Which is the best score and classification system for complex injuries of the limbs? Some recommendations based on a systematic literature review

Background Management of complex trauma of the upper and lower limbs represents a constant challenge for orthopedic surgeons and plastic surgeons, especially due to the difficulty encountered in the decision-making process of trying to save the affected limb and reducing the risk of poor prognosis. Score and classification systems have been developed to guide the surgical indication based on the objectivity of the clinical picture and the potential results that can be obtained. The aim of this paper is to evaluate and compare the different score and classification systems used to choose the most effective indications and surgical strategy in complex limb trauma. Methods The authors carried out a systematic review of the literature comparing the classifications of exposed limb fractures and scoring systems on the most suitable surgical indication, evaluating their reliability and impact on the preoperative decision-making process. Results From the PubMed search, the authors extracted and reviewed 53 studies published between 1976 and 2018. The following were compared: Gustilo-Anderson classification, Tscherne-Oestern classification, Orthopedic Trauma Association classification, Mangled Extremity System Score, Ganga Hospital Open Injury Severity Score, NISSSA (Nerve injury, Ischemia, Soft-tissue injury, Shock, and Age of Patient Score), and others. Pros and cons have been highlighted for each of them, particularly in terms of sensitivity and specificity. Conclusions The results of literature review showed that to date, there is no ideal classification for complex limb injuries and that even the most recently published recommendations use classifications that present important drawbacks. For complex trauma of the upper limb, the available classifications are even more incomplete. A multidisciplinary judgment, of both orthopedic and plastic surgeons on used score and classification systems, may give the patient an accurate reconstructive surgical treatment. As for amputative and sub-amputative trauma of the lower limb, the authors exhort to include the possibility of restoring plantar sensitivity in the factors to be used for decision-making. For the upper limb, they recommend to always check for the presence of a double level nerve injury; if the patient has suffered a preganglionic lesion of the brachial plexus, this may represent a contraindication to reimplant. Level of Evidence: Not gradable.