Results of the present study are consistent with the western and Indian studies [ Table 3 ]. The analysis did not validate the clinical utility of any of the scoring systems. We caution to keep realistic expectations regarding the ultimate functional result.

Both the patient and surgeon must anticipate multiple subsequent operative procedures, a long-term commitment to rehabilitation and a high probability of significant sequelae and functional limitations as an end result in these serious high injuries. National Center for Biotechnology InformationU. Journal List Indian J Orthop v. Author information Copyright and License information Disclaimer. Badole, Department of Orthopedics and Traumatology, M.

S, Sewagram -WardhaIndia. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Mangled lower extremity, Mangled extremity severity score, salvage versus amputation. Cases were selected as per the following inclusion criteria: Vascular injuries of lower limb except the foot, including dislocations of the knee, ankle, closed tibial or femoral fractures and penetrating wounds with vascular injury noted on color Doppler or at the time of surgery.

The injured limbs that were traumatic, near-amputation with only a small bridge of tissue connecting the distal extremity, thus were not reconstructable.