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Mangled Extremity Severity Score (MESS Score)

Calculators  Multiple body systems
MESS (Mangled Extremity Severity Score) is a simple scoring scale for extremity after trauma, that determines the need for salvage vs amputation.
Limb ischemia for > 6 hours
No
Yes
Limb ischemia
Reduced pulse but normal perfusion 1
Pulseless, paresthesias, slow capillary refill 2
Cool, paralysis, numb/insensate 3
Limb ischemia
Reduced pulse but normal perfusion 2
Pulseless, paresthesias, slow capillary refill 4
Cool, paralysis, numb/insensate 6
Patient age
< 30 0
30-50 1
≥ 50 2
Shock
SBP > 90 mmHg consistently 0
Transient hypotension 1
Persistent hypotension 2
Injury mechanism
Low energy (stab, gunshot, simple fracture) 1
Medium energy (dislocation, open/multiple fractures) 2
High energy (high speed MVA or rifle shot) 3
Very high energy (high speed trauma with gross contamination) 4
Result:

Background

Measured Factor
Mangled Extremity Severity Score
Measured Factor Disease
  • Lower limb extremity trauma
Measured Factor Detail
MESS predicts need of amputation following lower extremity trauma. This rating scale takes into consideration the patient's skeletal/soft-tissue damage, shock, limb ischemia and age. It was found that patients with salvaged limbs had a MESS less than or equal to 6 while all amputated limbs had a MESS greater than 6.
Speciality
Multi-Speciality
Body System
Multiple body systems
Measured Factor Low Impact
  • MESS scores < or = 6 predictive of the limb salvage.
Measured Factor High Impact
  • MESS scores > 6 predictive of the multiple instances of amputation

Result Interpretation

Ranges Ranges
  • Critical High: greater than 6 score
  • Normal: less than or equal to 6 score
  • Normal Adult Male: less than or equal to 6 score
  • Normal Adult Female: less than or equal to 6 score
Result High Conditions
  • Skeletal injury
  • Soft-tissue injury
  • Ischaemia of the limb
  • Systolic blood pressure of 90 mmHg
False Positive
  • The use of MESS scoring system in children shows 100 % sensitivity but only 66 % specificity
  • The MESS use age as a parameter, thus making a differentiation among paediatric patients is difficult
  • MESS also use shock parameter that is based on systolic blood pressure which is inapplicable in light to children
  • Lower extremity injuries severity scores work differently in children than in adults
References: 3
Test Limitations
MESS score is less accurate in predicting limbs that require amputation when applied for the evaluation of severe IIIB injuries.
References: 4

Studies

Study Validation 1
The aim of this retrospective study was to evaluate the reliability of mangled extremity severity score (MESS) in both upper and lower extremities. 139 patients with Gustillo Anderson Type III open fractures of both the upper and lower extremities were recruited in the study. Patients were divided into two groups: amputated and limb salvage group. MESS scores (range 6-11) were evaluated based on the data for patient age, fire arm type, transporting time from the field to the hospital (and the method), injury severity scores, fracture types, infections if any. The mean MESS scores for upper and lower extremity were 8.8 and 9.24 respectively in amputated group while in the limb salvage group scores were 5.29 and 5.19 respectively. This study concluded that as MESS score showed a higher negative predictive value for upper and lower extremities it is not a good predictive indicator in related extremity injuries.
References: 5
Study Validation 2
The aim of this study was to validate the functioning of Mangled Extremity Severity Score (MESS) for predicting the measures for soldiers who are presented with combat-related Gustilo-Anderson type III open tibia fractures. Data of 155 Soldiers with combat-related type III open tibia fractures occurring between 2003 and 2007 was collected in the study. The primary outcomes measures were MESS score amputation or limb salvage. The mean MESS values for amputees and patients treated with limb salvage were 5.8 and 5.3 (P = 0.057), respectively. Sensitivity and specificity of MESS score for predicting amputation was forund to be 5.8 and 5.3 (P = 0.057), respectively with positive predictive value of 50% for MESS value of ≥7. This study concludes that MESS was not a strong score in predicting amputation.
References: 6
Study Validation 3
This study aimed to validate the Mangled Extremity Syndrome Index Mangled Extremity Severity Score [MESS] in children. A total 200 children with lower extremity long bone open fractures were involved in the study. MESS score (range 6-11) was utilized to measure the severity of limb injury. Children were scrutinized in amputation and limb salvage group based on grade of open fractures and severity of injury. The mean MESS score in the amputation group was 7.5 ± 1.59 compared with 6.4 ± 2.02 in the limb salvage group (p = 0.04). The adequate clinical discriminator power was calculated as MESS ≥ 6.5 (sensitivity = 73%, specificity = 54%). The study concluded that MESS score can be effective scale to identify patients with a high risk of amputation at early stage
References: 7
Study Additional 1
This study aimed to validate the Mangled Extremity Syndrome Index Mangled Extremity Severity Score [MESS] in children. A total 200 children with lower extremity long bone open fractures were involved in the study. MESS score (range 6-11) was utilized to measure the severity of limb injury. Children were scrutinized in amputation and limb salvage group based on grade of open fractures and severity of injury. The mean MESS score in the amputation group was 7.5 ± 1.59 compared with 6.4 ± 2.02 in the limb salvage group (p = 0.04). The adequate clinical discriminator power was calculated as MESS ≥ 6.5 (sensitivity = 73%, specificity = 54%). The study concluded that MESS score can be effective scale to identify patients with a high risk of amputation at early stage
References: 8
Study Additional 2
This 3 year retrospective study from 1987 to 1990 was aimed to validate the MESS score in predicting amputation and determine its accuracy. Data from 37 patients presented with 43 open fractures or with mangled upper extremity injuries was collected and studied at New Mexico Regional Trauma Centre (NMRTC). MESS score was applied to all the patients and results showed that  9 patients who scored  > 7 MESS score were amputated and remaining patients with MESS score < 7 were  salvaged. This study concluded that MESS score can be utilized in indentifying early and adequate extremities
References: 9
Study Additional 3
This study was conducted from 2002 to 2007 with purpose of evaluating the MESS score in predicting upper extremity vascular injury. A total 52 patients with UEVIs were included in the study. MESS score was assigned to all patients of age 15-59 years. Ischemic time, mechanism of injury, demographic information and amputation rate were the primary evaluation parameters and there correlation with amputation was found. Multivariate analysis revealed only MESS score was factor which correlated with the amputation. A mess score with more than 7 was indicative of amputation. This study concluded that MESS score was accurate measure in predicting the risk of amputation in patients with upper extremity vascular injury (UEVI)
References: 10

References

  1. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990 May;30(5):568-72
  2. Togawa S, Yamami N, Nakayama H, Mano Y, Ikegami K, Ozeki S. The validity of the mangled extremity severity score in the assessment of upper limb injuries. J Bone Joint Surg Br. 2005;87(11):1516-9.
  3. Stewart DA, Coombs CJ, Graham HK. Application of lower extremity injury severity scores in children. J Child Orthop. 2012;6(5):427-31.
  4. Shanmuganathan R. The utility of scores in the decision to salvage or amputation in severely injured limbs. Indian J Orthop. 2008;42(4):368-76.
  5. Ege T, Unlu A, Tas H, Bek D, Turkan S, Cetinkaya A. Reliability of the mangled extremity severity score in combat-related upper and lower extremity injuries. Indian J Orthop. 2015 Nov-Dec;49(6):656-60. doi: 10.4103/0019-5413.168759.
  6. Sheean AJ, Krueger CA, Napierala MA, Stinner DJ, Hsu JR; Skeletal Trauma and Research Consortium (STReC). Evaluation of the mangled extremity severity score in combat-related type III open tibia fracture.J Orthop Trauma. 2014 Sep;28(9):523-6. doi: 10.1097/BOT.0000000000000054.
  7. Stewart D, Coombs C, Graham H. Evaluation of mangled extremity severity score (MESS) as a predictor of lower limb amputation in children with trauma. Eur J Pediatr Surg. 2013 Aug;23(4):333-4. doi: 10.1055/s-0032-1333117
  8. Behdad S, Rafiei MH, Taheri H, Behdad S, Mohammadzadeh M, Kiani G, Hosseinpour M. Evaluation of Mangled Extremity Severity Score (MESS) as a predictor of lower limb amputation in children with trauma. Eur J Pediatr Surg. 2012 Dec;22(6):465-9. doi: 10.1055/s-0032-1322541.
  9. Slauterbeck JR, Britton C, Moneim MS, Clevenger FW. Mangled extremity severity score: an accurate guide to treatment of the severely injured upper extremity. J Orthop Trauma. 1994 Aug;8(4):282-5.
  10. Prichayudh S, Verananvattna A, Sriussadaporn S, Sriussadaporn S, Kritayakirana K, Pak-art R, et al. Management of upper extremity vascular injury: outcome related to the Mangled Extremity Severity Score. World J Surg. 2009 Apr;33(4):857-63. doi: 10.1007/s00268-008-9902-4.