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Year |
2001 |
|---|---|
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Question Number |
157 |
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Category |
Select |
Question
A 19-year-old man sustained a fracture dislocation of the ankle and a talar neck and body fracture when his foot was run over by a truck. Examination reveals no pulse in the ankle and an ischemic foot. The anterior posterior tibial arteries are transected. He has no other injuries. A clinical photograph is shown in Figure 52. Treatment should consist of
1- repair of the posterior tibial artery and ankle fusion
2- repair of the anterior tibial artery and pantalar fusion
3- repair of both arteries and internal fixation of the talus
4- repair of the posterior tibial artery and nerve an external fixation
5- amputation
Figures
Answer (click for answer)
Answer 5
In these type of questions on the in service exam, the answer is almost always amputate. The picture shows a near complete amputation of the foot at the ankle. The only nerve that may be intact is the posterior tibialis and the question states that both arteries are transected. This is a grade IIIC injury which caries a high amputation rate.
The referenced article refers to the MESI or mangled extremity syndrome index. They state that this is too difficult to use. They also talk of the MESS, mangled extremity severity score. They divide the scoring system into four parts, energy level of injury, shock level, degree of ischemia, and age. A score greater than 7 was 100% predictive of amputation.
The patient in this question has a MESS of at least 8 and therefore should have the foot amputated.
Reference: Gregory P, Sanders R: The management of severe fractures of the lower extremities. Clin Othop 1995; 318:95-105.
Tornetta P III, Olson SA (eds): Amputation versus limb salvage. Instr Course Lect 1997; 46:511-18.