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Crush Injuries of the Hand

Article  in  The Journal of hand surgery · April 2017

DOI: 10.1016/j.jhsa.2017.03.028

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 CURRENT CONCEPTS

Crush Injuries of the Hand

Avi D. Goodman, MD,* Christopher J. Got, MD,*
Arnold-Peter C. Weiss, MD*

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Disclosures for this Article
Editors
David T. Netscher, MD, has no relevant conflicts of interest to disclose.
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All authors of this journal-based CME activity have no relevant conflicts of interest to
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Learning Objectives
Upon completion of this CME activity, the learner should achieve an understanding of:
 The pattern and sequence of injured structures with increasing damaging energy and
stage of the injury
 Clinical assessment
 Initial and subsequent management
 Acute and long-term effects of hand compartment syndromes
 Long-term complications and secondary injuries
Deadline: Each examination purchased in 2017 must be completed by January 31, 2018, to
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Crush injuries of the hand are a rare but devastating phenomenon, with historically poor
outcomes. A compressive force, usually caused by a high-energy mechanism such as a motor
vehicle or industrial accident, crushes and transiently increases the pressures within the hand.
This force acts on the incompressible blood in the vasculature and leads to a dramatic rise in
tissue pressures and damage to multiple tissue types, including bones, blood vessels, nerves,
and soft tissues. A wide zone of injury results from a delayed inflammatory reaction involving
the zone bordering the crushed cells, which may initially belie the severity of the injury. As

From the *Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown Corresponding author: Avi D. Goodman, MD, Department of Orthopaedic Surgery, Warren
University, Providence, Rhode Island. Alpert Medical School, Brown University, 593 Eddy St., Providence, RI 02903; e-mail:
avi_goodman@brown.edu.
Received for publication January 7, 2017; accepted in revised form March 22, 2017.
0363-5023/17/4206-0009$36.00/0
No benefits in any form have been received or will be received related directly or indirectly http://dx.doi.org/10.1016/j.jhsa.2017.03.028
to the subject of this article.

456 r  2017 ASSH r Published by Elsevier, Inc. All rights reserved.

 CRUSH INJURIES OF THE HAND 457

such, these injuries go on to produce tremendous inflammation and swelling, potentially

followed by compartment syndrome or other vascular damage, infection, neurological
injury, and tissue necrosis. Crush injuries with minimal skin disruptions can be particularly
challenging to accurately diagnose and manage. This paper provides a review of the
initial evaluation of hand crush injuries as well as short- and long-term management strate-
gies. (J Hand Surg Am. 2017;42(6):456e463. Copyright  2017 by the American Society for
Surgery of the Hand. All rights reserved.)
Key words Crush injuries, hand compartment syndrome, contracture management, review, case
report.

C
RUSH INJURIES TO THE HAND ARE a rare but
devastating phenomenon, with historically
poor outcomes.1,2 A compressive force,
usually caused by a high-energy mechanism such as a
motor vehicle or industrial accident, crushes and
transiently increases the pressures within the hand.
This force acts on the incompressible blood in
the vasculature and leads to a dramatic rise in tissue
pressures causing damage to bones, blood vessels,
nerves, and soft tissues.3 A wide zone of injury results
from a delayed inflammatory reaction involving the
bordering zone, which may initially belie the severity
of the damage. These injuries go on to produce
tremendous inflammation and swelling, potentially
followed by compartment syndrome, vascular damage,
infection, neurological injury, and tissue necrosis.4
Crush injuries with minimal skin disruption can be
particularly challenging to accurately diagnose and
manage. This paper provides a review of the initial
evaluation of hand crush injuries as well as short- and
long-term management strategies.
DIAGNOSIS AND INITIAL MANAGEMENT
Many such injuries are associated with high-energy
trauma, and Advanced Trauma Life Support princi-
ples must be applied as necessary to preserve life over
limb. The patient must be evaluated in a systematic
fashion to avoid missed injuries.
History
Once the patient is stable, a pertinent medical history
should be obtained with particular attention to injury
timing and mechanism; the former is crucial in
determining salvage versus amputation because
devascularized muscle can only survive 4 to 6 hours
of warm ischemia.5 An understanding of the injury
mechanism can help infer energy level of the crush-
ing force and raise suspicion for occult injuries.
Learning the patient’s occupation, handedness, and
comorbidities helps determine functional needs and
goals. Although several scoring systems attempt to
estimate outcomes, these do not accurately predict the
need for amputation over salvage in upper extremity
crush injuries.4,6
Clinical examination
The examination begins with an inspection, looking
for wounds that may indicate open fractures, tendon
or nerve injuries, or even an “exploded hand” as
described by Graham.3 In this constellation, the
compressive force generates a predictable injury
pattern, beginning with interosseous muscle extrusion
through a tension failure of the skin, commonly in
the first web space where the skin is weakest; this
portends a grave prognosis.3 Gross swelling and
palmar convexity may be clues to impending
compartment syndrome or fracture-dislocations.1,3 A
thorough neurological examination should assess the
new baseline status of each nerve, including signs of
acute carpal tunnel syndrome. In patients unable
to cooperate, look for dry, red skin as a sign of
sympathetic paralysis; if present, this usually
indicates more serious nerve damage (as opposed to
neurapraxia). Tendon function in all fingers and the
thumb should be assessed, through both tenodesis
and active motion of each joint, if possible. Most
importantly, assess the hand for perfusion through
pulses, capillary refill (especially dorsal paronychial
tissue), warmth/color, and Doppler signals because
vascular compromise will often determine operative
urgency. Acute bleeding should be controlled, most
frequently with direct pressure only because clamp-
ing can easily injure nearby nerves.
Knowledge of injury patterns assists in prompt and
appropriate methodical evaluation. Graham3 pro-
posed that the “exploded hand” suffers a sequential
pattern, beginning with extrusion of the thenar
musculature (noted previously) as the thumb becomes

J Hand Surg Am. r Vol. 42, June 2017

458 CRUSH INJURIES OF THE HAND

FIGURE 1: A, B A 3-year-old had an automobile wheel roll over his hand. The hand is swollen and the thumb is forced into extension
and abduction through the hydrostatic effects of swelling. CeE Multiple basilar metacarpal fractures seen on radiographs. F First
web space compartment pressure taken in the operating room measures 97 mm Hg. This was treated by compartment releases and
percutaneous K-wire fixations. G Device used to measure compartment pressures (Stryker, Kalamazoo, MI). (AeF Clinical pictures
courtesy of David Netscher, MD.)

coplanar with the hand, in addition to thumb ray
dislocation and/or fracture. As the arches of the
hand flatten, the force proceeds through metacarpal
headelevel dissociation and carpometacarpal (CMC)
fracture-dislocation of rays II to V. The third stage
involves the pericapitate transmission of forces,
manifested by intercarpal ligament disruption. The
fourth stage sees characteristic longitudinal fractures
of the tubular bones. Finally, the fifth stage is neu-
rovascular compromise, resulting in compartment
syndrome.
The surgeon must be vigilant for signs and symp-
toms of compartment syndrome; with 10 separate
muscular compartments, the hand poses a particular
challenge (Fig. 1). Profuse edema and inflammation
increase the volume within the fascial compartments,
decreasing perfusion to soft tissues and nerves. Of the
classic “5 Ps” of compartment syndrome (pain, pallor,
paresthesias, pulselessness, and paralysis), only pain
(both out of proportion to clinical examination findings
and with passive stretch) is thought to present early
enough to recognize and treat the pathology before
deep tissue necrosis occurs.1,7 However, even this
conventional wisdom may be unreliable, as a study by
del Piñal et al1 investigating compartment syndrome
in crushed hands showed a significant proportion of
patients had no pain with passive stretch, perhaps due
to concomitant neurological injury or masked by
fractures. A rising analgesia requirement is a useful
alternative in children and the unconscious. The classic
intrinsic-minus position of hand compartment syn-
drome is also obscured by the significant swelling
associated with crush injuries. In all cases of hand
compartment syndrome following a closed crush
injury, del Pinal et al1 found that the thenar and first
web space muscles were involved. In addition,
Ouellette et al8 showed that 15 of 17 patients (88%)
were obtunded at the time of developing compartment
syndrome. Because of the lack of reliability of clinical
symptoms and serious implications of a missed diag-
nosis, the surgeon must have a low threshold for
directly measuring compartment pressures.
Compartment pressures can be considered either
in absolute terms or relative to the diastolic blood

J Hand Surg Am. r Vol. 42, June 2017

 CRUSH INJURIES OF THE HAND
pressure. Whereas the value of absolute intra-
compartmental pressure needed for compartment syn-
drome has been debated (often 30 mm Hg or more) the
relative pressure difference (DP) is accepted as more
accurate. A study did not find any evidence delineating a
particular DP causing reduced circulation in the upper
extremities, but using lower extremity data, it is
accepted that a DP less than 30 mm Hg for longer than
2 hours compromises perfusion and is more sensitive
and specific than clinical signs.9 The complication rates
with delayed diagnosis are high and include long-term
pain, dysfunction, and intrinsic contractures of
the hand; thumb contractures are especially poorly
tolerated.2,10 Edema and bleeding can evolve over time,
and as such, it is important to perform serial examina-
tions. To minimize ischemia, early recognition and
judicious action to relieve the elevated pressures are
critical, including removing extrinsic compression,
elevating the extremity, and ultimately fasciotomizing
all involved compartments.7,8,11
Imaging and laboratory tests
Radiographs of the hand, wrist, and forearm can
identify for fractures, dislocations, and preexisting
bony conditions. If the clinical examination is fairly
benign and the mechanism is unknown, abnormal
fracture patterns can indicate a crush mechanism,
especially longitudinal tubular bone fractures.3 A
computed tomography scan can also be obtained for
better characterization of intra- or periarticular frac-
tures and dislocations, although this should not delay
operative intervention. Basic laboratory tests as well
as whole blood lactate, creatine kinase, and urinary
myoglobin can assess for blood loss anemia, meta-
bolic derangements, hypoperfusion, and muscle
damage. Fluid resuscitation is often needed to
improve end-organ perfusion. Once the initial work-
up is complete, the decision must be made to take
the patient to the operating room, and how quickly.
MANAGEMENT OF CRUSH INJURIES
Initial operative management
Given the complexities of such crush injuries, it is
important to consider both short-term tactics and
long-term strategies for management of each
component: soft tissues, fractures, and neurovascular
injuries. First, salvage versus amputation must be
addressed, but given that no criteria exist for reliably
and accurately predicting the salvageability of the
upper extremity, most surgeons lean heavily toward
initial salvage, while maintaining late amputation as
an option. If the patient is able to communicate, it is
J Hand Surg Am.
459
crucial to assess and discuss handedness, occupa-
tional and functional demands, and treatment goals.
After appropriate antibiotic administration, anes-
thesia, and tourniquet inflation, proximal vascular
injuries should be addressed with a bypass, graft,
or shunt. A careful evaluation is followed by
an aggressive debridement of all suspect tissue.
Bernstein et al5 state that the goal of initial debride-
ment is to achieve a clean wound that looks surgically
created and ready for reconstruction. Pressure moni-
toring and compartment releases are performed when
necessary, as is provisional coverage over tendons
and neurovascular structures.a,b Conflicting data exist
regarding the precise timing of coverage, but trends
suggest that the most important factor in preventing
complications is the thoroughness of debridement.
Skeletal management begins with debridement
of devitalized bones, followed by stabilization of frac-
tures or dislocations (using K-wires, plates, or external
fixation), with the goal of early motion and stiffness
prevention. Extensive dissection associated with plate
fixation should be avoided to preserve any bone-healing
biology, especially in the acute phase. In addition to
restoring blood flow, venous drainage should be rees-
tablished, with the selective addition of heparin-soaked
pledgets, nail plate removal, and leeches. Nerve man-
agement is guided by the examination, with exploration
warranted if an injury is suspected. If found in conti-
nuity, it should be gently cleaned, and if transected,
should be either cut to the level of healthy tissue and
repaired or tagged for later repair.5 The surgeon
should have a low threshold for decompression at
Guyon canal and the carpal tunnel; the latter should
always accompany compartment releases.
Once the initial debridement and repair is
completed, the tourniquet should be released to further
address perfusion. Wound dressings are dictated by the
extent, quality, and cleanliness of the wound bed.
Antibiotic beads may be considered in particularly
contaminated wounds. Negative pressure wound
therapy can be a useful adjunct in temporary coverage,
minimizing swelling and the number of dressing
changes, although the effect on bacterial load, infec-
tion, and time to closure is debated.12,c Alternatively,
damp-to-dry dressings remain the mainstay of treat-
ment. The hand should be treated with orthosis fabri-
cation, often in the intrinsic-plus position, and elevated
to the level of the heart. Depending on coverage and
vascular repairs, micro-precautions—with a goal of
minimizing peripheral vascular constriction—may be
advisable, including increased room temperature
and/or heating blanket, anticoagulants (including
heparin and variants, aspirin, dextran, and others), and
r Vol. 42, June 2017
460 CRUSH INJURIES OF THE HAND
TABLE 1. Local Flap Coverage Options for Finger
Tissue Defects
Local Flap Coverage
Injury Option
Smaller finger defects Cross-finger, thenar, dorsal
metacarpal artery, turnover
Larger finger defects Radial forearm, posterior
interosseous
Thumb fingertip loss Homodigital flap
Thumb fingertip loss Moberg, V-Y advancement,
(with bone exposure) dorsal metacarpal artery
Thumb pulp loss Free vascularized toe pulp,
partial toe transfers
maintenance of nothing-by-mouth status in case of
vascular repair failure.13
Subsequent operative management
The second debridement should take place 2 to 3
days after the first. With definitive coverage now a
higher priority, a number of local flaps have been
successfully used (Table 1), as have distant options.13
Because stiffness is the rule rather than the
exception, tenolysis is often indicated when rehabil-
itation has plateaued.3 Because crush injuries often
include damage to the thenar musculature, an oppo-
nensplasty may be needed to restore function to the
thumb, along with other tendon transfers as needed.
As the soft tissue improves, bony fixation should
progress from temporizing to definitive and address
nonunion with bone grafting and malunion with
osteotomy, as appropriate. If a digit or ray is detrimental
to the functional outcome, then amputation is warranted.
Although the first subsequent debridement may be too
early, delayed management of neurovascular injuries
can include grafting for segmental deficits, neurolysis of
adhesions, and sympathectomy to improve perfusion.
Depending on the level of contamination, neurovascular
damage, and soft tissue loss, multiple trips to the oper-
ating room may be necessary.
Complications and prognosis
Literature regarding the complications and outcomes
of crush injuries to the hand is limited and varies based
on the extent of the initial injury.7,14 A systematic
review of forearm compartment syndrome revealed
that neurological deficits were the most common
complication (18%), followed by contractures and
muscle necrosis.14,15 Increased time to fasciotomies
(> 6 hours after presentation) was found to be signif-
icantly associated with developing complications.10
J Hand Surg Am.
Functional outcomes of severe crush injuries are
notoriously poor, often from stiffness secondary to
contractures and neurodeficits.3,16 Data from lower
extremity compartment syndrome demonstrated that
lower-energy injuries, shorter time to fasciotomy,
younger age, and absence of fractures is associated
with better outcomes.14 A retrospective evaluation of
22 patients with upper extremity compartment syn-
drome demonstrated that, based on motor function,
sensation, or stiffness, 17 (74%) reported excellent
outcomes and 5 (22%) reported fair outcomes after a
fasciotomy.17
PREVENTION AND TREATMENT OF
COMPLICATIONS
In addition to neurological deficits, hand contractures
may result either from improper positioning of the
injured hand or from the ischemic effect of a missed
compartment syndrome. Contractures from each
present, and are managed differently.
Early involvement of a hand therapist to develop
a rehabilitation plan will minimize posttraumatic
contractures.14 Early interventions include teaching
and assisting with passive, active-assisted, and active
range of motion exercises, as well as customizing an
intrinsic-plus splint.18 Immediately after injury, the
hand assumes an intrinsic-minus position as edema
develops at the dorsum of the hand in the loose
subcutaneous and subtendinous space.16,18 If the
hand is allowed to stay in this suboptimal position,
the joints stiffen as the protein-laden exudate causes
interstitial adhesions.16
The 3 most common posttraumatic hand contrac-
tures, caused by allowing the crushed hand to rest
in an intrinsic-minus position, include meta-
carpophalangeal (MCP) joint hyperextension, prox-
imal interphalangeal (PIP) and distal interphalangeal
(DIP) joint flexion, and thumb adduction.16 If pre-
sent, MCP contractures should first be managed with
either orthosis fabrication or serial casting for 1 to 2
months. If conservative interventions fail, operative
release of the MCP includes splitting the extensor
tendon, elevating the capsule, and performing a dor-
sal capsulectomy.16 Fibrosis of the thumb adductor is
at additional risk for inadequately treated compart-
ment syndrome because it is the deepest muscle,
analogous to the “ellipsoid” infarct of the forearm;
this can be particularly difficult to treat. Proximal and
distal tenolysis and excision of the dorsal fibers of the
collateral ligaments should be performed until 70 of
flexion is achieved, followed by 2 to 3 days of
orthosis treatment or 5 to 7 days of K-wire immobi-
lization. It is important to minimize interventions to
r Vol. 42, June 2017
 CRUSH INJURIES OF THE HAND 461

FIGURE 2: A Preoperative clinical picture and B, C radiographs of the reported crushed hand.

FIGURE 3: A, B Immediate postoperative radiographs.

those strictly required because excessive collateral
ligament disruption may cause joint instability,
thereby defeating the purpose of the surgery. After
this short immobilization, the patient must begin
working to maintain these range of motion gains.
Proximal interphalangeal joint flexion contractures
should initially be managed with dynamic orthosis
treatment or serial casting for several months.16 A
review of over 400 PIP joint flexion contractures
initially treated conservatively demonstrated that 87%
of these contractures were managed effectively non-
surgically.19 If these fail, the checkrein ligaments are
carefully transected via a volar approach to the PIP
joint. If the contracture persists, a volar capsulotomy
is performed to allow for a volar plate and accessory
collateral ligament release.
Thumb adduction contractures should initially be
managed with dynamic orthosis treatment, with
an abduction force to the thumb CMC joint.16 If con-
servative interventions are unsuccessful, the deep fascia
is split longitudinally and the insertion of the adductor
pollicis muscle is transected. If adduction contracture
persists, a thumb CMC capsulotomy allows release of
the volar intermetacarpal and oblique CMC joint liga-
ments, while preserving the radial CMC joint ligament to
prevent instability. Correction of the adduction contrac-
ture results in a skin deficit that often requires coverage.
Ischemic hand contractures often result from
missed compartment syndrome and present with MCP
flexion, PIP and DIP joint extension, and thumb
adduction—opposite to the contractures seen with an
intrinsic-minus hand.16 Delayed hand compartment

J Hand Surg Am. r Vol. 42, June 2017

462 CRUSH INJURIES OF THE HAND
syndrome can be detected while the hand is positioned
in the intrinsic-plus position by passively extending
the MCP joint daily. If this is painful, fasciotomies
should be performed early. Immediately after surgery,
the hand should not be positioned in the intrinsic-plus
position in order to minimize additional ischemia.
If ischemic contractures develop, the goals of treat-
ment are to prevent stiffness and deformity and to restore
motion.11 Supervised stretching, mobilization exer-
cises, and orthosis treatment with a hand therapist are
the first line of treatment. Littler’s technique involved
releasing the extensor component of the intrinsic
muscles from the PIP joints and active splinting.
Clinical adjuncts to surgery
The hands allow us to perform functions that define us
as humans, including social interaction, self-care,
communication, and expression. Given the high de-
gree to which we rely on our hands in everyday life,
hand injuries can have a significant psychological
impact on ability to make adjustments and recover
from injury.20 Although hand surgeons must under-
stand and recognize the psychological consequences of
hand injury (such as posttraumatic stress disorder),
hand therapists are in a unique position to screen and
monitor these consequences. Psychological distress
can interfere with recovery if not appropriately
recognized and addressed. Therefore, patients should
be screened by incorporating questions about changes
in sleep patterns, mood, and behavior and, if positive,
referred for additional psychological support within
3 months after the initial injury.
CASE PRESENTATION
A 66-year-old right-handed gentleman sustained an
isolated injury to his right hand, which was crushed by
a 250-ton press for approximately 10 seconds. In
addition to a degloving injury about his carpus and
metacarpals, he had exposed metacarpal fractures and
lacerated extensor tendons (Fig. 2A). His sensory ex-
amination was variable, and his motor examination
was notable for an inability to fire most flexors
(although flexor pollicis longus function was main-
tained). Despite a Doppler signal present at his palmar
arch, no signals were found in the digits, and his digits
were cool. Radiographs revealed fractures of meta-
carpals I to V, including dislocations at the base of the
first and neck of the second (Fig. 2B, C). His medical
history was significant only for hyperlipidemia and a
25-pack-year smoking history. In the emergency
department, the patient was provisionally irrigated,
supplied with an orthosis, and given appropriate anti-
biotics. He was then taken emergently to the operating
J Hand Surg Am.
room for an attempt at salvage, although the possibility
of amputation was discussed.
In the operating room, an irrigation and debride-
ment cleaned the wounds of nonviable tissue. An
autologous vein graft (taken from the forearm) was
needed to restore blood flow from the superficial arch
to the common digital artery to the middle and ring
fingers. Nerves to the thumb, middle, ring, and little
fingers were noted to have segmental injuries. Each
metacarpal was reduced and pinned with K-wires
(Fig. 3), and the carpal tunnel was released; no further
compartment releases were needed given the extent
of the injury. After the wound was loosely approxi-
mated and dressed, the arm was treated with an
orthosis and the patient maintained on microsurgery
precautions. Four days later, the patient returned to
the operating for a repeat irrigation and debridement,
as well as tagging of the extensor tendons (done
without tourniquet to prevent injury to the micro-
vascular repair). After an uneventful hospital course,
he was discharged home 10 days after injury.
After surgery, he was seen weekly for 2 weeks (with
therapy initiated at 1 week), then every other week for 8
weeks, mostly complaining of stiffness and neuro-
pathic pain. Despite no longer smoking, his healing
was slower than expected. His examination stabilized
with healed wounds, diminished but intact sensation in
all fingers (with variable hypersensitivity), limited
motion of all fingers, and well-perfused digits.
ACKNOWLEDGMENTS
The authors thank Jeremy Raducha, MD, and Joseph
A. Gil, MD, for their clinical care and preparation of
the manuscript.
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15. Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV. Compartment
syndrome of the forearm: a systematic review. J Hand Surg Am.
2011;36(3):535e543.
16. Tajima T. Treatment of post-traumatic contracture of the hand.
J Hand Surg Br. 1988;13(2):118e129.
17. Kanj WW, Gunderson MA, Carrigan RB, Sankar WN.
Acute compartment syndrome of the upper extremity in children:
JOURNAL CME QUESTIONS
Crush Injuries of the Hand
1. Which of the following is most frequently
associated with crush injuries of the hand?
a. Compartment syndrome involving thenar and
first webspace
b. Compartment syndrome involving hypothenar
space
c. Perilunate dislocation
d. Fingertip amputations
e. Vascular compromise
2. What is the typical radiographic finding with
crush injuries of the hand?
a. Hamate fracture
b. Longitudinal fractures of tubular bones
c. Metacarpophalangeal joint dislocation of ulnar
fingers
d. Radial styloid fracture
e. Scapholunate disassociation
To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.
J Hand Surg Am.
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diagnosis, management, and outcomes. J Child Orthop.
2013;7(3):225e233.
18. Dorf E, Blue C, Smith BP, Koman LA. Therapy after injury to the
hand. J Am Acad Orthop Surg. 2010;18(8):464e473.
19. Weeks PM, Wray RC, Kuxhaus M. The results of non-operative
management of stiff joints in the hand. Plast Reconstr Surg.
1978;61(1):58e63.
20. Hannah SD. Psychosocial issues after a traumatic hand injury:
facilitating adjustment. J Hand Ther. 2011;24(2):95e103.
EDITOR’S SUGGESTIONS FOR MORE
INFORMATION
The Editor chose to include these references and video to provide readers
with additional information.
a. Leversedge FJ, Moore TJ, Peterson BC, Seiler JG. Compartment syn-
drome of the upper extremity. J Hand Surg Am. 2011;36(3):544e559.
b. Stevanovic M. Fasciotomy for Compartment Syndrome [see Video;
available on the Journal’s Web site at www.jhandsurg.org)]. Presented
at: American Society for Surgery of the Hand and American Associ-
ation for Hand Surgery Specialty Day: March 23, 2013; Chicago, IL.
Also available at: Hand-e: http://www.assh.org/Hand-e.
c. Taylor CJ, Chester DL, Jeffery SL. Functional splinting of upper limb
injuries with gauze-based topical negative pressure wound therapy.
J Hand Surg Am. 2011;36(11):1848e1851.
3. What is the most accurate scoring system for
crushing hand injuries to assess the need for
amputation?
a. No scoring system has proven sufficiently
predictive
b. Mangled Extremity Severity Score (MESS)
c. Injury Severity Score (ISS)
d. Disability of Arm, Hand and Shoulder (DASH)
score
e. Glasgow coma score
4. Which of the following is inessential at the initial
surgery following a crush injury?
a. Thorough debridement to bleeding tissue
b. Reestablish vascular flow
c. Skeletal stabilization
d. Definitive soft tissue coverage
e. Release necessary compartments
r Vol. 42, June 2017