The evolution of the surgical management of severe lower extremity trauma.

A hundred years ago, the question of whether to amputate a severely injured extremity could be answered rather easily and did not pose a serious dilemma. However, the increasing reconstructive capabilities have permitted the retreat to amputation to be made less frequently and occasionally create a dilemma concerning the best means of securing optimal function for the traumatized extremity. The surgeon must carefully balance the extent of trauma with the likelihood that his or her reconstructive efforts would surpass the functional results afforded by prompt amputation and prosthetic fitting. Although the mechanisms of limb destruction have changed in the past 2 centuries, the fundamental dilemma confronting the trauma surgeon has remained unchanged. In the words of Samuel D. Gross: "The cases which may reasonably require and those which may not require interference with the knife are not always so clearly and distinctly defined as not to give rise, in very many instances, to the most serious apprehension ... that, while the surgeon endeavors to avoid Scylla, he may not unwittingly run into Charybdis, mutilating a limb that might have been saved, and endangering life by the retention of one that should have been promptly amputated."