Treatment of a mangled lower extremity represents a major challenge in mass-casualty incidents. The decision whether to amputate or attempt reconstruction is currently based upon surgical evaluation. The aim of this chapter is to propose a new approach to surgical evaluation based on scoring systems and local clinical status of the patient, as well as comorbidities, mechanism of trauma, and hospital resources.

Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision making in these situations.

Despite a borderline Mangled Extremity Severity Score (see Table II in K. Johansen et al.[1]), in some cases reconstruction can be attempted considering the overall health status of the patient and local clinical status, with preserved plantar sensitivity and satisfactory capillary perfusion.

In conclusion, management of mangled extremity treatment should refer to evidence-based literature in correlation with clinical evaluation of every individual patient. Scores are helpful but should not be taken as a sole indication for amputation.