Mangled Extremity Severity Score

What is the Mangled Extremity Severity Score?

The Mangled Extremity Severity Score (MESS) is a clinical tool designed to assist medical practitioners in assessing the severity of limb injuries, particularly in lower extremity trauma. It aids in predicting the likelihood of successful limb salvage versus the necessity for amputation. It is used for patients with severe lower extremity injuries, including vascular trauma and extensive soft tissue injuries.

Medical practitioners use MESS in trauma centers and in active combat zone medical facilities like field hospitals and casualty collection points. It is used for evaluating patients with mangled extremities resulting from high-speed trauma, multiple fractures, gross contamination, or active combat. The scoring system assesses four critical criteria: skeletal/soft tissue injury, limb ischemia, shock, and patient age. The total score informs the decision-making process regarding limb salvage or the need for early amputation.

The MESS is particularly valuable in managing extremity trauma in both civilian and combat-related injuries, providing a standardized approach for evaluating injury extent and guiding appropriate treatment strategies.

How does our Mangled Extremity Severity Score template work?

Our template is designed to guide you through systematically evaluating patients with severely injured lower extremities first. Here’s how to use the MESS:

1. Evaluate the type of trauma (e.g., high-speed injury, multiple fractures, or simple fractures). Look at the wound to determine the nature of the injury. Check for signs like open fractures, severe tissue damage, or deformities. You may ask the patient themselves about the trauma if they are conscious, or ask the first responders about the trauma. You may also use X-rays, CT scans, or MRIs to assess the extent of bone and soft tissue damage.
2. Classify the trauma as low, medium, high, or very high energy according to the table.
3. Assess vascular injuries and limb perfusion. Look for pallor, coolness, and delayed capillary refill in the affected limb. Check for the presence of distal pulses (e.g., dorsalis pedis and posterior tibial pulses). You may also use a handheld Doppler device to detect blood flow in the arteries of the injured limb. Note the duration of ischemia as well.
4. Score the trauma based on the presence and severity of ischemia, noting that prolonged ischemia (>6 hours) doubles the score.
5. Determine the patient’s hemodynamic status, scoring for transient or persistent hypotension. Measure blood pressure, heart rate, and respiratory rate to assess for signs of shock. Look for symptoms of shock such as altered mental status, cold and clammy skin, and rapid breathing. Evaluate the patient’s response to fluid resuscitation as well, and check for markers of shock, such as lactate levels and base deficit in blood tests.
6. Score the trauma based on the patient's hemodynamic status. Transient hypotension (corrected with fluids) scores 1 point, while persistent hypotension (requiring ongoing resuscitation) scores 2 points.
7. Assign points based on age brackets (<30, 30-50, >50). The age may be obtained by asking the patient or looking at their identification either via ID cards or medical records.
8. Sum the points from each category to obtain the extremity severity score.

Scoring and results of the MESS

Skeletal injuries, ranging from simple fractures to high-energy trauma, are scored from 1 to 4. Limb ischemia scores from 1 to 6, factoring in the duration and severity of blood flow impairment. Shock is assessed from 0 to 2, while age contributes 0 to 2 points.

Interpretation and next steps

The total MESS score predicts limb salvage potential or the need for amputation. A score of 7 or higher typically suggests a poor prognosis for limb salvage, guiding toward amputation to prevent secondary complications.

The steps indicated previously include ways to assess the trauma and a comprehensive evaluation of the injury mechanism. These details are vital to planning appropriate treatments for the patient. For lower extremity injuries with high scores, consider discussing potential outcomes with the patient and their family. Make sure that you explain the risks and the benefits of limb salvage versus having amputated limbs.

Collaboration with a multidisciplinary team, including orthopedic and vascular surgeons, ensures that the patient receives optimal care tailored to the specific injury, whether it involves simple fractures or complex issues like nerve injury.

Benefits of using our template

Utilizing our template offers advantages in managing lower extremity trauma and severely injured upper extremities. It streamlines the assessment process by providing a structured approach to evaluating key factors such as soft tissue injury, patient age, limb ischemia, and skeletal injury.  A standardized scoring system also ensures consistency in evaluating lower extremity injuries across different practitioners and trauma centers. This ensures a comprehensive evaluation of mangled extremities for more accurate predictions for limb salvage versus amputation.

The clinical utility is evident in the scale's ability to aid decision-making in complex cases involving gross contamination, high-speed trauma, and severe soft tissue damage. Quantifying the severity of extremity injuries helps prioritize treatment options, facilitating timely interventions such as vascular repair and addressing limb ischemia. Lastly, our template enhances communication and collaboration among medical professionals and improves patient outcomes.