Crush injuries of the hand

By Abhishek Singh
BOT –(4th year)
Introduction

 The hand more than any other body part, enables man to control and man
his her surroundings. some of the functions of the hand include:
 Grasping
 For identification i,e, fingerprint
 Sensation
 To form precise movements, e.g. writing and sewing
 Pinching
 A means of communication e.g. sign language for the deaf
 For forensic purposes
Hand anatomy

 Hand consist of 27 bones

I. 14 phalangeal bones (the digits)
II. 5 metacarpal bones (the palm)
III. 8 carpal bones (wrist)
Intrinsic muscles of the hand
1.(a)three muscles of thinner eminence
 Abductor pollicis brevis.
 Flexor pollicis brevis.
 Apponens pollicis brevis.
(b) one adductor of thumb
 Adductor pollicis
2. Four hypothenar muscles
 Palmaris brevis.
 Abductor digiti minimi.
 Flexor digiti minimi.
 Opponense digiti minimi.
3. Four lumbricals.
4. Four palmar interossei.
5. Four dorsal interossei.
DEFINITIONS

 Crush injury is defined as compression of extremities or other parts of the

body that causes muscle swelling and/or neurologic disturbances in the
affected areas of the body, usually the extremities.
 Crush syndrome is the systemic manifestation of breakdown of muscle cells
caused by the compression, provoking the releasing of cell components
(creatine kinase, lactic acid, myoglobin, and potassium) into the
extracellular fluid. This causes hypovolemia, hyperkalemia, metabolic
acidosis, renal hypoperfusion, and ischemia resulting in acute renal failure
(ARF).
CRUSH INJURY OF THE HAND

 Crush Injury of the hand is sustained when the fingers, hand or wrist are
caught between two surfaces (sharp, blunt, smooth or irregular) forcibly
producing damage to the skin and its enclosed contents of soft tissues and
bone.
 The degree of damage is proportional to the amount of force applied per
square inch and the duration the compression is in place.
 The tissues that will be likely affected include skin, muscle, tendons, bone,
blood vessels, fascia and nerves.
CAUSES OF CRUSH INJURIES OF THE
HAND
 • Machineries in the industries
 • RTA
 • Agricultural injuries
 • Fall of heavy objects
 • Building collapse
 • The hand being trapped in a door.
CAUSES OF CRUSH INJURIES

 Compressive type of force to the tissues.

 Most Common Causes:
 -Machine Injuries In The Industries
 -RTA
 -Agricultural Injuries
 -Fall of heavy objects in building collapse, during earthquakes etc.
Classification

• Closed Injuries
 - Fractures
 – Tendon Injuries
 – Sprain
• Open Injuries
 - Crush Injuries
 - Tendon Injuries
 - Traumatic Amputations
Effects on the Tissues
Skin and Subcutaneous Tissue

Lacerations and contusions

Foreign material --- embedded in the wounds.
Alternatively, the skin may look largely intact.
Muscles

 Overstretching and tearing of the muscle bleeding and

swelling within the muscle itself.
 A disruption of muscle-tendon connections may result in
loss of function.
Tendons

 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, resulting in loss of joint motion and
hand function.
Nerves

 Usually, nerves are not torn by a crush injury.

 Conduction disrupted
 It may take weeks to even months to determine whether
the loss of nerve activity is permanent.
Blood Vessels

 Direct compression or shearing forces, which may injure the inner

layer
 If the injured vessel is an artery --- Ischemia
 If the injured vessels are veins--- restriction of venous outflow
Bone and Joints

 Joint capsules and surrounding ligaments may rupture

 In children, the growth plates of the bones may be
disrupted.
 Disruption of growth plates interferes with subsequent
bone growth, and the bone may not grow to its proper
length.
Crush injuries result in:

 Damage to the overlying soft tissue envelope

 Laceration
 Fracture
 Bleeding
 Loss of vascular integrity
 The neurovascular structures and the bony ligamentous structures.
SIGNS AND SYMPTOMS OF CRUSH
INJURIES OF THE HAND
 Bleeding
 Soft tissue damage Fracture
 Laceration
 Loss of vascular integrity
 Pain
 Numbness
 Decrease range of motion (difficulty moving) Weakness
 Pallor (pale or bloodless)
PATHOPHYSIOLOGY

 Depending on the severity of the crush injury, symptoms will differ. For a
minor injury, there can be bruising, lacerations and moderate pain, while
for a major crush, there is often serious damage below the skin, including
tissues, organs, muscles and bones.
 When a major crush injury occurs, energy is transferred from an offending
object into the tissues and the tissues are stretched.
 When tissues are stretched beyond their normal tolerance, damage
occurs.
 If compression continues over an extended time (typically longer than 4
hrs), the muscle tissue will actually begin to break down and may cause
systemic problems by releasing toxins into the blood stream. These toxins
can cause cardiac problem, a drop in blood pressure and renal failure.
PATHOPHYSIOLOGY

 " As the tissue is compressed, it is deprived of blood flow and becomes

ischemic, eventually leading to cellular death.
 The time to injury and cell death varies with the crushing force involved;
however, skeletal muscle can often tolerate ischemia for up to 2 hr without
permanent injury.
 This results in hypovolemia by hemorrhagic volume loss and the rapid shift of
extracellular volume into the damaged tissues. Acute renal failure (ARF) is
caused by hypoperfusion of the kidneys.
 Return of circulation to the injured and ischemic area after rescue also results in
injury, as reperfusion leads to increased neutrophil activity and the release of
free radicals. " A second effect from pressure and reperfusion is the release of
debris from the damaged cells into the circulation.
 Another complication of reperfusion is the development of compartment
syndrome
Blood Supply(BS):

 i. Hand and digits has dual (BS) with contributions

from the radial and ulnar arteries.
 i. Proximal portions of the hand (BS) come from the
deep and superficial arches on the palmar and
dorsal side.
 ii. BS of the fingers is distributed by the digital
arteries that arises from the superficial palmer arch.
FIRST AID (AT SCENE OF ACCIDENT)
 Extrication (Rescue)
 ABC of resuscitation
 Arrest Bleeding
 Amputated parts should never be discarded, they should be
brought to the hospital
 Remove rings as soon as possible, as they may become stuck
if the hand swells.
 Remove any foreign bodies.
 Immobilize potential fractures.
 Elevate the involved extremities
 Use ice to reduce swelling and for pain control
SURGICAL MANAGEMENT

 Excision of all devitalised structures

 Salvaging of the potentially viable structures
 Debridement
 Skeletal stabilisation: External fixators should be planned
such that they do not obstruct flap coverage
 Revascularisation
 Skin grafting
 Flap cover
 Nerve and tendon repairs or grafting and
reconstruction.
HOW to prevent amputation with critical repetitive
clinical examination and proper care

 What is the status of blood loss following an injury? If the blood loss is
absolute or irreversible, amputation is the only salvage procedure.
 Examine the hand for the possibility of return of hand function.
 Can the residual intact finger/fingers compensate for the loss of function
due to an accident of the important five tissues: skin, tendon, nerve, bone
and joint?
 Permanent loss of neuronal and muscular function in adult will require
bionic arm with sensor, but otherwise amputation is the only solution in
adults.
 Salvage of the thumb is most important and should always be taken care
off
Treatment of crush injuries

 Assessment:
 Occupational therapists start by conducting a comprehensive assessment of the
patient's physical, cognitive, and psychosocial functioning.
 Evaluate the extent of the injury, including fractures, soft tissue damage, nerve
damage, and any associated complications.
 Pain Management:
 Address pain management through various techniques, including modalities like
heat, cold, or electrical stimulation.
 Teach patients relaxation techniques to cope with pain and stress.
Treatment of crush injuries

 Splinting and Orthotics:

 Design and provide custom splints or orthotic devices to protect and support
injured limbs.
 Ensure proper positioning and alignment to prevent contractures and promote
healing.
 Range of Motion (ROM) Exercises:
 Develop and implement range of motion exercises to prevent joint stiffness and
muscle contractures.
 Gradually progress exercises as the patient's condition improves.
Treatment of crush injuries

 Strengthening Exercises:
 Design strength training programs to help patients regain muscle strength in
affected areas.
 Focus on functional activities that are relevant to the patient's daily life.
 Activities of Daily Living (ADL) Training:
 Assist patients in relearning or adapting ADLs, such as bathing, dressing,
grooming, and cooking.
 Use adaptive equipment if necessary to facilitate independence.
Treatment of crush injuries

 Sensory Re-education:
 If there is nerve damage, occupational therapists can help retrain the sensory
system to regain sensation and improve proprioception.
 Use techniques like desensitization and graded sensory input to reduce
hypersensitivity or numbness.
 Scar Management:
 Provide scar management techniques to improve tissue mobility and minimize
scar contractures.
 Techniques may include scar massage, silicone sheets, and pressure garments.
Treatment of crush injuries

 Assistive Devices:
 Evaluate the need for assistive devices such as wheelchairs, crutches, or mobility
aids to enhance patient mobility and independence.
 Home Modifications:
 Assess the patient's home environment for safety and accessibility.
 Recommend modifications or adaptations to improve accessibility and reduce
fall risks.
Treatment of crush injuries

 Psychosocial Support:
 Offer emotional support and counseling to help patients cope with the
psychological impact of their injuries.
 Assist with goal-setting and motivation to maintain a positive outlook during
rehabilitation.
 Work and Vocational Rehabilitation:
 If the patient has work-related goals, occupational therapists can provide
vocational rehabilitation services to help them return to work or explore new
career options.
 Education and Training:
 Educate patients and their families about self-care techniques, injury prevention,
and strategies to manage their condition in the long term.