An Update on the Management of Severe Crush Injury to the Forearm and Hand

The use of hyperbaric oxygen therapy in the treatment of hand crush injuries

Hyperbaric oxygen therapy (HBOT) has been used as an adjuvant treatment for crush injury because it can improve tissue hypoxia and stimulate wound healing. However, the actual role of HBOT in crush hand injury is still unknown. This study is to assess the efficacy of HBOT for crush hand patients, as well as the impact of HBOT initiation timing. Between 2018 and 2021, 72 patients with crush hand injury were retrospectively reviewed. The patients were divided into the HBOT and control group, and each group had 36 patients. The average session of HBOT was 18.2 (5-32 sessions) per patient, and no patient had a complication related to the treatment. The two groups had similar demographics, but HBOT group had larger injured area (73.6 ± 51.0 vs. 48.2 ± 45.5 cm2 , p = 0.03). To better control the confounding factors, we performed the subgroup analysis with cut-off injured area of 50 cm2 . In the patients with smaller injured area (≦50 cm2 ), the HBOT group had shorter wound healing time (29.9 ± 12.9 vs. 41.0 ± 18.9 days, p = 0.03). The early HBOT group (first session ≤72 h post-operatively) had shorter hospital stay (8.1 ± 6.4 vs. 15.5 ± 11.4 days, p = 0.04), faster wound healing (28.7 ± 17.8 vs. 41.1 ± 18.1 days, p = 0.08) and less operations (1.54 ± 0.78 vs. 2.41 ± 1.62, p = 0.06) although the latter two didn't achieve statistical significance. HBOT is safe and effective in improving wound healing of hand crush injury. Early intervention of HBOT may be more beneficial. Future research is required to provide more evidence.

Crush syndrome: a review for prehospital providers and emergency clinicians

INTRODUCTION

Disasters and accidents have occurred with increasing frequency in recent years. Primary disasters have the potential to result in mass casualty events involving crush syndrome (CS) and other serious injuries. Prehospital providers and emergency clinicians stand on the front lines of these patients' evaluation and treatment. However, the bulk of our current knowledge, derived from historical data, has remained unchanged for over ten years. In addition, no evidence-based treatment has been established to date.

OBJECTIVE

This narrative review aims to provide a focused overview of, and update on, CS for both prehospital providers and emergency clinicians.

DISCUSSION

CS is a severe systemic manifestation of trauma and ischemia involving soft tissue, principally skeletal muscle, due to prolonged crushing of tissues. Among earthquake survivors, the reported incidence of CS is 2-15%, and mortality is reported to be up to 48%. Patients with CS can develop cardiac failure, kidney dysfunction, shock, systemic inflammation, and sepsis. In addition, late presentations include life-threatening systemic effects such as hypovolemic shock, hyperkalemia, metabolic acidosis, and disseminated intravascular coagulation. Immediately beginning treatment is the single most important factor in reducing the mortality of disaster-situation CS. In order to reduce complications from CS, early, aggressive resuscitation is recommended in prehospital settings, ideally even before extrication. However, in large-scale natural disasters, it is difficult to diagnose CS, and to reach and start treatments such as continuous administration of massive amounts of fluid, diuresis, and hemodialysis, on time. This may lead to delayed diagnosis of, and high on-site mortality from, CS. To overcome these challenges, new diagnostic and therapeutic modalities in the CS animal model have recently been advanced.

CONCLUSIONS

Patient outcomes can be optimized by ensuring that prehospital providers and emergency clinicians maintain a comprehensive understanding of CS. The field is poised to undergo significant advances in coming years, given recent developments in what is considered possible both technologically and surgically; this only serves to further emphasize the importance of the field, and the need for ongoing research.

Reconstruction of Hand and Foot Defects with Free Serratus Carpaccio Flap and Free Serratus Fascia Flap: A Comparative Retrospective Study of Surgical Outcomes

BACKGROUND

Defects of the hand and foot often require an individualized reconstructive approach, due to their unique functional and aesthetic characteristics. Transferred tissues should be thin, pliable, and durable, with free fascial flaps meeting these requirements. This study aimed to evaluate the serratus fascia flap and the serratus carpaccio flap, which is a modification of the fascia flap, by including a thin muscle layer, with the goal of enhancing flap resilience and lowering morbidity rates.

METHODS

Between January 2000 and December 2017, 31 patients underwent microsurgical reconstruction of the hand or foot either by serratus fascia flap (fascia group) or serratus carpaccio flap (carpaccio group). The serratus fascia flaps were mainly harvested between 2000 and 2012, and the serratus carpaccio flaps between 2013 and 2017. Patient records were reviewed retrospectively, regarding demographics, complications, overall flap survival, additional revision surgeries, and surgical outcome. Categorical variables were compared using Fisher's exact test and continuous data with the Mann-Whitney tests. Logistic regression was used to examine the correlation between comorbidities and postoperative complication rates. Differences were considered significant when p < 0.05.

RESULTS

The fascia group consisted of 17 patients and the carpaccio group of 14 patients. The average patient age in the fascia group was 39.2 ± 10.5 years, and it was 39.1 ± 14.7 years in the carpaccio group. Overall complication rates were significantly lower in the carpaccio group than in the fascia group (28.6% vs. 70.6%, p = 0.03). The rates of overall flap survival (85.7% in the carpaccio group vs. 74.5% in the fascia group, p = 0.66) and partial flap loss (14.3% in the carpaccio group vs. 47.1% in the fascia group, p = 0.07) did not differ significantly among both groups. One postoperative hematoma of the donor site requiring revision surgery was reported in the carpaccio group (7.1%, p = 0.45) while no donor-site morbidity was reported in the fascia group.

CONCLUSIONS

Our findings indicate that the serratus carpaccio flap presents a promising alternative to the serratus fascia flap. This modification has proven to be effective in substantially reducing postoperative complications requiring additional surgical interventions. Therefore, the serratus carpaccio flap can be considered a dependable reconstructive option for addressing complex soft tissue defects of the hand and foot, with complication rates that are within an acceptable range.

Multi-staged management of a mangled, exploded hand crush injury with long-term outcome: the critical link between surgery and therapy

A 38-year-old right-hand dominant man sustained a severe, work-related left-hand crushing injury. A multi-staged approach to salvage was employed in conjunction with aggressive hand therapy involvement for a successful, functional outcome. Now at approximately 5 years postinjury, the patient can perform daily activities, coaches sports and has returned to and maintained his full-time work position. Mangled, severe hand crush injuries warrant immediate treatment to debride non-salvageable tissues, stabilise and revascularise the hand in an effort to maximise reconstructive potential and functional capacity. It is critical to recognise that these cases require multiple stages of operative reconstruction with direct and ongoing involvement of hand therapy and pending degree of injury, rehabilitation often lasting months to years.

Reconstruction of extra-large severe punching hole injury in the palm: A case report

A 48-year-old man sustained a severe punching hole injury of 8 cm in diameter on the palm of his left hand using a punching instrument (for making the bottom of drink cans), and his middle and ring fingers were almost amputated. A flow-through type immediate ALT (anterolateral thigh) flap was used to bypass the distal blood flow and a titanium plate for mandibular reconstruction and plantar glabrous skin were used to preserve the floating amputated fingers. As there has been no report of reconstruction of a punching hole in the palmar region that exceeds 8 cm in diameter, this report is novel and educational.

Effect of Comprehensive Rehabilitation Training Program in Orthopedic Nursing of Patients with Residual Limb Injury Caused by Crush

This study was developed to explore the role and application value of a comprehensive rehabilitation training (CRT) program based on the remote monitoring system of limb rehabilitation training (LRT-RM system) in the rehabilitation nursing of patients with residual limb injuries caused by crush. The LRT-RM system was constructed based on the characteristics of limb movement and using the time-domain analysis method and support vector machine (SVM). The 84 crush injury patients were selected as the research objects and divided into a control group (Con group, received conventional rehabilitation therapy) and a CRT group (received conventional rehabilitation therapy + functional training) according to different therapies, with 42 people in each group. The incidence of compound injuries and the incidence of residual limb injuries were counted and compared for patients in two groups. The differences in renal function, blood electrolytes, and biochemical indicators before and after treatment were analyzed. The MOS 36-item short-form health survey (SF-36) scale was selected to evaluate the improvement of physical and mental health of the patients before treatment and 1 month (time point (TP1)), 3 months (TP2), 6 months (TP3), and 12 months (TP4) after the treatment. It was found that, after the intervention, the values of serum creatinine (Scr), blood urea nitrogen (BUN), uric acid (UA), K+, P3+, and white blood cells (WBC) of patients in CRT group were obviously lower than those of Con group (P < 0.05), and the values of carbon dioxide combining power (CO2CP), Ca2+, hemoglobin (Hb), red blood cell (RBC), total protein (TP), and albumin (ALB) were obviously higher than the values in Con group (P < 0.05). In the CRT group, the residual limb injury rate was lower in elbow, wrist, shoulder joint, ankle joint, and toe (P < 0.05) and extremely lower in knee joint in contrast to that in the Con group (P < 0.001). The score of SF-36 was dramatically higher than that in the Con group (P < 0.05). It suggested that the CRT program based on the LRT-RM system was helpful for the rehabilitation of patients with crush injuries, and it can reduce the incidence of residual limb injuries in patients. Results of this study could provide a reference basis for the treatment of residual limb injuries caused by crush.

Management of a mutilated hand: the current trends

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

Soft and tissue repair of the hand and digital reconstruction

This article summarizes the current views and proposed approaches to treating soft tissue defects of the hand. The article also outlines some key considerations of digital reconstruction. There are many options in treating soft tissue defects. For defects of the hand, local flaps are primarily considered if the defects are small or moderate in size. A vascularized free flap is only considered for a defect of large size (3 cm long or larger). Thumb reconstruction is of primary importance, while reconstruction of two fingers is necessary when all fingers are lost. Reconstructions of a missing distal part of a finger or reconstruction of an entire finger if only one finger is lost are cosmetic restorations; functionally these defects do not need reconstruction. Sensation is of great importance in repair or reconstruction of the tip of the thumb or finger. Therefore, sensory evaluation is a key factor in assessing and selecting the best options of surgery.