Professional Documents
Culture Documents
The Validity of The Mangled Extremity Severity Score in The Assessment of Upper Limb Injuries
The Validity of The Mangled Extremity Severity Score in The Assessment of Upper Limb Injuries
S. Togawa, The Mangled Extremity Severity Score (MESS) may be used to decide whether to perform
N. Yamami, amputation in patients with injuries involving a limb. A score of 7 points or higher indicates
H. Nakayama, the need for amputation. We have treated three patients with a MESS of 7 points or higher,
Y. Mano, in two of which the injured limb was salvaged. This scoring system was originally devised
K. Ikegami, to assess injuries to the lower limb. However, a MESS of 7 points as a justification for
S. Ozeki amputation does not appear appropriate when assessing injuries to the major vessels in
the upper limb.
From Tokyo Medical
and Dental University
Hospital Faculty of The Mangled Extremity Severity Score (MESS)1 respectively (Table III). The ischaemic time in
Medicine, Tokyo and was originally designed as a standard for two cases was more than six hours and so the
Dokkyo University deciding on amputation for severe injuries to score was doubled.
School of Medicine, the lower limb. It allocates points to four Amputation was performed in one patient
Saitama, Japan aspects of the injury, namely the degree of skel- with a MESS of 11 points. The injured limb
etal or soft-tissue injury, ischaemia of the limb, was salvaged in two cases including the two
S. Togawa, MD, Research the degree of shock using a systolic blood pres- cases with a MESS of 7 points or higher (Tables
Fellow
H. Nakayama, MD, PhD, sure of 90 mmHg as a cut-off and the age of the III and IV). The amputation was performed in
Research Fellow patient. In recent years its application has been order to achieve early haemostasis since the
Y. Mano, MD, PhD,
Chairman expanded to the upper limb but without patient could not be brought out of primary
Department of Hyperbaric proper examination of its validity. This study is shock and recovery of function was uncertain
Medicine
N. Yamami, MD, PhD, based on our experience of patients with inju- because of the severity of the injury. In the two
Associate Professor ries involving major vessels of the upper limb. limbs which were salvaged, a vein graft was
Graduate School of Health
Science performed, and in one a nerve graft was also
Tokyo Medical and Dental Patients and Methods used.
University Hospital Faculty
of Medicine, 1-5-45 Yushima Of 1024 patients seen at our trauma centre In the two patients whose limbs were sal-
Bunkyo-Ku, Tokyo 113-5819, from May to December 1999, there were five vaged, a crush syndrome did not develop.
Japan.
with injuries to the upper limb involving arter- However, the amputee developed disseminated
K. Ikegami, MD, PhD,
Professor ies, three of whom had a MESS of 7 points or intravascular coagulation but recovered after
Trauma and Critical Care higher. transfusion and drug treatment.
Center
S. Ozeki, MD, PhD, There were two women and one man rang- The final function of the salvaged limb was
Orthopaedic Surgeon, ing in age from 26 to 77 years. At the time of graded as 2 for two cases using the criteria of
Associate Professor
Department of Orthopaedics arrival at hospital the haemoglobin level was Chen et al2 (Table IV).
Koshigaya Hospital, Dokkyo 1.4 to 9.5 mg/dl and the maximum systolic Limb salvage in patients with a MESS of 7
University School of
Medicine, 2-1-50 Minami- blood pressure ranged from unmeasurable to points or higher
Koshigaya, Koshigaya-city 85 mmHg. The causes of injury were being Case 1. A 26-year-old man was trapped in a
Saitama 343-8555, Japan.
trapped in a machine at work, trapped in a conveyor belt at a cleaning factory and trans-
Correspondence should be vehicle following a road-traffic accident and a ferred to our hospital two hours later. On
sent to Dr S. Togawa; e-mail:
stogawa@muc.biglobe.ne.jp self-inflicted crush injury (Table I). The vessels arrival, his systolic blood pressure was 85
©2005 British Editorial
and nerves involved are listed in Table II. mmHg and the haemoglobin was 9.5 mg/dl.
Society of Bone and The injury extended from the right axilla to the
Joint Surgery
doi:10.1302/0301-620X.87B11.
Results fingertips. There were multiple fractures of the
16512 $2.00 MESS and treatment. The MESS ranged from radius, ulna and metacarpals, skin loss in the
J Bone Joint Surg [Br]
7 to 11 points, including skeletal and soft- upper arm, anterior aspect of the elbow and
2005;87-B:1516-19. tissue injury classified as ‘very high’ in two the palm, and crush injuries to the flexor
Received 14 March 2005;
Accepted after revision
cases and ischaemia of the limb classified as muscles of the elbow, wrist and fingers. The
1 June 2005 ‘pulseless’ and ‘cool’ in one and two cases, brachial artery was occluded for about 10 cm
Case Site of fracture Injured blood vessels Injured nerves Injured muscles/tendons
1 Radius, ulna, 2nd Brachial occlusion None Flexor tendons to the wrist, fingers and elbow
metacarpal, phalanges Deep and superficial carpal arches and the thenar and interosseous muscles
2 None Radial and ulnar arteries Radial and ulnar nerves Flexor tendons to the wrist and fingers
3 Humerus, radius, ulna Brachial, radial and ulnar arteries Musculocutaneous and All muscles in the upper arm and forearm
median nerves
Energy of
Case the injury Shock Ischaemia Age Total MESS
1 4 1 3 x 2* 0 11
2 1 2 2 x 2* 0 7
3 4 2 3 2 11
* ischaemic time > 6 hours, so score is doubled
Outcome
Case Blood vessels Nerves Muscles/tendons (point)
1 Two vein grafts None Five tendon 2*
transfers
2 Two vein grafts Two nerve grafts Six tendon grafts 2*
3 Ligature Amputation Amputation Amputation Fig. 1
* according to the criteria of Chen et al2 The injured right upper limb upon arrival at hospital of a 26-year-old man
(case 1); the flexor muscles of the elbow and wrist joints are crushed and
defective; the brachial artery is in continuity but occluded.
Fig. 3a Fig. 3b
Fig. 5a Fig. 5b
Almost normal extension and flexion three years after injury (case 2).