Abstract
Background: Plantar sensation is considered to be a critical factor
in the evaluation of limb-threatening lower extremity trauma. The present
study was designed to determine the long-term outcomes following the treatment
of severe lower extremity injuries in patients who had had absent plantar
sensation at the time of the initial presentation.
Methods: We examined the outcomes for a subset of fifty-five
subjects who had had an insensate extremity at the time of presentation. The
patients were divided into two groups on the basis of the treatment in the
hospital: an insensate amputation group (twenty-six patients) and an insensate
salvage group (twenty-nine patients), the latter of which was the group of
primary interest. In addition, a control group was constructed from the parent
cohort so that the patients in the study groups could be compared with
patients in whom plantar sensation was present and in whom the limb was
reconstructed. Patient and injury characteristics as well as functional and
health-related quality-of-life outcomes at twelve and twenty-four months after
the injury were compared between the subjects in the insensate salvage group
and those in the other two groups.
Results: The patients in the insensate salvage group did not report
or demonstrate significantly worse outcomes at twelve or twenty-four months
after the injury compared with subjects in the insensate amputation or sensate
control groups. Among the patients in whom the limb was salvaged (that is,
those in the insensate salvage and sensate control groups), an equal
proportion (approximately 55%) had normal plantar sensation at two years after
the injury, regardless of whether plantar sensation had been reported to be
intact at the time of admission. No significant differences were noted among
the three groups with regard to the overall, physical, or psychosocial scores.
At two years after the injury, only one patient in the insensate salvage group
had absent plantar sensation.
Conclusions: Outcome was not adversely affected by limb salvage,
despite the presence of an insensate foot at the time of presentation. More
than one-half of the patients who had presented with an insensate foot that
was treated with limb reconstruction ultimately regained sensation at two
years. Initial plantar sensation is not prognostic of long-term plantar
sensory status or functional outcomes and should not be a component of a
limb-salvage decision algorithm.
Level of Evidence: Prognostic Level I. See Instructions
to Authors for a complete description of levels of evidence.
The treatment of severe, leg-threatening injuries often necessitates an
immediate or early decision between limb reconstruction and amputation. This
initial decision requires a prediction of treatment outcomes on the basis of
patient and injury characteristics. Although a multitude of guidelines and
scoring systems have been devised to assist with this
decision1-5,
recent work by Bosse et
al.6 has challenged
their usefulness. Of the five systems that were evaluated, three included
plantar sensation as a limb-scoring element. In a recent analysis of the
factors that were identified by treating surgeons as having affected the
decision to amputate a severely injured extremity, Swiontkowski et
al.7 identified the
absence of plantar sensation as one of the most important variables used in
the decision process.
In the current investigation, we sought to determine whether an insensate
foot is an accurate indicator of the need for amputation. More specifically,
we hypothesized that the outcomes associated with amputation and
reconstruction would be no different among patients who had an insensate foot
at the time of admission.
Study Population
The data for the current study were collected as part of the Lower
Extremity Assessment Project (the LEAP study), a multicenter, prospective
outcome study of 601 patients with severe, limb-threatening lower extremity
injuries8,9.
Eligible study patients included individuals between the ages of sixteen and
sixty-nine years who had been admitted to one of eight level-I trauma centers
with an injury distal to the femur. The injuries that were studied included
Gustilo and
Anderson10
type-IIIB and type-IIIC fractures, selected type-IIIA fractures, injuries
associated with dysvascular limbs (i.e., knee dislocations, closed tibial
fractures, or penetrating wounds associated with vascular injury), major
soft-tissue injuries (i.e., degloving or severe crush/avulsion injuries), or
severe foot and ankle injuries (i.e., open pilon or type-IIIB ankle fractures
or severe hindfoot or midfoot injuries). Patients were excluded if they had a
substantial brain injury (as indicated by a Glasgow Coma Scale score of <15
at twenty-one days after the injury or at the time of discharge), spinal cord
deficit, previous leg or foot amputation, or third-degree burns on the injured
leg. Patients also were excluded if they had been transferred to the
participating center more than twenty-four hours after the injury, if they did
not speak English or Spanish, if they had documented psychiatric disorders or
mental retardation, or if they were on active military duty or lived outside
the catchment area and were unable to return for follow-up at the
participating centers. Informed consent was obtained from all patients in
accordance with each center's institutional review board.
The current study is based on a subset of fifty-five patients with a
unilateral injury who did not have plantar sensation at the time of hospital
admission and on a matched subgroup of patients who did
(Fig. 1). Although 601 patients
were enrolled in the LEAP study, 112 were excluded from this analysis because
the severity of the limb injury had resulted in traumatic amputation
(forty-two patients) or had necessitated immediate amputation (thirty-eight
patients) or because they had sustained a bilateral injury (thirty-two
patients). Of the remaining 489 subjects, fifty-five had an insensate foot at
the time of admission and were divided into two groups according to treatment.
The first group (the insensate amputation group) comprised twenty-six patients
with absent plantar sensation who underwent amputation after the first
twenty-four hours (and after the initial operation on the limb) but during the
primary hospital admission, and the second group (the insensate salvage group)
comprised twenty-nine patients with absent plantar sensation in whom the limb
was reconstructed.
A third group (the sensate control group), comprising twenty-nine subjects
from the LEAP study in whom plantar sensation had been intact at the time of
admission and in whom the limb was salvaged, was constructed so that we could
compare the outcomes for subjects who had had an insensate extremity at the
time of admission (the insensate salvage group) with those for patients who
had had a sensate extremity at the time of admission (the sensate control
group). The twenty-nine patients in the sensate control group were matched to
the twenty-nine patients in the insensate salvage group on the basis of four
injury characteristics: (1) the severity of the muscle damage, (2) the
severity of the venous injury, (3) the severity of the tibial fracture, and
(4) the presence of an associated foot injury. These four injury
characteristics were selected because they were previously identified (in
addition to the absence of plantar sensation) as being the most important
predictors (in that order) of whether an extremity was amputated or
reconstructed during the initial
hospitalization7. A
table in the Appendix describes the criteria used to grade the severity of the
selected characteristics.
For each subject in the insensate salvage group, we identified all possible
controls with the same level of severity in terms of each of the four selected
injury characteristics. In all but three cases, at least one control who was
exactly matched in terms of all four injury criteria was found. In the
remaining three cases, one control was matched exactly in terms of the first
three criteria (i.e., severity of the muscle damage, venous injury, and tibial
fracture) and two controls were matched exactly in terms of the first two
criteria (i.e., severity of the muscle damage and venous injury). Whenever
more than one possible control was found, one was randomly selected. The total
study population consisted of eighty-four subjects who were divided into three
study groups, depending on the status of plantar sensation at the time of the
initial presentation and the type of limb treatment received during the
hospital stay (Fig. 1).
Data Collection
Subjects were enrolled in the study during the initial hospitalization and
were asked to return to the trauma center for a follow-up evaluation at three,
six, twelve, and twenty-four months after the injury. Prior to discharge from
the hospital, subjects were interviewed to obtain background sociodemographic
data and preinjury health-status
information9. At the
time of hospital admission, the attending orthopaedic surgeon documented the
nature and severity of the index injury according to several classifications
and/or scoring systems: (1) the Gustilo and
Anderson10 and
Tscherne and
Gotzen11
classifications of all tibial and foot fractures, (2) the Orthopaedic Trauma
Association12 and
AO13
classifications of long-bone fractures and soft-tissue tibial injuries, and
(3) all components of the Mangled Extremity Severity Score
(MESS)3, the
Hannover Fracture Scale
(HFS)14, the Limb
Salvage Index
(LSI)5, and the
Predictive Salvage Index
(PSI)2.
Different components of these systems were used to classify the severity of
each index injury according to three dimensions: (1) osseous injury, (2)
soft-tissue injury, and (3) neurovascular injury (see Appendix). Plantar
sensation was recorded as a dichotomous variable as either present (but not
necessarily normal) or absent. The presence or absence of plantar sensation
was determined on the basis of a clinical evaluation by the attending
orthopaedic surgeon and not on the basis of surgical exploration and
evaluation of the posterior tibial nerve.
The attending orthopaedic surgeon also recorded the primary treatment that
was received during the initial hospitalization (i.e., immediate or delayed
amputation as opposed to reconstruction) and whether the limb was initially
reconstructed and was subsequently amputated after discharge (i.e., late
amputation). The medical records for each patient and the trauma registries at
each site were used to obtain information on associated injuries, the
mechanism of injury, and the length of the hospital stay. All injuries were
classified according to the Abbreviated Injury
Scale15 and the
Injury Severity
Score16.
At twelve and twenty-four months after the injury, subjects underwent a
clinical evaluation (performed by the attending orthopaedic surgeon), a
functional status evaluation (performed by a physical therapist), and an
interview. The orthopaedic surgeon documented the clinical recovery in
relation to the index injury in terms of osseous and soft-tissue healing, any
limb complications that had occurred, and all treatment that had been received
in relation to the index injury. The physical therapy assessment included an
evaluation of leg impairment and function. Leg impairment was measured in
terms of range-of-motion limitations, pain, and impaired or absent plantar
sensation. Summary active range-of-motion scores were derived according to the
American Medical Association's Guides to the Evaluation of Permanent
Impairment17.
Pain was assessed with use of a visual analog scale. Patients were asked to
mark an X on a 100-mm line at the point that best described the pain that they
felt in the leg during a typical day (with 0 mm indicating no pain and 100 mm
indicating unbearable
pain)18. The
physical therapists also documented the subjects' current weight-bearing
status, use of orthoses or walking aids, and ability to ascend and descend a
flight of stairs reciprocally.
Sensation was evaluated at twenty-four months after the injury. Subjects
were examined and were asked if they had normal sensation in each leg.
Subjects who demonstrated or reported any type of abnormal sensation were
further examined with an assessment of their sensitivity to pinprick. For the
purposes of the current study, we report the results of sensation testing on
the plantar surface of the salvaged foot in three areas: the first
metatarsophalangeal joint, the middle part of the heel, and the middle part of
the lateral aspect of the foot. The physical therapist rated the sensation of
each of these areas as normal, impaired, or absent. If the sensation varied
among the three areas of the foot in a particular subject, the sensation of
the foot was classified as impaired.
Finally, health-related quality of life was assessed by asking subjects to
complete the Sickness Impact Profile
(SIP)19,20.
The SIP is a general health-status questionnaire that is used to evaluate 136
limitations in physical and psychosocial health across twelve health domains:
sleep and rest, eating, work, home management, recreation and pastimes,
walking ability, mobility, body care and movement, social interaction,
alertness, emotional behavior, and communication. SIP scores range from 0 to
100; the higher the score, the greater the dysfunction. The SIP has been
validated across different demographic and cultural groups and across
different types of injury and
illness8,19,21-28.
Analysis
The outcomes for subjects with absent plantar sensation at the time of the
initial evaluation who were managed with limb reconstruction (the insensate
salvage group) were compared with those for other patients with severe lower
limb injuries, specifically, subjects without plantar sensation who underwent
amputation during admission (the insensate amputation group) and subjects with
plantar sensation in whom the limb was salvaged (the sensate control group).
To ensure that differences in outcome were not due to differences in patient
characteristics or injury severity, we compared the patient characteristics
and injury severity in the insensate salvage group with those in the insensate
amputation and sensate control groups. For groups that had similar patient and
injury severity characteristics, functional and health-related quality-of-life
outcomes were compared. When one group was compared with another, a chi-square
statistic was used when the characteristic or outcome was categorical and a
Student t test was used when the variable of interest was continuous. For all
analyses, differences were considered to be significant if p < 0.05.
However, because of the small sample sizes within each group, differences were
also noted if p = 0.10.
With the numbers available, there were no significant differences in
sociodemographic or preinjury health characteristics between subjects without
plantar sensation who underwent reconstruction (the insensate salvage group)
and those in the other two study groups (see Appendix). No significant
differences in the length of hospital stay were noted among the study groups
(mean range, 13.7 to 19.7 days; p = 0.16).
The comparison of injury characteristics according to treatment group
revealed few differences in injury severity between subjects in the insensate
salvage group and those in the insensate amputation and sensate control
groups, with a few exceptions (see Appendix). First, subjects in the insensate
amputation group were more likely to have sustained substantial bone loss
compared with subjects in the insensate salvage group (23% compared with 3%; p
= 0.04). Second, subjects in the sensate control group were significantly more
likely to have normal limb perfusion compared with subjects in the insensate
salvage group (72% compared with 41%; p = 0.02).
We found no significant difference between the patients managed with
reconstruction (that is, between the insensate salvage and sensate control
groups) in terms of the rate of late amputation at two years after the injury
(15.8% [three of nineteen patients] and 18.2% [four of twenty-two patients],
respectively). With the numbers available, no significant differences were
noted between subjects in the insensate salvage group and those in the
insensate amputation and sensate control groups in terms of physical
impairment. Among subjects in whom the limb was salvaged (the insensate
salvage and sensate control groups), an equal proportion (approximately 55%)
either reported normal foot sensation or tested normally for pinprick
sensation, regardless of whether they had had intact or absent plantar
sensation at the time of hospital admission. Five (25%) of the patients in the
sensate cohort had development of plantar sensory dysfunction over the course
of the limb reconstruction. Only one patient who underwent limb reconstruction
after presenting with absent sensation remained insensate at two years.
Similarly, with the numbers available, no significant differences were noted
between subjects in the insensate salvage group and those in the insensate
amputation and sensate control groups in terms of pain or range-of-motion
scores at twelve or twenty-four months after the injury.
Functionally, subjects in the insensate amputation and sensate control
groups were significantly more likely to wear an immobilization device (cast,
splint and orthosis, or prosthesis) compared with subjects in the insensate
salvage group (p < 0.05). Subjects in the insensate amputation group also
were significantly more likely to use a walking aid (crutches, walker, or
cane) at twelve months compared with subjects in the insensate salvage group
(71% compared with 38%; p = 0.04). Finally, at twelve months, subjects without
plantar sensation who had undergone amputation (the insensate amputation
group) also were significantly less likely to be able to climb and descend
stairs reciprocally compared with subjects without plantar sensation in whom
the limb was salvaged (the insensate salvage group) (18% compared with 54%; p
= 0.02).
We found no significant differences among the treatment groups with regard
to the proportion of subjects who completed the twelve-month (range, 90% to
93%; p = 0.88) or twenty-four-month follow-up evaluation (range, 69% to 90%; p
= 0.14) (Table I). With the
numbers available, we found no significant differences between the subjects in
the insensate salvage group and those in the insensate amputation and sensate
control groups with regard to health-related quality-of-life activities at
twelve or twenty-four months. Overall, the physical, psychosocial, and work
SIP scores were similar between the groups
(Table II). All study groups
reported poorer health-related quality of life at twelve and twenty-four
months after the injury as compared with a preinjury sample of patients with
similar but less severe
injuries29. Among
subjects who had been working before the injury, we found no significant
differences between those in the insensate salvage group and those in the
other study groups with regard to percentage of subjects who had returned to
work at twelve or twenty-four months after the injury.
Although excluded from this study design, the thirty-eight patients who
were managed with immediate amputation (that is, those in whom amputation was
the index procedure) were reviewed to determine the status of plantar
sensation at the time when the limb-treatment decision was made. All of these
patients had had absent plantar sensation.
The findings of the present study do not support the belief that the
initial plantar sensory status in patients who have a leg-threatening injury
is correlated with poor late outcome if limb salvage is attempted. The current
analysis demonstrated that although patients with severe injuries and absent
plantar sensation at the time of presentation had substantial impairment at
twelve and twenty-four months, the patients managed with limb salvage did not
have worse outcomes than those managed with amputation. Of importance was the
finding that the group of patients who had had absent plantar sensation at the
time of presentation and who were managed with limb salvage (the insensate
salvage group) was not significantly different from a control group of
patients with similar injuries in whom plantar sensation had been intact at
the time of presentation (the sensate control group) in terms of outcome,
final plantar sensory status, or the need for late amputation.
Our results suggest that tibial nerve dysfunction on clinical examination
cannot be assumed to be equivalent to nerve disruption. Ten (67%) of fifteen
subjects in the insensate salvage group (excluding three patients in whom the
limb was later amputated) had normal foot sensation at two years after the
injury. It is likely that a substantial number of these cases were the result
of reversible ischemia or neurapraxic injuries of peripheral nerves rather
than permanent loss of tibial nerve function.
Absent plantar sensation has been identified as a critical element in the
decision-making process when selecting amputation or limb reconstruction for
patients with a severe injury of the lower extremity. The current treatment of
a severely injured lower limb may be influenced by the belief that plantar
sensation dysfunction and late outcomes are related. Swiontkowski et
al.7 studied the
decision-making process in order to determine the critical elements used by
the surgeon to make the initial treatment decision between amputation and limb
salvage. At the time of the initial presentation, the treating surgeon
rank-ordered critical injury and patient characteristics that were
hypothesized to impact the treatment decision. Tibial nerve dysfunction was
identified as the most important clinical finding, ranking even higher than
limb ischemia. At the conclusion of patient enrollment, the surgeons who had
managed the patients were surveyed to determine the limb injury
characteristics that had driven the decision process. Plantar sensation was
considered to be the most important physical finding directing treatment. The
Mangled Extremity Severity Score
(MESS)3; the Nerve
Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age (NISSSA)
score4; and the
Hannover Fracture
Scale14 heavily
weight the results of the initial plantar sensory examination, with the
assumption that a sensory impairment correlates with diminished limb-salvage
capacity and that the initial examination represents the final deficit. Bosse
et al.6
prospectively evaluated the clinical utility of the lower-extremity injury
severity scores and were unable to validate the scores as useful clinical
tools for the amputation decision-making process. Three of the five scores
that were evaluated contained elements that included plantar sensation. The
origin of the relative importance of tibial nerve function in this patient
group is difficult to trace. The long-term outcomes for patients with tibial
nerve dysfunction following extremity trauma are unknown. Despite the belief
among some investigators that an insensate foot precludes successful treatment
of an injured lower extremity, the insensate foot is routinely treated without
amputation in patients with other conditions, including diabetes and spinal
cord
injury30-33.
Lange et al.34
suggested a decision-making protocol based on absolute and relative
indications for immediate amputation. The presence of one of two absolute
indications (either complete tibial nerve disruption or a crush injury with
warm ischemia of more than six hours' duration) or of two of three relative
indications (serious associated polytrauma, severe ipsilateral foot trauma, or
a projected long course to full recovery) was suggested as an indication for
immediate amputation. One of the limitations of this protocol is that, in most
cases, complete tibial nerve disruption is difficult to confirm at the time of
decision-making, and in many cases it is inferred by examination of sensory
function on the plantar surface of the foot. Surgical exploration of the nerve
within the zone of injury is usually contraindicated as it causes additional
soft-tissue injury.
The employment of the initial plantar sensory examination in the
decision-making process may yield a self-fulfilling prophecy. It is possible
that orthopaedic surgeons are performing early limb amputation on the basis of
the plantar sensory examination of extremities that have the potential to
perform as well, if reconstructed. In the parent study, thirty-eight patients
were managed with immediate limb amputation; all of those patients lacked
plantar sensation. It is difficult to determine the extent to which this
finding influenced the decision to amputate the limb, if at all. Bosse et
al.8 found that the
two-year outcomes for patients with severe lower extremity injuries who had
been managed with amputation were no different from those who had been managed
with reconstruction and concluded that limb reconstruction efforts should
continue. In the present study, the subanalysis comparing the insensate
salvage group with the sensate control group and the insensate amputation
group led to the same conclusion.
The results of the present study should be interpreted in light of its
limitations. The project was not a randomized, controlled trial, but every
effort was made to enable comparisons among similarly injured groups. The
sample size was small and approximately 30% of patients had been lost to
follow-up by twenty-four months, thereby limiting our ability to detect small
but potentially important differences between the groups. Likewise, the small
sample size limited our ability to conduct multivariate analyses and to
control for different patient and injury characteristics when evaluating
outcomes among the three treatment groups. These differences have been shown
to affect the final SIP
score8. However, our
bivariate analyses revealed few significant differences between the three
treatment groups according to patient or injury characteristics.
The results of the present study demonstrated that patients with a severe
lower extremity injury in whom plantar sensation had been absent at the time
of initial presentation had substantial impairment at twelve and twenty-four
months. This impairment appeared to be independent of treatment with either
amputation or limb salvage. The outcome at two years did not appear to be
adversely affected by limb salvage, despite the presence of an insensate foot
at the time of admission. Surgeons employing limb-salvage scores to direct the
decision-making process should critically assess the elements of these scores
and the weight, if any, given to plantar sensation. The use of an insensate
foot as an indicator of the need for amputation should be avoided.
Tables showing the definition of leg injury characteristics used in this
study and detailed patient and injury characteristics are available with the
electronic versions of this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM).?
Note: The Leap Study Group includes Ellen J. MacKenzie, PhD;
Michael J. Bosse, MD; James F. Kellam, MD; Andrew R. Burgess, MD; Lawrence X.
Webb, MD; Marc F. Swiontkowski, MD; Roy Sanders, MD; Alan L. Jones, MD; Mark
P. McAndrew, MD; Brendan Patterson, MD; and Melissa L. McCarthy, ScD.
Gregory RT, Gould RJ, Peclet M, Wagner
JS, Gilbert DA, Wheeler JR, Snyder SO, Gayle RG, Schwab CW. The mangled
extremity syndrome (M.E.S.): a severity grading system for multisystem injury
of the extremity. J Trauma.1985;25:
1147-50.251147
1985
[PubMed][CrossRef]
Howe HR Jr, Poole GV Jr, Hansen KJ,
Clark T, Plonk GW, Koman LA, Pennell TC. Salvage of lower extremities
following combined orthopaedic and vascular trauma. A predictive salvage
index. Am Surg.1987;53:
205-8.53205
1987
[PubMed]
Johansen K, Daines M, Howey T, Helfet D,
Hansen ST Jr. Objective criteria accurately predict amputation following lower
extremity trauma. J Trauma.1990;30:
568-73.30568
1990
[PubMed][CrossRef]
McNamara MG, Heckman JD, Corley FG.
Severe open fractures of the lower extremity: a retrospective evaluation of
the Mangled Extremity Severity Score (MESS). J Orthop Trauma.1994;8:
81-7.881
1994
[PubMed][CrossRef]
Russell WL, Sailors DM, Whittle TB,
Fisher DF Jr, Burns RP. Limb salvage versus traumatic amputation. A decision
based on a seven-part predictive index. Ann Surg.1991;213:
473-81.213473
1991
[PubMed][CrossRef]
Bosse MJ, MacKenzie EJ, Kellam JF,
Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP,
Patterson BM, McCarthy ML, Cyril JK. A prospective evaluation of the clinical
utility of the lower-extremity injury-severity scores. J Bone Joint
Surg Am.2001;83:
3-14.833
2001
[CrossRef]
Swiontkowski MF, MacKenzie EJ, Bosse MJ,
Jones AL, Travison T; for the LEAP Study Group. Factors influencing the
decision to amputate or reconstruct after high-energy lower extremity trauma.
J Trauma.2002;52:
641-9. Erratum in: J Trauma. 2002;53:48.52641
2002
[PubMed][CrossRef]
Bosse MJ, MacKenzie EJ, Kellam JF,
Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP,
Patterson BM, McCarthy ML, Travison TG, Castillo RC. An analysis of outcomes
of reconstruction or amputation after leg-threatening injuries. N Engl
J Med.2002;347:
1924-31.3471924
2002
[CrossRef]
MacKenzie EJ, Bosse MJ, Kellam JF,
Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP,
Patterson TM, McCarthy ML. Characterization of patients with high-energy lower
extremity trauma. J Orthop Trauma.2000;14:
455-66.14455
2000
[PubMed][CrossRef]
Gustilo RB, Anderson JT. Prevention of
infection in the treatment of one thousand and twenty-five open fractures of
long bones: retrospective and prospective analyses. J Bone Joint Surg
Am.1976;58:
453-8.58453
1976
Tscherne H, Gotzen LE, editors.
Fractures with soft tissue injuries. New York: Springer;
1984.
1984
Fracture and dislocation compendium. Orthopaedic Trauma Association
Committee for Coding and Classification. J Orthop Trauma.1996;10 Suppl 1:v-ix,
1-154.101
1996
[PubMed][CrossRef]
Muller ME, Nazarian S, Koch P, Schatzker
J. The comprehensive classification of fractures of long bones.
New York: Springer; 1990.
1990
Tscherne H, Oestern HJ. [A new classification of soft-tissue damage
in open and closed fractures (author's transl)].
Unfallheilkunde.1982;85:
111-5. German.85111
1982
[PubMed]
The abbreviated injury scale. Des Plaines, IL:
Association for the Advancement of Automotive Medicine;
1990.
1990
Baker SP, O'Neill B, Haddon W Jr, Long
WB. The injury severity score: a method for describing patients with multiple
injuries and evaluating emergency care. J Trauma.1974;14:
187-96.14187
1974
[PubMed][CrossRef]
Guides to the evaluation of permanent impairment.
4th ed. Chicago: American Medical Association; 1993.
1993
Scott J, Huskisson EC. Graphic
representation of pain. Pain.
1976;2:
175-84.2175
1976
[PubMed][CrossRef]
Bergner L, Hallstrom AP, Bergner M,
Eisenberg MS, Cobb LA. Health status of survivors of cardiac arrest and of
myocardial infarction controls. Am J Public Health.1985;75:
1321-3.751321
1985
[PubMed][CrossRef]
Bergner M, Bobbitt RA, Carter WB, Gilson
BS. The Sickness Impact Profile: development and final revisions of a health
status measure. Med Care.1981;19:
787-805.19787
1981
[PubMed][CrossRef]
Deyo RA, Inui TS, Leininger J, Overman
S. Physical and psychosocial function in rheumatoid arthritis. Clinical use of
a self-administered health status instrument. Arch Intern Med.1982;142:
879-82.142879
1982
[PubMed][CrossRef]
Deyo RA, Diehl AK, Rosenthal M. How many
days of bed rest for acute low back pain? A randomized clinical trial.
N Engl J Med.1986;315:
1064-70.3151064
1986
[PubMed][CrossRef]
Drossman DA, Patrick DL, Mitchell CM,
Zagami EA, Appelbaum MI. Health-related quality of life in inflammatory bowel
disease. Functional status and patient worries and concerns. Dig Dis
Sci.1989;34:
1379-86.341379
1989
[CrossRef]
Follick MJ, Smith TW, Ahern DK. The
sickness impact profile: a global measure of disability in chronic low back
pain. Pain.1985;21:
67-76.2167
1985
[PubMed][CrossRef]
Hart LG, Evans RW. The functional status
of ESRD patients as measured by the Sickness Impact Profile. J Chronic
Dis.1987;40 Suppl 1:
117S-36S.40117S
1987
[CrossRef]
Jurkovich G, Mock C, MacKenzie E, Burgess A, Cushing B, deLateur B,
McAndrew M, Morris J, Swiontkowski M. The Sickness Impact Profile as a tool to
evaluate functional outcome in trauma patients. J Trauma.1995;39:
625-31.39625
1995
[PubMed][CrossRef]
McSweeny AJ, Grant I, Heaton RK, Adams
KM, Timms RM. Life quality of patients with chronic obstructive pulmonary
disease. Arch Int Med.1982;142:
473-8.142473
1982
[CrossRef]
Temkin N, McLean A Jr, Dikmen S, Gale J,
Bergner M, Almes MJ. Development and evaluation of modifications to the
Sickness Impact Profile for head injury. J Clin Epidemiol.1988;41:
47-57.4147
1988
[PubMed][CrossRef]
MacKenzie EJ, Burgess AR, McAndrew MP,
Swiontkowski M, Cushing BM, deLateur BJ, Jurkovich GJ, Morris JA Jr.
Patient-oriented functional outcome after unilateral lower extremity fracture.
J Orthop Trauma.1993;7:
393-401.7393
1993
[PubMed][CrossRef]
Garland DE, Saucedo T, Reiser TV. The
management of tibial fractures in acute spinal cord injury patients.
Clin Orthop Relat Res.1986;213:
237-40.213237
1986
[PubMed]
Nottage WM. A review of long-bone
fractures in patients with spinal cord injuries. Clin Orthop Relat
Res.1981;155:
65-70.15565
1981
Pinzur MS, Shields N, Trepman E, Dawson
P, Evans A. Current practice patterns in the treatment of Charcot foot.
Foot Ankle Int.2000;21:
916-20.21916
2000
[PubMed]
Simon SR, Tejwani SG, Wilson DL, Santner
TJ, Denniston NL. Arthrodesis as an early alternative to nonoperative
management of Charcot arthropathy of the diabetic foot. J Bone Joint
Surg Am.2000;82:
939-50.82939
2000
Lange RH, Bach AW, Hansen ST Jr,
Johansen KH. Open tibial fractures with associated vascular injuries:
prognosis for limb salvage. J Trauma.1985;25:
203-8.25203
1985
[PubMed][CrossRef]