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Lower Extremities

  • Tina A. Maxian
  • Michael J. Bosse

Abstract

A 28-year-old motorcyclist, who lost control of his bike, is brought to the trauma bay by the emergency medical technicians for evaluation and definitive management of multiple injuries. The patient has been hemodynamically stable throughout his transport and upon arrival. He is alert, oriented, and complaining only of left lower extremity pain. Advanced Trauma Life Support protocol was initiated. In addition to scattered torso abrasions and superficial lacerations of bilateral lower extremities, the patient was found to have an unstable left knee. The involved extremity has no palpable dorsalis pedis and posterior tibial pulses. Plain radiography of the neck and chest demonstrated no obvious injuries. Focused abdominal sonography revealed no fluid accumulation. After life-threatening injuries were ruled out, the knee dislocation was reduced with no return of pulses. What is the most appropriate management plan at this time?

Keywords

Vascular Injury Compartment Syndrome Septic Arthritis Femoral Neck Fracture Necrotizing Fasciitis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Wong C-H, Chang H-C, Pasupathy S, Khin L-W, Tan J-L, Low C-O. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am 2003; 85A:1454–1460.Google Scholar
  2. 2.
    Mills WJ, Swiontkowski MF. Fatal group A streptococcal infection with toxic shock syndrome: complicating minor orthopaedic trauma. J Orthop Trauma 1996; 10:149–155.PubMedCrossRefGoogle Scholar
  3. 3.
    Takahira N, Shindo M, Tanaka K, Soma K, Ohwada T, Moritoshi I. Treatment outcomes of nonclostridial gas gangrene at a Level I trauma center. J Orthop Trauma 2002; 16:12–17.PubMedCrossRefGoogle Scholar
  4. 4.
    Elliott DC, Kufera JA, Myers R. Necrotizing soft tissue infections: risk factors for mortality and strategies for management. Ann Surg 1996; 224:672–683.PubMedCrossRefGoogle Scholar
  5. 5.
    Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med 1996; 334:240–245.PubMedCrossRefGoogle Scholar
  6. 6.
    Cunningham JD, Silver L, Rudikoff D. Necrotizing fasciitis: a plea for early diagnosis and treatment. Mt Sinai J Med 2001; 68:253–261.PubMedGoogle Scholar
  7. 7.
    Dahl PR, Perniciaro C, Holmkvist K, O’Connor MI, Gibson LE. Fulminant group A streptococcal necrotizing fasciitis: clinical and pathologic findings in 7 patients. J Am Acad Dermatol 2002; 47:489–492.PubMedCrossRefGoogle Scholar
  8. 8.
    Rocca AF, Moran EA, Lippert FG. Hyperbaric oxygen therapy in the treatment of soft tissue necrosis resulting from a stingray puncture. Foot Ankle Int 2001; 22:318–323.PubMedGoogle Scholar
  9. 9.
    Trent JT, Kirsner RS. Necrotizing fasciitis. Wounds 2002; 14:284–292.Google Scholar
  10. 10.
    Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev 2002; 15:527–544.PubMedCrossRefGoogle Scholar
  11. 11.
    Jung ST, Rowe SM, Moon ES, Song EK, Yoon TR, Seo HY. Significance of laboratory and radiologic findings for differentiating between septic arthritis and transient synovitis of the hip. J Pediatr Orthop 2003; 23:368–372.PubMedCrossRefGoogle Scholar
  12. 12.
    Levine MJ, McGuire KJ, McGowan KL, Flynn JM. Assessment of the test characteristics of C-reactive protein for septic arthritis in children. J Pediatr Orthop 2003; 23:373–377.PubMedCrossRefGoogle Scholar
  13. 13.
    Choi IH, Pizzutillo PD, Bowen JR, Dragann R, Malhis T. Sequelae and reconstruction after septic arthritis of the hip in infants. J Bone Joint Surg Am 1990; 72A:1150–1165.Google Scholar
  14. 14.
    Aroojis A, Johari AN. Epiphyseal separations after neonatal osteomyelitis and septic arthritis. J Pediatr Orthop 2000; 20:544–549.PubMedCrossRefGoogle Scholar
  15. 15.
    Salvati EA, Gonzalez Della Valle A, Masri BA, Duncan CP. The infected total hip arthroplasty. Instr Course Lect 2003; 52:223–245.PubMedGoogle Scholar
  16. 16.
    Hanssen AD, Spangehl MJ. Treatment of the infected hip replacement. Clin Orthop 2004; 420:63–71.PubMedCrossRefGoogle Scholar
  17. 17.
    Joseph TN, Chen AL, DiCesare PE. Use of antibioticimpregnated cement in total joint arthroplasty. J Am Acad Orthop Surg 2003; 11:38–47.PubMedGoogle Scholar
  18. 18.
    Roth A, Fuhrmann R, Lange M, Mollenhauer J, Straube E, Venbrocks R. Overwhelming septic infection with a multi-resistant Staphylococcus aureus (MRSA) after total knee replacement. Arch Orthop Trauma Surg 2003; 123: 429–432.PubMedCrossRefGoogle Scholar
  19. 19.
    Sierra RJ, Trousdale RT, Pagnano MW. Above-the-knee amputation after a total knee replacement. J Bone Joint Surg Am 2003; 85A:1000–1004.Google Scholar
  20. 20.
    Fenelon GCC, von Foerster G, Engelbrecht E. Disarticulation of the hip as a result of failed arthroplasty. J Bone Joint Surg Am 1980; 62B:441–446.Google Scholar
  21. 21.
    Henke PK. Approach to the patient with acute limb ischemia: diagnosis and therapeutic modalities. Cardiol Clin 2002; 20:513–520.PubMedCrossRefGoogle Scholar
  22. 22.
    Rutherford RB, Baker D, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997; 26:517–538.PubMedCrossRefGoogle Scholar
  23. 23.
    Nypaver TJ, Whyte BR, Endean ED, Schwarcz TH, Hyde GL. Nontraumatic lower-extremity acute arterial ischemia. Am J Surg 1998; 176:147–152.PubMedCrossRefGoogle Scholar
  24. 24.
    Eliason JL, Wainess RM, Proctor MC, et al. A national and single institutional experience in the contemporary treatment of acute lower extremity ischemia. Ann Surg 2003; 238:382–390.PubMedGoogle Scholar
  25. 25.
    Kumar SR, Rowe VL, Petrone P, Kuncir EJ, Asensio JA. The vasculopathic patient: uncommon surgical emergencies. Emerg Med Clin North Am 2003; 21:803–815.PubMedCrossRefGoogle Scholar
  26. 26.
    Tawes RL, Harris EJ, Brown WH, et al. Arterial thromboembolism: a 20-year perspective. Arch Surg 1985; 120:595–599.PubMedGoogle Scholar
  27. 27.
    Blaisdell FW. The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. Cardiovasc Surg 2002; 10(6):620–630.PubMedCrossRefGoogle Scholar
  28. 28.
    Feliciano DV. Heroic procedures in vascular injury management: the role of extra-anatomic bypass. Surg Clin North Am 2002; 82:115–124.PubMedCrossRefGoogle Scholar
  29. 29.
    Fulkerson E, Razi A, Tejwani N. Review: acute compartment syndrome of the foot. Foot Ankle Int 2003; 24:180–187.PubMedGoogle Scholar
  30. 30.
    Blick SS, Brumback RJ, Poka A, Burgess AR, Ebraheim NA. Compartment syndrome in open tibial fractures. J Bone Joint Surg Am 1986; 68A:1348–1353.Google Scholar
  31. 31.
    Sandhu R, Como JJ, Scalea TS. Renal failure and exerciseinduced rhabdomyolysis in patients taking performanceenhancing compounds. J Trauma 2002; 53:761–764.PubMedCrossRefGoogle Scholar
  32. 32.
    Nixon RG, Brindley GW. Hemophilia presenting as compartment syndrome in the arm following venipuncture. Clin Orthop 1989; 244:176–181.PubMedGoogle Scholar
  33. 33.
    Hope MJ, McQueen MM. Acute compartment syndrome in the absence of fracture. J Orthop Trauma 2004; 18:220–224.PubMedCrossRefGoogle Scholar
  34. 34.
    Whitesides TE, Heckman MM. Acute compartment syndrome: update on diagnosis and treatment. J Am Acad Orthop Surg 1996; 4:209–218.PubMedGoogle Scholar
  35. 35.
    Elliott KGB, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Am 2003; 85B:625–632.Google Scholar
  36. 36.
    Pacheco RJ, Oxborrow NJ, Weeber AC, Allerton K. Gluteal compartment syndrome after total knee arthroplasty with epidural postoperative analgesia. J Bone Joint Surg Am 2001; 83B:739–740.CrossRefGoogle Scholar
  37. 37.
    Price C, Ribeiro J, Kinnebrew T. Compartment syndromes associated with postoperative epidural analgesia. J Bone Joint Surg Am 1996; 78A:597–599.Google Scholar
  38. 38.
    Strecker WB, Wood MB, Bieber EJ. Compartment syndrome masked by epidural anesthesia for postoperative pain. J Bone Joint Surg Am 1986; 68A:1447–1448.Google Scholar
  39. 39.
    Morrow BC, Mawhinney IN, Elliott JRM. Tibial compartment syndrome complicating closed femoral nailing: diagnosis delayed by an epidural analgesic technique-case report. J Trauma 1994; 37:867–868.PubMedCrossRefGoogle Scholar
  40. 40.
    Janzing HMJ, Broos PLO. Routine monitoring of compartment pressure in patients with tibial fractures: beware of overtreatment. Injury 2001; 32:415–421.PubMedCrossRefGoogle Scholar
  41. 41.
    Gaspard DJ, Kohl RD. Compartment syndromes in which the skin is the limiting boundary. Clin Orthop 1975; 113: 65–68.PubMedCrossRefGoogle Scholar
  42. 42.
    Mubarak SJ, Owen CA. Double-incision fasciotomy of the leg for decompression in compartment syndromes. J Bone Joint Surg Am 1977;59A:184–187.Google Scholar
  43. 43.
    Tarlow SD, Achterman CA, Hayhurst J, Ovadia DN. Acute compartment syndrome of the thigh complicating fracture of the femur. A report of three cases. J Bone Joint Surg Am 1986;68A:1439–1443.Google Scholar
  44. 44.
    Bleicher RJ, Sherman HF, Latenser BA. Bilateral gluteal compartment syndrome. J Trauma 1997; 42:118–122.PubMedCrossRefGoogle Scholar
  45. 45.
    Perry MD, Manoli A. Foot compartment syndrome. Orthop Clin North Am 2001; 32:103–111.PubMedCrossRefGoogle Scholar
  46. 46.
    Fakhouri AJ, Manoli A. Acute foot compartment syndromes. J Orthop Trauma 1992; 6:223–228.PubMedGoogle Scholar
  47. 47.
    Bouachour G, Cronier P, Gouello JP, Toulemonde JL, Talha A, Alquier P. Hyperbaric oxygen therapy in the management of crush injuries: a randomized double-blind placebo controlled clinical trial. J Trauma 1996; 41:333–339.PubMedCrossRefGoogle Scholar
  48. 48.
    Morykwas MJ, Howell H, Bleyer AJ, Molnar JA, Argenta LC. The effect of externally applied subatmospheric pressure on serum myoglobin levels after a prolonged crush/ischemia injury. J Trauma 2002; 53:537–540.PubMedCrossRefGoogle Scholar
  49. 49.
    McKee MD, Garay ME, Schemitsch EH, Kreder HJ, Stephen DJG. Irreducible fracture-dislocation of the hip: a severe injury with a poor prognosis. J Orthop Trauma 1998; 12:223–229.PubMedCrossRefGoogle Scholar
  50. 50.
    Yang R-S, Tsuang Y-H, Hang Y-S, Liu T-K. Traumatic dislocation of the hip. Clin Orthop 1991; 265:218–227.PubMedGoogle Scholar
  51. 51.
    Jacob JR, Rao JP, Ciccarelli C. Traumatic dislocation and fracture dislocation of the hip. Clin Orthop 1987; 214:249–263.PubMedGoogle Scholar
  52. 52.
    Jaskulka RA, Fischer G, Fenzl G. Dislocation and fracturedislocation of the hip. J Bone Joint Surg Am 1991; 73B: 465–469.Google Scholar
  53. 53.
    Alonso JE, Volgas DA, Giordono V, Stannard J. A review of the treatment of hip dislocations associated with acetabular fractures. Clin Orthop 2000; 377:32–43.PubMedCrossRefGoogle Scholar
  54. 54.
    Nerubay J. Traumatic anterior dislocation of hip joint with vascular damage. Clin Orthop 1976; 116:129–132.PubMedGoogle Scholar
  55. 55.
    Siegmeth A, Menth-Chiari W, Amsuess H. A rare case of irreducible knee dislocation in a seventy-three-year-old male. J Orthop Trauma 2000; 14:70–72.PubMedCrossRefGoogle Scholar
  56. 56.
    Wand JS. A physical sign denoting irreducibility of a dislocated knee. J Bone Joint Surg Am 1989; 71B:862.Google Scholar
  57. 57.
    Hill JA, Rana NA. Complications of posterolateral dislocation of the knee: case report and literature review. Clin Orthop 1981; 154:212–215.PubMedGoogle Scholar
  58. 58.
    Stannard JP, Sheils TM, Lopez-Ben RR, McGwin G, Robison JT, Volgas DA. Vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. J Bone Joint Surg Am 2004; 86A: 910–915.Google Scholar
  59. 59.
    Kleinberg EO, Crites BM, Flinn WR, Archibald JD, Moorman CT. The role of arteriography in assessing popliteal artery injury in knee dislocations. J Trauma 2004; 56:786–790.CrossRefGoogle Scholar
  60. 60.
    Wascher DC. High-velocity knee dislocation with vascular injury. Clin Sports Med 2000; 19:457–477.PubMedCrossRefGoogle Scholar
  61. 61.
    Scheid DK. Treatment of the multiple ligament injured knee and knee dislocations: a trauma perspective. Instr Course Lect 2003; 52:409–411.PubMedGoogle Scholar
  62. 62.
    Harner CD, Waltrip RL, Bennett CH, Francis KA, Irrang JJ. Surgical management of knee dislocations. J Bone Joint Surg Am 2004; 86A:262–273.Google Scholar
  63. 63.
    Bibbo C, Anderson RB, Davis WH. Injury characteristics and the clinical outcome of subtalar dislocations: a clinical and radiographic analysis of 25 cases. Foot Ankle Int 2003; 24:158–163.PubMedGoogle Scholar
  64. 64.
    Plancher KD, Donshik JD. Femoral neck and ipsilateral neck and shaft fractures in the young adult. Orthop Clin North Am 1997; 28:447–459.PubMedCrossRefGoogle Scholar
  65. 65.
    Swiontkowski MF, Winquist RA, Hansen ST. Fractures of the femoral neck in patients between the ages of twelve and forty-nine years. J Bone Joint Surg Am 1984; 66A:837–846.Google Scholar
  66. 66.
    Keller CS, Laros GS. Indications for open reduction of femoral neck fractures. Clin Orthop 1980; 152:131–137.PubMedGoogle Scholar
  67. 67.
    Calandruccio RA, Anderson WE. Post-fracture avascular necrosis of the femoral head: correlation of experimental and clinical studies. Clin Orthop 1980; 152:49–84.PubMedGoogle Scholar
  68. 68.
    Frangakis EK. Intracapsular fractures of the neck of the femur. J Bone Joint Surg Am 1966; 48B:17–30.Google Scholar
  69. 69.
    Bosch U, Schreiber T, Kretteck C. Reduction and fixation of displaced intracapsular fractures of the proximal femur. Clin Orthop 2002; 388:59–71.Google Scholar
  70. 70.
    Bray TJ. Femoral neck fracture fixation. Clin Orthop 1997; 339:20–31.PubMedCrossRefGoogle Scholar
  71. 71.
    Asnis SE, Wanek-Sgaglione L. Intracapsular fractures of the femoral neck. J Bone Joint Surg Am 1994; 76A:1793–1803.Google Scholar
  72. 72.
    Scheck M. The significance of posterior comminution in femoral neck fractures. Clin Orthop 1980; 152:138–142.PubMedGoogle Scholar
  73. 73.
    Browner B, Trafton P, Green N, Swiontkowski M, Jupiter J, Levine A. Skeletal Trauma: Basic Science, Management, and Reconstruction, 3rd ed. Philadelphia: Saunders, 2003.Google Scholar
  74. 74.
    Crawfurd EJP, Emery RJH, Hansell DM, Phelan M, Andrews BG. Capsular distension and intracapsular pressure in subcapital fractures of the femur. J Bone Joint Surg Am 1988; 70B:195–198.Google Scholar
  75. 75.
    Stromqvist B, Nilsson L, Egund N, Thorngren K-G, Wingstraad H. Intracapsular pressures in undisplaced fractures of the neck. J Bone Joint Surg Am 1988; 70B:192–194.Google Scholar
  76. 76.
    Harper WM, Barnes MR, Gregg PJ. Femoral head blood flow in femoral neck fractures. J Bone Joint Surg Am 1991; 73B:73–75.Google Scholar
  77. 77.
    Watson JT, Moed BR. Ipsilateral femoral neck and shaft fractures. Clin Orthop 2002; 399:78–86.PubMedCrossRefGoogle Scholar
  78. 78.
    Swiontkowski MF, Hansen ST, Kellam JF. Ipsilateral fractures of the femoral neck and shaft. J Bone Joint Surg Am 1984; 66A:260–268.Google Scholar
  79. 79.
    Aucar JA, Hirshberg A. Damage control for vascular injuries. Surg Clin North Am 1997; 77:853–862.PubMedCrossRefGoogle Scholar
  80. 80.
    Weaver FA, Papanicolaou G, Yellin AE. Difficult peripheral vascular injuries. Surg Clin North Am 1996; 76:843–859.PubMedCrossRefGoogle Scholar
  81. 81.
    Frykberg ER, Dennis JW, Bishop K, Laneve L, Alexander RH. The reliability of physical examination in the evaluation of penetrating extremity trauma for vascular injury: results at one year. J Trauma 1991; 31:502–511.PubMedCrossRefGoogle Scholar
  82. 82.
    Bandyk DF. Vascular injury associated with extremity trauma. Clin Orthop 1995; 318:117–124.PubMedGoogle Scholar
  83. 83.
    Keeley SB, Snyder WH, Weigelt JA. Arterial injuries below the knee: fifty-one patients with 82 injuries. J Trauma 1983; 23:285–292.PubMedCrossRefGoogle Scholar
  84. 84.
    Francis H, Thal ER, Weigelt JA, Redman HC. Vascular proximity: is it a valid indication for arteriography in asymptomatic patients? J Trauma 1991; 31:512–514.PubMedCrossRefGoogle Scholar
  85. 85.
    Frykberg ER. Popliteal vascular injuries. Surg Clin North Am 2002; 82:67–89.PubMedCrossRefGoogle Scholar
  86. 86.
    Feliciano DV, Herskowitz K, O’Gorman RB, et al. Management of vascular injuries in the lower extremities. J Trauma 1988; 28:319–328.PubMedCrossRefGoogle Scholar
  87. 87.
    Johansen K, Lynch K, Paun M, Copass M. Non-invasive vascular test reliably exclude occult arterial trauma in injured extremities. J Trauma 1991; 31:515–522.PubMedCrossRefGoogle Scholar
  88. 88.
    Carrillo EH, Spain DA, Miller FB, Richardson JD. Femoral vessel injuries. Surg Clin North Am 2002; 82:49–65.PubMedCrossRefGoogle Scholar
  89. 89.
    Reber PU, Patel AG, Sapio NLD, Ris H-B, Beck M, Kniemeyer HW. Selective use of temporary intravascular shunts in coincident vascular and orthopedic upper and lower limb trauma. J Trauma 1999; 47:72–76.PubMedCrossRefGoogle Scholar
  90. 90.
    Wolf YG, Rivkind A. Vascular trauma in high-velocity gunshot wounds and shrapnel-blast injuries in Israel. Surg Clin North Am 2002; 82:237–244.PubMedCrossRefGoogle Scholar
  91. 91.
    Granchi T, Schmittling Z, Vasquez J, Schreiber M, Wall M. Prolonged use of intraluminal arterial shunts without systemic anticoagulation. Am J Surg 2000; 180:493–497.PubMedCrossRefGoogle Scholar
  92. 92.
    Starr AJ, Hunt JL, Reinert CM. Treatment of femur fracture with associated vascular injury. J Trauma 1996; 40:17–21.PubMedCrossRefGoogle Scholar
  93. 93.
    Drost TF, Rosemurgy AS, Proctor D, Kearney RE. Outcome of treatment of combined orthopedic and arterial trauma to the lower extremity. J Trauma 1989; 29:1331–1334.PubMedCrossRefGoogle Scholar
  94. 94.
    McHenry TP, Holcomb JB, Lindsey RW. Fractures with major vascular injuries from gunshot wounds: implications of surgical sequence. J Trauma 2002; 53:717–721.PubMedCrossRefGoogle Scholar
  95. 95.
    Ashworth EM, Dalsing M, Glover JL, Reilly MK. Lower extremity vascular trauma: a comprehensive, aggressive approach. J Trauma 1988; 28:329–336.PubMedCrossRefGoogle Scholar
  96. 96.
    Muscat JO, Rogers W, Cruz AB, Schenck RC. Arterial injuries in orthopaedics: the posteromedial approach for vascular control about the knee. J Orthop Trauma 1996; 10:476–480.PubMedCrossRefGoogle Scholar
  97. 97.
    Elek SD. Experimental staphylococcal infections in the skin of man. Ann NY Acad Sci 1957; 65:85–90.CrossRefGoogle Scholar
  98. 98.
    Khatod M, Botte MJ, Hoyt DB, Meyer RS, Smith JM, Akeson WH. Outcomes in open tibia fractures: relationship between delay in treatment and infection. J Trauma 2003; 55:949–954.PubMedCrossRefGoogle Scholar
  99. 99.
    Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma 2002; 16:484–490.PubMedCrossRefGoogle Scholar
  100. 100.
    Pollak AN, Castillo RC, Jones AL, Bosse MJ, MacKenzie EJ, Group LS. Time to definitive treatment significantly influences incidence of infection after open high-energy lower-extremity trauma. In Orthopaedic Trauma Association 19th Annual Meeting, Salt Lake City, UT, 2003: 98–100.Google Scholar
  101. 101.
    Weitz-Marshall AD, Bosse MJ. Timing of closure of open fractures. J Am Acad Orthop Surg 2002; 10:379–384.PubMedGoogle Scholar
  102. 102.
    Olson SA, Schemitsch EH. Open fractures of the tibial shaft: an update. Instr Course Lect 2003; 52:623–631.PubMedGoogle Scholar
  103. 103.
    Yang EC, Eisler J. Treatment of isolated type I open fractures: is emergent operative debridement necessary? Clin Orthop 2003; 410:289–294.PubMedCrossRefGoogle Scholar
  104. 104.
    Webb LX. New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg 2002; 10:303–311.PubMedGoogle Scholar
  105. 105.
    Hercovici D, Sanders RW, Scaduto JM, Infante A, Dipasquale T. Vacuum-assisted wound closure (VAC therapy) for the management of patients with highenergy soft tissue injuries. J Orthop Trauma 2003; 17:683–687.CrossRefGoogle Scholar
  106. 106.
    Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation of leg-threatening injuries. N Engl J Med 2002; 347:1924–1931.PubMedCrossRefGoogle Scholar
  107. 107.
    Smith DG, Castillo RC, MacKenzie EJ, Bosse MJ, Group LS. Functional outcome of patients who have late amputation after trauma is significantly worse than for those who have early amputation. In Orthopaedic Trauma Association 19th Annual Meeting, Salt Lake City, UT, 2003: 101–102.Google Scholar
  108. 108.
    Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am 2001; 83A: 3–14.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Tina A. Maxian
    • 1
  • Michael J. Bosse
    • 2
  1. 1.Department of Orthopaedic SurgeryState University of New York Upstate Medical UniversitySyracuseUSA
  2. 2.Department of Orthopaedic SurgeryCarolinas Medical CenterCharlotteUSA

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