CRUSH INJURY TO THE HAND

1. PRINCIPLES UNDERLYING THE
MANAGEMENT OF A 20 YEAR OLD
LABOURER WITH CRUSH INJURY TO
THE RIGHT HAND
PRESENTER
EZEAKU CHIZOWA
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2. 2

3. OUTLINE
• INTRODUCTION
• AETIOLOGY
• CLASSIFICATION
• PRINCIPLES OF MANAGEMENT
• COMPLICATION
• REHABILITATION
• PROGNOSIS
• CONCLUSION
• REFERENCE
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4. INTRODUCTION
• The hand is the part of the upper limb distal to
the wrist.
• It is highly mobile, functional, and strong.It is a
major distinguishing point between human
beings and the nonhuman primates.
• “Next to the brain, the hand is the greatest
asset to man, and to it is due the development
of man’s handiwork.”– Sterling Bunnel
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5. • Crush injury are extremity injury due to
compressive pressure which may be severe to risk
limb viability.
• Crush injuries are commonly encountered in
different societies as mechanization provides risk
for these types of injury.
• These injuries occur as a result of high-energy
trauma in the young and otherwise healthy
people.
• Management of this injury will require careful
planning and meticulous execution of treatment.
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6. Anatomy
• The hand is a very complex organ with
multiple joints, different types of ligaments,
tendons and nerves.
• Hand is made of 19 bones arranged in five
rays.
• Rays are numbered 1 to 5
• Each digit has a proximal, middle and distal
phalanx, except thumb.
• There are five metacarpals
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7. Function
Fine job- surgeons, musicians
Fine pinch – picking up a pin
Power grip – holding a hammer
Key grip - holding a key
Chuck grip – holding a pen
Hook grip – holding a suit case
Tool of communication
Sensory tool – for discrimination
Organ of defense
Expression of joy, love & satisfaction
Medico legal instrument
Aesthetic function
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8. Functional proportion of the hand
• Thumb- 40%
• Index Finger-20%
• Middle Finger- 20%
• Ring Finger-10%
• Little Finger- 10%
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9. Aetiology
• RTA
• Blast injuries
• Injuries from grinding machines
• Other domestic accidents
• Gun shot injuries
In a study by Olaitan Etal, on pattern of hand injury, the following were noted:RTA-39.2%, Blast injuries,
2.8%, Avulsion from grinding machines, 13.5%, Other domestic accidents, 8.2% , Broken bottles, 5.4%,
Glass cut, 5.4%, Farm accidents, 8.2%,
Electrical burns, 5.4%, Gun shot injuries, 4.0%,
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10. Classification
Rank and Wakefield
a). Tidy wounds
-Incised
-Sliced-With tissue loss-skin, flap
-Puncture
b). Untidy
-avulsion
-crushed
-injected
c). Indeterminate
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11. Management
• Managed using the ATLS protocol
• Pre hospital trauma care
• Primary survey
• Secondary survey
• Tertiary survey
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12. Primary survey
• Airway and cervical spine control
• Breathing and ventilatory support
• Circulation and haemorhage/shock control
• Disability of the neurological system
• Exposure and temperature control
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13. Secondary survey
• Detailed history
• Detailed examination
– Head to toe
– Region to region
– Hand
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14. Tertiary survey
• Further clinical review
• Review of initial investigation
• Further investigations
• Definitive treatment
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15. Detailed history
 Age
 Hand dominance
 Occupation/hobbies
 Current injury-When and where did this injury take place?
 Mechanism of injury (nature of injuring force, name the
machine, part that caused the injury, was there entrapment,
for how long, how was the hand released, was heat involved)
 Circumstances: Assault ? suicide? Accident?
 Position of the hand when it was injured
 Determine if the patient was wearing protective device eg
gloves
 Indicate tissues involved-may not be fully possible till
anaesthesia is administered
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16. Detailed history
• Blood loss at the scene ,how was hemostasis
achieved
• Prehospital treatment
• Past history of treatment or surgery in the hand
• Pre-injury hand functional limitations from
contractures/scars/surgeries
• History of previous hand problems
• Past medical history- diabetes, vascular problems,
epilepsy
• Smoking history
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17. Examination
• Done in quiet room with good light
• Sedation may be required especially in
children
• Systematic, head to toe, note vital signs.
• The whole patient is examined to exclude life
threatening injury which may take precedence
over the hand.
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18. Examination of the hand
• Expose the entire upper limb
• Temporary and constricting dressings, rings,
bracelets and bandages are removed.
• Always compare with the uninjured limb
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19. • Examination:-Look, Feel, Move
Look
Expose all upper limb and remove rings
Inspection ,(Waterenberg sign)
Skin-Colour Change, Swellings, Asymmetry, Shape, Shrinkage
(Wasting), Scars, Cuts, cascade, a) rotation or “scissoring” b) shortening of digits
• compare contralateral limb
• Feel (Palpation)
Tenderness, Temperature,
• Circulation(capillary refill, radial, ulnar pulse, Allen’s test .)
• Sensation(nerve distribution zone-median,ulnar ,radial,)
• Two-point discrimination(static< 6mm and dynamic< 3mm).
• Tinel’s test, wrinking test, immersion test
Move
Active and passive across all joints
Range of motion
• Tendon assessment(flexors and extensors)
• Froment sign
• Never test tendons against resistance if tendon laceration is suspected
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20. • If there are amputated parts, they should be
preserved properly, kept with the patient and
brought to surgery.
• At initial assessment, no tissue should be
discarded, as there may be potential for
replantation or use for biological “spare
parts”.
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21. • NB-Arterial bleeding from a volar digital laceration
could indicate nerve laceration(nerves in digits are
superficial to arteries).
• Compartment Syndrome: Watch out for these signs
with a closed or open injury: tense, painful extremity
(worse on passive stretch), distal pulselessness (often
late in process),paraesthesia/paralysis, and contracture
(irreversible ischemia).
• Intracompartmental pressures over 30 mm Hg for more
than 8 hours require urgent fasciotomy.
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22. Investigation
• Clinical photograph
• X-ray-AP, Oblique, Lateral ,fingers in cascade Stress-Soft
tissues, Foreign bodies, air, bones & joints
• Wound swab M/C/S
• FBC,
• FBS,
• Urinalysis,
 CT scan-especially for carpal bone/ligament injuries
 MRI: high sensitivity for detection of soft tissue injuries
(ruptured ligaments/tendons)
 USS & Doppler:- Soft Tissue and Vascular lesions
 Angiography / MR angiography. 22

23. Aims of treatment
Restore distal circulation
Restore the basic hand unit
Provide a sensate mobile digit
Provide a stable coverage
Preserve functional length
Preserve function
Preserve appearance
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24. Initial treatment
 Analgesia
 Antibiotic
 Intravenous fluids
 Blood transfusion
 Tetanus Prophylaxis
 Elevation
 Control of bleeding
 Wound lavage and dressing
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25. Decision point
• The key decisions to be made involve the following
considerations:
• A determination of what needs to be discarded, either due to contamination,
unsuitability for salvage or lack of ultimate functional contribution. This
decision may be modified during the initial exploration.
• For example in the thumb, shortening until the interphalangeal joint has minimal
functional consequence.
• If more than two tissues in the digit have a defect that needs replacing,
amputation should be considered.
• The potential for sensory preservation, recovery or reconstruction in the limb.
• Sensation is often more important than length.
• The necessity and suitability of any parts for replantation or for use as spareparts.
• Apart from thumb amputations, the loss of a single digit does not affect ultimate
hand function.
• Extensive damage(dead or dying): total ablation and left hand development.
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26. Indication of amputation (and left
hand development)
• Life threatening hand injury(“life over limb”)
• Prolonged limb ischaemia
• Severe soft tissue loss
• Non-reconstruction bone injury
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27. 27

28. • What repair or reconstruction is necessary for each of the tissues involved:
• Bone and joint. Considerations include debridement, need for
shortening, fixation technique, fusion and the need for bone grafting.
• Vessel and nerve. The need for microsurgical repair and or grafting.
• Tendons. The need for repair either primary or grafting. There may also
• be total loss of the musculotendinous unit, requiring reconstruction by
• tendon transfer or free muscle transfer.
• Skin and soft tissue cover: The need for skin cover of vital structures.
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29. TIMING OF DEFINITIVE SURGERY
Primary vs Staged reconstruction
• Severe contamination
• Long delay before surgery
• Poor patient condition
• Difficult to ascertain extent of surgery at first
surgery.
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30. PRIORITIES
• Based on the considerations, the priorities for a crush
hand reconstruction are:
• A stable and opposable thumb of adequate length (at
least up to interphalangeal joint.
• At least one and preferable two digits for pinch with
the thumb.
• The digits should have adequate length and mobility to
reach the thumb.
• Good sensation of the reconstructed hand.
• Good skin and soft tissue cover that is durable and
facilitates further reconstruction.
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31. Intra-operative Principles
-Operative consent
-Alert and competent team
-Adequate anesthesia, -Bier’s block, Brachial plexus
block, G.A., Nerve blocks etc
-Good and fine instruments
-Appropriate sutures
-Good lighting,
-Hand rest,
-Bloodless field-torniquet
-Magnification-use of loupe and operating microscope
-Adequate debridement without tissue wastage
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32. Intra-operative Principles(CONTD)
-Replace like with like
-Retain/ restore opposition function of thumb
-Nerve and tendon should be primarily repaired
where possible.
-Incisions must not cross skin creases and must not
run across an interdigital web.
-Mid-axial or Bruner’s zigzag incision are used for
the sides and volar surface of the finger respectively
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33. Intra OP
• The superficial veins of the upper limb should
be marked for possible harvest.
• In addition, the legs should be prepared for
nerve and vein grafts.
• Reassesment of the wound under
anaesthesia.
• Urinary catheterization
• High quality photographs
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34. INITIAL SURGERY
• The first surgery is critical to the final outcome for the
crushed hand. The key goals during this surgery are:
• Removal of devitalized tissue(serial debridement)
• Removal of contamination
• Restoring good vascularity to the remaining tissues and
replantation as required
• Haemostasis
• Achieving bony stabilization
• Repair and reconstruction of other tissues if the
situation is suitable
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35. • If a staged reconstruction is planned, the first
surgery must achieve good debridement,
• stabilization of the fractures (with temporary
or definitive techniques) and a good
• vascularity of the remaining tissues before the
patient leave the operating theatre.
• The wound can be temporarily covered with a
dressing.
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36. Arterial Repair
• to prevent ischaemic complications
Vessels are sequentially resected until
normal intima is reached.
Tension-free repair- Interposition with
reversed vein grafts(low threshold).
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37. Replantation (Orthotopic vs heterotopic)
• With modern microsurgical techniques and appropriate skill,
amputated digits or hands can be replanted.
Cold ischaemic time for a finger- 30hrs.
Warm ischaemic time- <6hrs..
• Order of repair: bone, tendon, muscle unit, artery, nerve & vein
Amputated digits
Stump cleansed with saline and dressed with a nonadherent
gauze and bulky dressing.
Care of Amputated part
Washed with ringers lactate and wrapped in moist gauze
Placed in sealed plastic bag
Bag(Styrofoam container) placed in ice water bath(4 C)
Do not use dry ice, and do not allow the part to contact ice
directly; frostbite can occur in the amputated part,
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38. Indications for replantation
Clean guillotine amputation
Amputation proximal to DIP
Bilateral hand injuries
Multiple digit amputation
Amputation of thumb
Occupational value of the hand
Amputation in children
Contraindication to replantation
Severely crushed or mangled digit
Amputation at multiple level
Mentally unstable patient
Unstable patient
Single digit amputation(especially in males)
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39. Fracture fixation
• Proper reduction and stabilization of fractures
prevents further tissue injury, improves distal
perfusion and is the foundation for the rest of the
reconstruction and post-operative rehabilitation.
Treatment options
Reduction- open and closed
Fixation-Splint or internal (Kirschner wire, mini
plate and screw, intra-articular wire fixation) or
external fixation
immobilisation
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40. RELOOK SURGERY AND DEFINITIVE
RECONSTRUCTION
• If staged reconstruction has been planned, a
relook surgery should be done within 48–72
hours. This provides an opportunity to reassess
the wound for tissue viability and infection.
• At this point, definitive reconstruction can be
performed if the wound is clean and no further
debridement is necessary.
• If the wound is not ready, regular relook surgery
and debridement is performed until the wound is
clean with no infection and non-viable tissue.
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41. Skin and soft tissue cover
• Healing by secondary intention(defects≤ 1cm2)
•
Bone shortening + direct closure
•
Skin (split thickness and full )
•
Composite graft(replacement)
•
Local flaps: V-Y, volar advancement
•
Regional flap: Cross finger, thenar, hypothenar
•
Distant flap: arm flap, chest wall flap
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42. NERVE AND TENDON REPAIR
• Once the wound is ready for cover, nerve and
tendon repair or grafting can be done.
• Standard techniques can be used. Alternatively,
nerve and tendon reconstruction may be
deferred until good wound healing. If repair or
grafting is not possible,
• Reconstruction using tendon transfers,
arthrodesis, or free tissue transfers are usually
done later.
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43. • Nerve Repair:
Epineural or Perineural repair .
If under tension, Interposition with sural
graft,
Tinel’s test to assess.
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44. Tendon repair
• Technique
Placement of a “core suture” of 4-0 Prolene.
the 6-stranded technique.
• Kessler
• Bunnel
• Modified Kessler technique
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45. Role of physiotherapist
• The hand therapist is a key player in the
management of the mutilating hand injuries.
• Post-operative therapy contributes much to the
outcome.
• Referral is made immediately after the first
surgery.
• This allows an early assessment by the therapist,
and early mobilization of the unaffected joints to
prevent stiffness.
• This will proceed on to definitive therapy of the
injured part once surgery is completed.
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46. Secondary procedures
• Part of a staged surgery
• Toe transfers
• Joint release and tenolysis
• Web widening
• Scar revision surgery
• Continuous Local Anaesthesia infiltration
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47. Role of prosthesis
• Could be immediate fitting.
• Provide function in terms of grasp
• Helps to restore body image and encourage
the patient to display the hand.
• Acceptance, expensive ,wear and tear and
need replacement.
• Eg myoelectric prosthesis with life like silicon
over glove.
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48. Post Operative Measures
Splint position
Elevation
Early physiotherapy
Antibiotics choice
Post operative pictures
Follow up
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49. Complications
• Stiffness
Painful neuromas
Skin contractures
Non union, malunion of fracture
Osteomyelitis
Nerve deficits-especially finger tips
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50. Rehabilitation
• Physiotherapist
• Psychologist
• Support groups
• Workman’s compensation act
• Prosthesis
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51. Prognosis
• Outcomes are variable.
• Depends of mechanism and severity of injury,
age, psychological makeup and surgeons
expertise.
• Adhrence to principles of management makes
a big difference to eventual outcome.
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52. Conclusion
• Hand is a very important part of the body and
crush injury to the hand , though devastating,
through proper management protocol gives a
salvagable hand with good aesthetic, sensory
and functional capacity.
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53. THANKS FOR LISTENING
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54. REFERENCES
• Management of hand Injuries-Lecture by Prof.
P.O. Olaitan
• Chong K.S. Priniciples of management of
mangled hand:Indian J Plast surg.
May,2011;44(2):pg219-226
• Townsend m Etal. :Hand Surgery. Sabiston
Textbook of Surgery, 20th edition,2017: pg
1970-1981
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