Upper Extremity Injuries and Correlates with Amputation Outcome following Combat Traumallrs.org/LLRS...

Upper Extremity Injuries and Correlates with Amputation Outcome

following Combat Trauma

John J Carroll, MD Peter C Rhee, DO

Jessica C Rivera, MD

US Army Institute of Surgical Research And

San Antonio Military Medical Center Department of Orthopaedic Surgery

Select SLIDE MASTER to Insert Briefing Title Here

10-Aug-16 Name/Office Symbol/(703) XXX-XXX (DSN XXX) / email address

The author have no disclosures to report related to this work. The authors acknowledge the Department of Defense Trauma Registry (DoDTR) for providing data for this study. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.



Introduction

• UE amputations 14% of OIF/OEF combat amputations

• Predictors of UE amputations less explored compared to LE

• Vascular status not predictive

Tennent D, et al. Characterization and outcomes of upper extremity amputations. Injury, 2014; 45(6): 965-9. Prichayudh S, et al. Management of upper extremity vascular injury: outcome related to the Mangled Extremity Severity Score. World J Surg, 2009; 33(4): 857-63 MacKenzie EJ, et al. Characterization of patients with high-energy lower extremity trauma. J Orthop Trauma, 2000; 14(7): 455-66.



Question

Are there acute injury predictors of amputation for the combat related upper extremity injury?

Hypothesis: Vascular and nerve injury most predictive of limb retention.

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Methods

DoDTR search for neurovascular injuries to UE between 2002 and 2007

Cross reference amputation search through 201

Annotate tissue injured: Nerve, Vessel, Bone, Muscle

Chi-Square and Logistic regression to test associate between tissues injured and amputation outcome



Results

397 subjects with UE injures • 87 traumatic amputations excluded

310 subjects analyzed • 72 non-traumatic amputations • 238 retained limbs



Frequencies of Injuries in Subjects with and without Amputation

Amputa'on

N=72

NoAmputa'on

N=238

Frequency of injury χ2 P value Cramer’s V

Nerve Injury 62.5% 80.3% 0.002 -0.18

Vascular

Injury56.90% 34.03% <0.001 0.198

Fracture 68.10% 42.9% <0.001 0.2129

Muscle Loss 69.44% 32.80% <0.001 0.3145



Odds: Amputation Day 1-14

Model 1 Model 2 Model 3 Model 4 Model 5 Model 6

Injury

Severity

8.70**

(3.97-19.06)

8.27**

(3.73-18.34)

7.21**

(3.23-16.10)

5.96**

(2.64-13.47)

6.16**

(2.63-14.60)

5.91**

(2.44-14.31)

Nerve

Injury

0.79

(0.41-1.51)

0.90

(0.46-1.76)

0.86

(0.43-1.71)

0.65

(0.31-1.37)

0.24*

(0.09-0.65)

Vascular

Injury

2.27*

(1.23-4.18)

2.57*

(1.36-4.85)

2.59*

(1.32-5.12)

1.13

(0.47-2.69)

Fracture 3.45**

(1.76-6.77)

3.80**

(1.85-7.78)

1.67

(0.70-4.01)

Muscle

Loss

5.89**

(2.94-11.80)

2.28

(0.93-5.62)

Total

Injuries

2.15**

(1.31-3.52)

BIC 281.38 286.56§ 285.26ǂ 276.77ǂ 254.28ǂ 250.58ǂ*p < 0.01; **p<0.001; § BIC support for saved model; ǂ BIC support for current model



Odds: day 15 or greater Model 1 Model 2 Model 3 Model 4 Model 5 Model 6

Injury

Severity

4.27

(0.87-21.02)

4.39

(0.87-22.10)

4.99

(0.98-25.41)

4.40

(0.85-22.79)

3.56

(0.66-19.25)

3.02

(0.52-17.41)

Nerve

Injury

1.17

(0.23-6.02)

0.77

(0.13-4.46)

0.73

(0.12-4.43)

0.63

(0.10-3.97)

0.17

(0.02-1.66)

Vascular

Injury

0.36

(0.06-2.10)

0.38

(0.06-2.26)

0.44

(0.07-2.58)

0.08

(0.01-1.07)

Fracture 1.97

(0.47-8.32)

2.5

(0.56-11.32)

0.83

(0.13-5.45)

Muscle

Loss

8.03*

(1.57-41.14)

2.7

(0.39-18.70)

Total

Injuries

2.82

(0.97-8.19)

BIC 83.84 89.28§ 93.31§ 97.91§ 95.61ǂ 97.53§*p<0.05; § BIC support for saved model; ǂ BIC support for current model



Discussion

•  25% frequency of muscle conditions following extremity injury

•  High percent disability despite “successful” healing of limb

• Muscle disability increases with time

0 365 730 1095 1460 1825 2190

010203040506070

NR

TPI (days)

% D

isab

ility

Initial Final (With Initial Rating)Initial Final (With no Initial Rating)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

010203040506070

NR

Subject

% D

isab

ility

A

B

Corona BT, Rivera JC, Owens JG, Wenke JC, Rathbone CR. Volumetric muscle loss leads to permanent disability following extremity trauma. J Rehabil Res Dev, 2015; 52(7): 785-92. Rivera JC, Corona BT. Muscle-related disability following combat injury increases with time. US Army Med Dep J, 2016; Jan-Mar: 30-34.



Conclusion

• Nerve and vascular injury only weakly associated with limb loss

• Muscle injury most predictive after acute period has past

• Low “late” amputation rate may indicate differences in decision toward attempted reconstruction



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Upper Extremity Injuries and Correlates with Amputation Outcome following Combat Traumallrs.org/LLRS...

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