Crush Injuries of Hand

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Crush injuries of hand6/18/12

INTRODUCTION A crush injury is more complex and

may affect all of the tissues of the hand and forearmThe risk of long-term disability after a

crush injury is quite highInitial care plays an important role in

final functional outcome

6/18/12

CRUSH INJURYA crush injury occurs when a

compressive type of force is applied to the tissues. At the site of injury the tissues experience several forces simultaneously, including shearing, contusion, and stretching in addition to pressure

6/18/12

EXAMPLESGetting the fingers, hand, or forearm

caught in a roller machine.A motor vehicle accident that occurs

as the patient is resting an arm along the window sill on the outside of the car. The car flips over onto that side, crushing the extremity.Getting the hand or forearm caught

between two heavy objects that are compressed together. 6/18/12

EFFECTS ON THE TISSUE Skin and Subcutaneous Tissue multiple lacerations and contusions Foreign material may be embedded in

the wounds

large flaps of skin may have been

created by the injury

If the skin is detached from the

underlying fascia and muscle, the circulation to the skin is greatly compromised. The result can be 6/18/12 significant skin loss

EFFECTS ON THE TISSUE Muscle overstretching and tearing of the muscle bleeding and swelling within the muscle itself disruption of muscle-tendon connections

may result in loss of function three mechanisms are responsible for the

death of muscle cells: Immediate cell disruption: The local force of

the crush causes immediate cell disruption (lysis). Although the effects are immediate, it is probably the least important mechanism. 6/18/12

EFFECTS ON THE TISSUE Direct pressure on muscle cells: The direct

pressure of the crush injury causes the muscle cells to become ischemic. The cells then switch to anaerobic metabolism, generating large amounts of lactic acid. Prolonged ischemia then causes the cell membranes to leak. This process occurs during the first hour after crush injury. injury compresses large vessels, resulting in loss of blood supply to muscle tissue. Normally, muscle can withstand approximately 4 hours without blood flow (warm ischemia6/18/12 before time)

Vascular compromise: The force of the crush

EFFECTS ON THE TISSUE Tendons will not tear a tendon completely, the

stretching forces may create small, partial tears During the healing process, scar tissue forms

to heal such tears and may cause the tendons to adhere to surrounding tissues. Adhesions may interfere significantly with

the tendons ability to glide smoothly, resulting in loss of joint motion and hand function.6/18/12

EFFECTS ON THE TISSUENervesnerves are not torn by a crush injury

the nerves ability to conduct

electrical impulses may be temporarily or possibly permanently disrupted patient may experience tingling and numbness (paresthesia) or even painful hypersensitivity to touch6/18/12

damage to sensory nerves, the

EFFECTS ON THE TISSUE Blood Vessels Blood vessels can be injured by direct

compression (depending on how long the extremity was crushed) or shearing forces, which may injure the inner layer

cause the vessel to clot the injured vessel is an artery, the

surrounding tissues lose their blood supply and ischemia results venous outflow from the damaged area leads 6/18/12 to a build up of pressure in the tissues. This

the injured vessels are veins, diminution of

EFFECTS ON THE TISSUEBone and JointsJoint capsules and surrounding

ligaments may rupture, resulting in joint dislocation or joint instability bone is broken into several pieces (comminuted fracture)

Fractures may occur, and often the

6/18/12

COMPARTMENT SYNDROMEA compartment syndrome develops

when increased pressure builds up within a fixed, well-defined space (such as the tissues of the forearm).The increase in pressure prevents

venous and lymphatic outflow, which leads to a further increase in tissue pressureHigh tissue pressures also prevent

oxygen and nutrients from getting to 6/18/12

COMPARTMENT SYNDROME A by-product of the dead muscle, myoglobin, can

injure the kidneys and lead to permanent kidney damage

Signs and symptoms Severe pain in the affected extremity, out of

proportion to the injury

Significant swelling and tightness in the

forearm or hand tissues

Pain with passive stretch of a muscle group

(e.g., passive extension of the fingers or wrist stretches the flexor muscles and causes pain in the palmar forearm, whereas passive flexion of the fingers or wrist stretches the extensor muscles and 6/18/12 causes pain in the dorsal forearm)

EVALUATION History Extent of injury (e.g., fingers, hands, forearms) Mechanism of injury Force of crush (some pieces of equipment have

known compression forces) Duration of crush forces (seconds, minutes?) History of previous injury or chronic hand

problems (e.g., symptoms compatible with carpal tunnel syndrome) smoke because smoking may worsen the injury 6/18/12 to the tissues)

Smoking history (encourage patients not to

EVALUATION Physical Exam Appearance of skin (look for blisters,

open wounds, elevated areas, foreign material, other abnormalities) in the radial and Ulnar arteries, capillary refill in the fingers) (significant swelling, tissue tightness)*

Circulation to the hand (palpable pulses

Palpation of forearm and hand Neurologic exam (e.g., complaints of

6/18/12 tingling or numbness, ability to move

EVALUATIONTests:X-rays will be used to identify fractures. MRI, andCTmay identify more complex

soft tissue injury and internal injuries.blood chemistry parameters will be

measured to assess for blood loss

6/18/12

MANAGEMENTFirst-aid

Apply pressure to the wound to stop bleeding. possible, wash dirt or debris from the wound. the wound to prevent further contamination or injury. not remove large foreign bodies such as nails, hooks, or knives. the hand above theheart6/18/12

If

Cover Do

Elevate

Immobilize or splint the hand, if possible.

MEDICAL MANAGEMENTLocalanaesthesia(numbthe area) Wound preparation - cleansing and

irrigation, re-examinationCleaning and removal of dead tissue Wound repair or closure Dressing and splinting if necessary to

keep hand from movingPain medication Antibioticsif needed6/18/12

Fractures or dislocations should be

reduced and treated appropriatelyIf find any evidence of arterial

compromise, exploration and vascular reconstruction are needed. A specialist is required.If the patient has no evidence of a

compartment syndrome but reports numbness and tingling of the hand consistent with compression of the 6/18/12

Lacerations to the skin should be

cleansed thoroughly and examined carefully. If the tissues are soft and the skin is still attached to the underlying muscle, the wounds may be loosely closed.If any swelling in the tissues, leave

the wounds open. Closing may increase pressure in the tissues. Once the swelling resolves, close the 6/18/12 wounds or leave them to heal

TREATMENT OF COMPARTMENTAL SYNDROMEFasciotomyThe key to treating a compartment

syndrome is to open the involved tissue compartments to relieve the pressure before permanent tissue damage has occurred. room under general anaesthesia.

This procedure is done in the operating Skin incisions are made to access the

underlying muscle fascia. The fascia must be opened (hence the term 6/18/12

Forearm The forearm has three compartments: volar

(flexor), dorsal (extensor), and mobile wad (upper forearm muscles on the radial side). The compartments of the forearm are

somewhat interconnected. Opening (i.e., releasing) the volar compartment may relieve the pressure in the other two compartments. However, if the forearm still feels tight after

release of the volar compartment, an additional incision should be made to release 6/18/12

6/18/12

Post fasciotomy CareThe incisions should be left open A splint should be used to keep the hand

in neutral position The hand should be gently elevated

(higher than the elbow) to promote venous return and decrease swelling closure. In general, wait at least 34 days for the swelling to decrease 6/18/12

Further surgery is needed for wound

Elevate the hand and forearm

PREVENTION OF COMPARTMENT SYNDROME The patient must keep the injured hand and

forearm gently elevated and not let them dangle in a dependent position The dependent position promotes swelling of injured tissues. The hand should be higher than the elbow Use a splint instead of a cast for

immobilization of broken bones until the swelling has decreased A tight cast can contribute to an increase in

tissue pressure. If there is a fair amount of swelling in the forearm or hand Be sure that the splint is held loosely in place. It

is possible to secure the splint too tightly with an 6/18/12 Ace wrapbe careful

If an open wound is presentDo not close the skin if it seems at all

tight. It is better to have an open wound that heals with an ugly scar than to risk the development of a compartment syndrome by closing the skin tightly

6/18/12

TREATMENT GOALSMaintain full ROM of all uninvolved

joint of the upper extremityPromote healing Avoid infection on the surgical wound Maximize