Mangled Extremity Severity Score

We often encounter mangled limbs in which we must decide whether to attempt salvage or to perform primary amputation.  One method of determining salvagability is the Mangled Extremity Severity Score (MESS).

The MESS is based on the degree of energy imparted to the limb, ischemia, presence of shock and patient's age.  It has been validated in both retrospective and prospective studies and a total score of 6 or less predicts a salvageable limb.  A score of 7 or more predicts ultimate amputation of that limb.

Mangled Extremity Severity Score

Calculate by adding energy, shock, ischemia and age scores.

Type	Characteristics	Injuries	Points
1	Low energy	Stab wounds, simple closed fractures, small-caliber gunshot wounds	1
2	Medium energy	Open or multiple-level fractures, dislocations, moderate crush injuries	2
3	High energy	Shotgun blast (close range), high-velocity gunshot wounds	3
4	Massive crush	Logging, railroad, oil rig accidents	4
Shock Group
1	Normotensive hemodynamics	BP stable in field and in OR	0
2	Transiently hypotensive	BP unstable in field but responsive to intravenous fluids	1
3	Prolonged hypotension	Systolic BP <90 mm Hg in field and responsive to intravenous fluid only in OR	2
Ischemia Group (multiply by 2 if ischemic for over 6 hours)
1	None	Pulsatile limb without signs of ischemia	0[*]
2	Mild	Diminished pulses without signs of ischemia	1[*]
3	Moderate	No pulse by Doppler, sluggish capillary refill, paresthesia, diminished motor activity	2[*]
4	Advanced	Pulseless, cool, paralyzed, and numb without capillary refill	3[*]
Age Group
1	<30 y		0
2	>30 – <50 y		1
3	>50 y		2