Initial surgical management of injuries to the upper extremities for patients with multiple and/or severe injuries - a systematic review and clinical practice guideline update.

Clinical Snapshot

Key Findings

• P Value: Not reported

• Effect Size: Not quantitatively pooled; narrative synthesis only. Early surgery may improve functional outcomes and reduce complications, but adequate patient stabilisation is essential. Limb salvage recommended when MESS score <7 in sufficiently stable patients.

• Primary Outcome: Individualised timing of surgical intervention for upper extremity injuries in polytrauma patients, based on physiological status and injury pattern; limb salvage versus amputation decision-making using MESS score threshold

• Nnt Or Sensitivity: Sensitivity and specificity of scoring systems (including MESS) for predicting upper extremity amputation evaluated via included systematic review; specific values not reported in abstract. MESS score <7 used as threshold for limb salvage attempt recommendation.

• Confidence Interval: Not reported; no meta-analysis performed

Clinical Application

Recommendations are broadly feasible in well-resourced trauma centres with multidisciplinary teams including trauma surgeons, vascular surgeons, and plastic/reconstructive surgeons. The individualised, physiologically-guided approach to surgical timing is consistent with established damage control orthopaedics principles and does not require additional resources beyond standard Level 1 trauma centre capabilities. MESS score calculation is simple and requires no additional investigations beyond standard trauma assessment. In Australia, upper extremity polytrauma management is governed by RACS (Royal Australasian College of Surgeons) trauma guidelines and state-based Major Trauma Networks (e.g., The Alfred, Royal Melbourne Hospital, Royal Brisbane and Women's Hospital). The MESS score is already incorporated into Australian trauma practice for limb salvage decisions. TGA listing of relevant implants and vascular grafts is not a limiting factor. PBS does not directly govern surgical decision-making in this context. RACGP guidelines are not directly applicable to acute polytrauma surgical management. Australian trauma registries (AATD — Australian and New Zealand Trauma Registry) could contribute to future evidence generation in this area, given the acknowledged scarcity of high-quality studies. Rural and remote Australian contexts may face additional challenges regarding transfer times and specialist availability that are not addressed by this guideline. Adult polytrauma patients (multiple and/or severe injuries) presenting with upper extremity injuries including long bone fractures (humeral), vascular injuries requiring revascularisation, and mangled upper limb injuries requiring amputation versus salvage decisions. Applicability to isolated upper extremity injuries or paediatric polytrauma populations is not established by this review.

Abstract

PURPOSE: Our objective was to update the evidence-based and consensus-based recommendations for the initial surgical management of upper extremity injuries in patients with suspected multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2025 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries. METHODS: MEDLINE and Embase were systematically searched to September 2024. Further literature reports were obtained from clinical experts. Randomised controlled trials (RCTs) or observational studies reporting risk-adjusted outcomes were included if they compared early versus delayed surgical treatment for fractures, vascular injuries, or nerve injuries affecting the upper extremities in patients with multiple and/or severe injuries. Studies comparing limb salvage versus amputation or comparing amputation criteria for the upper extremities were also included. We considered patient-relevant outcomes such as mortality and limb salvage, as well as the sensitivity and specificity of scores for predicting upper extremity amputation. Risk of bias was assessed at the outcome level using ROBINS-I for observational studies and AMSTAR-2 for systematic reviews. We used available meta-analyses if possible; alternatively, we synthesised the evidence narratively. We used GRADE to rate the certainty of evidence. Expert consensus was used to develop recommendations and determine their strength. RESULTS: Among 2498 records screened for eligibility, four studies were included. Observational studies addressed the timing of humeral fixation, the timing of revascularisation, or compared limb salvage with amputation. A systematic review evaluated scoring systems for mangled upper limb salvage. Four recommendations were modified, and one consensus-based recommendation was added. All five recommendations achieved strong consensus. CONCLUSION: The timing of surgical intervention for upper extremity injuries in polytrauma patients should be individualized, based on the patient's physiological status, injury pattern, and the risks and benefits of early versus delayed surgery. Although early surgery may improve functional outcomes and reduce complications, adequate patient stabilization is essential before proceeding. Limb salvage should be attempted for patients with a MESS score of less than seven, provided the patient is sufficiently stable and depending on the condition of the amputated limb.Although the guideline addresses patients with multiple and/or severe injuries, the scarce evidence, heterogeneity of the included studies and the limited representation of true polytrauma cohorts may restrict the applicability of the findings to the broader critically injured trauma population.

References

1. 1.Berk, T., Könsgen, N., Lechler, P., Imach, S., Schär, M., Bieler, D., Horst, K., Hildebrand, F., & Goossen, K. (2026). Initial surgical management of injuries to the upper extremities for patients with multiple and/or severe injuries - a systematic review and clinical practice guideline update. European Journal of Trauma and Emergency Surgery: Official Publication of the European Trauma Society. https://doi.org/10.1055/a-2302-0858