LIMB SALVAGE

Dr. Rahadyan Magetsari, Sp.OT., Ph.D., FICS

Definition of limb salvage

Limb : extremity/ anggota gerak

Salvage
: save/ rescue
tindakan mempertahankan/
menyelamatkan
Limb salvage procedure :
Medical procedure taken to preserve
the limb and avoid amputation

ALL can be . Life threatening

or LIMB THREATENING

Kasus kasus :

Traumatic amputation :

Sharp instrument injury

Crushed injury

Compartment syndrome
Others :

Tumour
Infection
Peripheral vascular disease (DM, Buerger
disease, etc)

What must you

do as an
Emergency (ER)
Doctor??

ALL

MEDICAL PERSONEL (doctors, nurse, coAss

and medical students) must able to ASSESS and

LIMB SALVAGE VS AMPUTATION

After ABCD

Stabilize the
fracture
(to elicit
PAIN and
FURTHER
SOFT
TISSUE
injury

Warm Ischemia (Anoxic) Time

6 HOURS

irreversible necrotic
changes begin in muscle after 6 hours
Because

of ischemia without cooling (at 20C to 25C)

it is preferable to begin the replantation of

parts amputated proximal to the palm within
this time.

Musculoskeletal
Examination

Assess the

neurovascular status

Look : Redness / Pale

Feel : Warm / Cold,
Capillary Refill test < 2 seconds
Palpation for PULSE of the DISTAL artery
MOTORIC and SENSORY function of the nerve
distal to the injured side

Management of Amputee

Need GOOD team of specialist

Need good and supporting facilities
Microsurgery
Need GOOD orthopaedic specialist
NEED GOOD AMPUTEE

Management
(material handling
the hospital)

before

reaching

Management for Amputee

Major injuries should take precedence

Life >> Limb
Patient's condition should be stabilized
Found the amputee
Rinsed gently with sterile saline, lactated
Ringer, or other physiological solutions
contamination is removed
DO NOT clamp, dissect, ligate, or
cannulate vessels on the amputated part

Management for Amputee

It may be wrapped with sterile gauze or

other clean material, soaked in sterile
lactated Ringer or saline, and placed in a
plastic bag without fluid and then put
in the a cold fluid

DO NOT use Nonphysiological solutions

such as alcohol and formaldehyde should
not be used on the amputated part.

21/06/16

Demographics

Incidence:

Men 7.3/100,000
Women
0.7/100,000

Compartment Syndrome
pada fraktur supracondyler
humerus

69% due to trauma

36% fx tibia
9.8% distal radius
23% soft tissue injury without fx
10%

on anticoagulants

High energy = low energy incidence

Etiology

Trauma with bleeding/swelling

Bleeding disorders
Burns
Tight wraps, tight cast
Traction
Surgical positioning
Pneumatic antishock garment
Reprefusion swelling

Diagnosis

History
Clinical exam:
the 5 Ps
Measurement of Compartment pressures
Laboratory tests

CPK
Urine myoglobin

Compartment syndrome:
Gejala klinis :
5P
- Pain (nyeri)
- Pale (pucat)
- Pulseless
- Paresthesia
- Paralyzed

Compartment Syndrome
pada fraktur supracondyler
humerus

If Possible :
Measurement the Compartment
Pressures

Penatalaksanaan :
- Pasca pemasangan gips
Lepas gips
-Menurunkan tekanan intakompartemen :
Fasciotomy

Stryker Stic System

Easy to use
Can check multiple compartments
Different areas in one compartment

Treatment

Lower the involved extremity to level

of the heart
Remove the cast
Split all dressings down to skin
Fasciotomy if continued clinical findings
and/or elevated compartment pressure

Casting & Wraps

Casting increases pressure 3-7 times

Watch out for TIGHT Plaster cast
Positioning may effect pressure
Elevation of extremity changes A-V
gradient

Fasciotomy

TRAUMA to the
EXTREMITY
LIMB
SALVAGE
Compartment
syndrome

Volkmann Ischemic
Contracture

Limb Salvage in Chronic

condition

Peripheral vascular disease (Diabetes, Buergers, etc)

Limb salvage :
1. Treat the primary disease
(e.g : control blood glucose level !!)
2. Protect the foot (e.g : use sandals around the house)
3. Daily inspection of the foot

Malignancy (bone tumour): Excision, amputation or

Reconstruction with BONE REPLACEMENT or
MEGAPROSTHESES

Diabetic Foot

Prevention

Level of resection in
musculoskeletal Tumour

Autograft

Kasus GCT Distal Tibia

Allograft

Bone scaffold

To cover large bone defect

Natural : Bovine
hyrdroxyapatite
Synthetic : Coral, gypsum,
calcit (batu kapur) material

Bone scaffold

Recent RESEARCH :
Mega scaffold + mesenchymal stem
cell

Megaprosth
eses in
musculoskeletal
Malignancy