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    Mangled Extremity Severity Score (MESS Score)

    Estimates viability of an extremity after trauma, to determine need for salvage vs empiric amputation.
    When to Use
    Why Use

    The Mangled Extremity Severity Score can be applied to all adult patients who present with extremity trauma, particularly lower extremity trauma.

    The Mangled Extremity Severity Score (MESS) was developed to discriminate between salvageable and doomed limbs in the setting of lower extremity trauma.

    • MESS could provide an early prognosis on the injured limb at time of Emergency Department or initial contact with healthcare system.
    • Newer surgical techniques since the development of the score in the late 1980s may alter the outcome of patients with a MESS ≥7.
    • Has been validated for upper extremity injuries as well. however as the MESS creator Dr. Johansen suggests, upper extremities are profoundly more important than lower extremities and prosthesis much more primitive, so nearly every effort at salvage should be attempted.
    • Only large, prospective, multi-center study of the MESS found that a cut-off of 7 had poor sensitivity and mediocre specificity.
    • MESS Creator Dr. Johansen suggests that, due to newer techniques that increase the probability of limb salvage, a higher MESS “cut off” may be considered, perhaps 8 or 9.
    • The MESS can potentially identify at time of initial evaluation patients who are candidates for successful limb salvage vs future amputation.
    • The MESS utilizes variables that can be readily obtained without extensive and complicated measurements or calculations.
    Reduced pulse but normal perfusion
    Pulseless, paresthesias, slow capillary refill
    Cool, paralysis, numb/insensate
    < 30
    ≥ 50
    SBP > 90 mmHg consistently
    Transient hypotension
    Persistent hypotension
    Low energy (stab, gunshot, simple fracture)
    Medium energy (dislocation, open/multiple fractures)
    High energy (high speed MVA or rifle shot)
    Very high energy (high speed trauma with gross contamination)


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    Next Steps
    Creator Insights


    • All patients with significant trauma require a thorough trauma assessment and resuscitation.
    • Trauma victims require management of significant craniocerebral, thoracic, abdominal, and pelvic injuries prior to consideration of limb salvage.


    After initial stabilization and resuscitation in the Emergency Department, urgent orthopedics consultation or transfer to a higher level of care is critical as time of ischemia plays a significant role in the MESS.

    Critical Actions

    Patients with a MESS ≥ 7 are likely to require amputation secondary to their limb trauma.

    Content Contributors
    About the Creator
    Dr. Kaj Johansen
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