CRUSH INJURY

1. BY
RAJAH AMINA SULEIMAN
(RN, RM, RNE, RBPN, BNSc., MSc)

2.  The hand, more than any other body part, enables man to control and manipulate
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.
 A means of communication e.g. Sign Language for the deaf
 Pinching
 For forensic purposes

3.  The hand contains 27 bones.
 Each one belongs to one of three
regions: the carpals, (wrist), the
metacarpals, (the palm), and the
phalanges (the digits).

4.  Muscles acting on the hand
include:
 Adductor Pollicis
 Palmaris Brevis
 Interossei
 Lumbricals
 Thenar
 Hypothenar Muscles

6.  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).

7.  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.

8.  Machineries in the industries
 RTA
 Agricultural injuries
 Fall of heavy objects
 Building collapse
 The hand being trapped in a door.

9.  Bleeding
 Soft tissue damage
 Fracture
 Laceration
 Loss of vascular integrity
 Pain
 Numbness
 Decrease range of motion (difficulty moving)
 Weakness
 Pallor (pale or bloodless)

10.  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.

11.  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.

14.  Scene safety
 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

15.  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 .

16.  ABC of resuscitation
 History: History should include the following: When, How , Where, Age, Co-
morbidities, hand dominance and occupational history.
 Assessment:
Assess circulatory status of the hand (using Doppler’s device, arteriography and
checking distal pulse)
Sensory assessment of the radial nerve, the median nerve and the ulnar nerve using
two-point discrimination in three locations.
Motor assessment:
Assessing potential tendon injuries: Check for flexion and extension of each finger at
each joint.

17.  Examination: The principle of Life before Limb should be Applied.
 Amputated Parts: Amputated parts should be cleaned with saline, wrapped in a moist
gauze and placed in a dry plastic bag. The bag should be placed in a container with ice.
 Fluid Resuscitation
 X-ray of the limb up to the point of compression
 Clinical Photograph
 Blood Transfusion
 Medication: Antibiotics, Analgesics
 Tetanus
 Rehabilitation: maintain joint mobility, prevent adhesions and contractures and
enhance scar maturation.

18.  Primary prevention of crush injury might be possible only via industrial safety
regulations, building codes, and injury prevention programs.
 Once a crush injury has occurred, secondary prevention of crush syndrome may be
possible with timely management at the scene of injury and carried on through
field care, pre-hospital transport, and initial hospital care.

19.  Acute Pain related to crush injury of the hand evidenced by pain score of 10 out of
10.
 Ineffective Tissue Perfusion (Peripheral) related to decreased peripheral blood
flow to the hand evidenced by pulselessness.
 Impaired Skin Integrity
 Self-Care Deficit
 Risk for Infection

20. BY
RAJAH AMINA SULEIMAN
(RN, RM, RNE, RBPN, BNSc., MSc)

21.  A tendon is a tough, high-tensile-strength band of dense
fibrous connective tissue that connects muscle to bone.
 Tendons are similar to ligaments; both are made
of collagen. Ligaments connect one bone to another,
while tendons connect muscle to bone.
 Tendons are strong cords that connect muscles to bone.
 When muscles contract, their tendon(s) pull through
the attachments to bone and cause a joint to move.

22.  Tendons are composed
of approximately 90% to
95% of tenoblasts and
tenocytes, with the
remaining 5-10%
consisting of
chrondrocytes at the
bone attachment.

23.  Tendon Injuries are traumatic injuries to the tendons that can be caused by
laceration or trauma.
Stages of Tendon Injury Healing
 1. Inflammatory stage (48–72 hours) – inflammatory cells move into the site of
injury. They increase vascular permeability, initiate angiogenesis and stimulate
proliferation of tenocytes.
 2. Proliferation stage (5 days to 4 weeks) – fibroblastic and collagen-producing
cells enter and proliferate.
 3. Remodelling stage (6 weeks onwards) – tissue repair and fibrosis occur. Over
time, the fibrous tissue is replaced by the scar-like tissue of the tendon.

24. FLEXOR TENDONS
 Each finger has two flexor
tendons, the Flexor Digitorum
Profundus and the Flexor
Digitorum Superficialis and
the thumb has one (the Flexor
Pollicis Longus).

25.  Zone I – distal to FDS insertion
 Zone II – This extends from insertion of FDS up to
distal palmar crease. Zone II has been known as
“no man’s land” .
 Zone III – Extends from distal palmar crease up to
flexor retinaculum.
 Zone IV – This zone lies under flexor retinaculum
 Zone V – Extends from proximal border of flexor
retinaculum to musculo-tendinous junction of
flexor muscles.
 T 1 - distal to the interphalangeal joint (IP) in the
thumb
 T 2 - between the metacarpophalangeal (MCP) and
interphalangeal (IP) joints
 T 3 - proximal to the metacarpophalangeal (MCP)
to palmar flexion crease

26. Tendon Involved Deformity
Zone 1 FDP Jersey Finger
Zone 2 FDP and FDS Trigger Finger
Zone 3 neurovascular bundles Dupuytren’s Contracture
Zone 4 Carpal Tunnel and its contents (9 flexors
and Median Nerve)
Carpal Tunnel Syndrome

27. JERSEY FINGER
TRIGGER FINGER
DUPUYTREN’S CONTRACTURE CARPAL TUNNEL SYNDROME

29.  Zone 1 – DIP joint
 Zone 2 – middle phalanx
 Zone 3 – PIP joint
 Zone 4 – proximal phalanx
 Zone 5 – MCP joint
 Zone 6 – metacarpal
 Zone 7 – carpal and wrist joint
 Zone 8 – distal forearm
 Zone 9 – proximal forearm.
 The anatomical zones in the thumb are:
 Zone T1 – IP joint
 Zone T2 – proximal phalanx
 Zone T3 – MCP joint
 Zone T4 – first metacarpal.

30.  Mallet injuries (extensor zone I): Mallet fingers commonly result from closed
avulsion injuries.

31.  Boutonniere deformity: zone 3
 A Boutonniere deformity results from injury and disruption of the central slip at
the PIP joint.

32.  Surgical repair is required if 60% or more of the flexor tendon is cut but,
deceptively, a tendon may be 70–90% lacerated and still functional.
 Tendon repair is not an emergency; however, as time progresses the repair
becomes more difficult as the cut ends retract, tissue becomes more oedematous
and scarred, and the prognosis worsens.
 Therefore, repair should ideally be carried out within 7 days of injury
 The simplest repair technique is a two-strand approach called the Kessler
technique.
 RICE

33.  Patient education is critical in the management of tendon injuries.
 Patients need to be aware of the necessary precautions. The wound needs to be
kept clean and dry.
 The splint needs to stay on 24 hours a day, 7 days a week.
 For a flexor injury, the patient needs to keep the fingers cupped with the wrist in
neutral if the splint is off. This position does not put any stretch or tension on the
tendons.
 Therapy sessions are usually twice a week for the first two weeks post-surgery.
Thereafter, weekly sessions until around 10 weeks post-surgery.

34.  Early complications – infection, pain, tendon rupture, pulley rupture and poor
tendon gliding.
 Late complications – adhesions, stiffness, scarring and complex regional pain
syndrome.

35.  NOVEMBER 2019, PAPER II
 Mr. Onah, a 37 years old grinding machine operator and father of six (6) was rushed into
the emergency department with history of his right hand getting stuck in a moving
machine. He is obviously in extreme pain, and has an open wound. Diagnosis of crush
injury of the right hand is made after two (2) specific diagnostic procedures.
 Define crush injury (1 mark)
 Enumerate tissues that are likely to be affected in Mr. Onah’s hand (3 marks)
 Explain two (2) possible diagnostic procedures that could aid the diagnosis of Mr. Onah
(3 marks)
 Develop a nursing care plan to solve (3) nursing diagnoses of Mr. Onah (9 marks)
 Highlight the advice to give Mr. Onah on discharge bearing in mind the nature of his job and
socioeconomic effect it will have on his family (4 marks)

36.  Stewart, C. (2005). EMR textbook: Crush injuries. Retrieved February 4, 2007,
from http://www.wnysmart. org/References/Medical%20Subjects/Crush%20Injury.
Pdf
 Tendon injuries: Basic science and new repair proposals. Available from:
https://www.researchgate.net/publication/318746365_Tendon_injuries_Basic_scien
ce_and_new_repair_proposals [accessed Feb 03 2022].
 Griffin, M., Hindocha, S., Jordan, D., Saleh, M. & Khan, W. 2012. An overview of
the management of flexor tendon injuries. Open Orthop J, 6, 28–35.