Crush Injuries of the Hand

Clinical application of platelet rich plasma to promote healing of open hand injury with skin defect

Background

Skin defects caused by open hand trauma are difficult to treat clinically and severely affect the recovery of hand function. Autologous platelet-rich plasma (PRP) has been widely used in the treatment of refractory chronic wounds, but its use in hand trauma skin defects remains scarce.

Methods

This study compared the outcomes of 27 patients treated with PRP to 31 patients undergoing skin flap transplantation for hand wounds. We assessed several parameters, including healing times, duration of surgery, postoperative pain (VAS score), intraoperative amputation length, finger function, sensation restoration, nail bed preservation, and hospitalization expenses.

Results

PRP-treated patients showed a mean healing time of 21.59 ± 3.17 days. Surgical times were significantly shorter in the PRP group (22.04 ± 7.04 min) compared to the flap group (57.45 ± 8.15 min, P < 0.0001). PRP patients experienced longer postoperative healing times (20.15 ± 2.16 days) than those in the skin flap group (12.84 ± 1.08 days, P < 0.0001), but reported lower pain scores (1.3 ± 1.44 vs 2.55 ± 2.06, P = 0.0119). Range of Motion (ROM) at the proximal interphalangeal joint was better in the PRP group (96.26° ± 6.69) compared to the flap group (86.16° ± 15.24, P = 0.0028). Sensory outcomes favored the PRP group, with a two-point discrimination of 2.37 ± 1.34 mm versus 2.52 ± 1.27 mm in the flap group (P = 0.0274). Costs were lower in the PRP group ($2081.6 ± 258.14 vs $2680.18 ± 481.15, P < 0.0001).

Conclusion

PRP treatment for skin defects from hand trauma is effective, offering advantages in terms of reduced surgical time, pain, and cost, with comparable or superior functional outcomes to flap transplantation. Despite longer healing times, PRP may represent a preferable option for open hand injuries, preserving more nail beds and resulting in better sensation and joint motion.

The Evolution of Hand Injuries at a State's Only Level I Trauma Center: A Look From the 1980s Through the Global Pandemic

BACKGROUND

The purpose of this study is to evaluate any changes to hand trauma in the past three decades and through the COVID-19 pandemic. We hypothesized that improved consumer safety regulations, changes in access to care, and the impact of a global pandemic, among other variables, have significantly influenced the mechanisms and treatment of hand injuries between the 1980s, 2010s (pre-COVID-19), and 2020s (post-COVID-19).

METHODS

A retrospective single-center review was performed at the only level I trauma center in Mississippi, identifying all hand trauma consultations between 2012-2019 and 2020-2021, compared to aggregated data from 1989.

RESULTS

Car accidents, gunshots, saw injuries, door injuries, and falls increased in 2012-2019 and 2020-2021 compared to 1989, whereas knife injuries, glass injuries, industrial injuries, and burns decreased. Crush injuries, de-gloving injuries, and lacerations with irregular edges were increased in recent cohorts, corresponding with increased amputations and tissue loss. Skin and subcutaneous injuries decreased in modern cohorts, corresponding with a decreased ability for primary skin repair and the need for more flaps. Additionally, while hospitalizations have increased, patients have improved follow-up.

CONCLUSIONS

The nature of hand trauma has changed significantly over the past three decades. Increased numbers of cars and greater access to firearms might have led to increased rates of high-energy trauma, whereas burn and industrial injuries have decreased, potentially secondary to improved safety efforts. Despite increased overall hand trauma, time to treatment and follow-up have improved. Through this study, we can be more cognizant of the evolution of hand trauma in the modern era. This can allow improved access to care and further refine management to optimize functionality for hand injuries.

Advances in Soft Tissue Injuries Associated with Open Fractures

Management of soft tissue injury is a key component in the overall treatment of upper extremity fractures. Hand surgeons must rely on their armamentarium for treating soft tissue deficits for functional outcomes. Understanding the role of fracture fixation and wound adjuncts, including negative pressure wound therapy and dermal regenerative templates, is the keys to success. In addition, detailed knowledge of local and free tissue options is essential for hand reconstruction.

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.

6 February 2023, orthopedic experience in Kahramanmaraş earthquake and surgical decision in patients with crush syndrome

BACKGROUND

The decision of fasciotomy or amputation in crush syndrome is controversial and challenging for surgeons. We aimed to share our experiences after the Kahramanmaraş earthquake, to predict the severity of crush syndrome and mortality, and to guide the surgical decision.

METHODS

The clinical data of patients during their first week of hospitalization were analyzed retrospectively. Totally, 233 crush syndrome patients were included. Demographic data, physical and laboratory findings, surgical treatments, and outcomes were recorded.

RESULTS

The mean time under the rubble was 41.89 ± 29.75 h. Fasciotomy and amputation were performed in 41 (17.6%) and 72 (30.9%) patients. One hundred and two patients (56.7%) underwent hemodialysis. Fifteen patients (6.4%) died. Lower extremity injury, abdominal trauma, and thoracic trauma were associated with mortality. Mortality was significantly increased in patients with thigh injuries (p = 0.028). The mean peak CK concentration was 69.817.69 ± 134.812.04 U/L. Peak CK concentration increased substantially with amputation (p = 0.002), lower limb injury (p < 0.001), abdominal trauma (p = 0.011), and thoracic trauma (p = 0.048).

CONCLUSIONS

Thigh injury is associated with the severity of crush syndrome and mortality. Late fasciotomy should not be preferred in crush syndrome. Amputation is life-saving, especially in desperate lower extremity injuries.

Hyperbaric oxygen therapy for the treatment of a crush injury of the hand: a case report

We describe a case of hyperbaric oxygen therapy (HBOt) as an adjunct to treatment of a crush injury to the hand. A 34-year-old male paramedic was involved in a motor vehicle accident and admitted for diagnosis and surgical treatment. He sustained a crush injury to his right hand and presented with significant muscle damage, including multiple fractures and dislocations, an avulsion injury of the flexor tendons, and amputation of the distal phalanx of the little finger. He underwent reconstructive surgery and received HBOt over the following days. In the following 2 months, he lost the distal and middle phalanges of the little finger and recovered hand function. Posttraumatic compartment syndrome responds well to HBOt, which reduces edema and contributes to angiogenesis, as well as promoting the cascade of healing events. High-energy trauma causes massive cell destruction, and the blood supply is usually not sufficient to meet the oxygen demands of viable tissues. Hyperbaric oxygenation by diffusion through interstitial and cellular fluids increases tissue oxygenation to levels sufficient for the host's responses to injury to work and helps control the delayed inflammatory reaction. HBOt used as an adjunct to surgical treatment resulted in early healing and rehabilitation, accelerating functional recovery. The results suggest that adjunctive HBOt can be beneficial for the treatment of crush injuries of the hand, resulting in better functional outcomes and helping to avoid unnecessary amputations.

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.

Complete Occlusion of Radial and Ulnar Arteries Following Hand Crush Injury with Multiple Carpometacarpal Joint Fracture-Dislocations

Multiple dorsal fracture-dislocations of the carpometacarpal joints (CMCJ) occur from very high-energy trauma and are often associated with soft tissue injury or ischaemia. We report a 54-year-old male manual worker and a smoker who presented to the emergency room with history of compression of his right hand in a press machine. Radiographs showed dorsal fracture-dislocations of the scapho-trapezio-trapezoidal and third to fifth CMCJ's. Despite emergent Guyon canal and carpal tunnel release and closed reduction and pinning, skin pallor persisted in all digits. Brachial angiography revealed total occlusion of the radial and ulnar arteries and loss of the palmar arch at the level of the fracture. Heparin and Alprostadil were injected directly. On follow-up angiography three weeks later, the vessels were still occluded and collaterals provided digital circulation. Although digital sensations recovered, cold intolerance and stiffness resulted in a poor functional outcome. Level of Evidence: Level V (Therapeutic).

Reliability of Jeweler Rings and a Revised Figure-of-Eight Circumference Protocol for the Assessment of Finger and Hand Circumferences

Background: Assessing the circumference of the hand and fingers can be challenging. Therefore, we studied the reliability of jeweler rings and a revised figure-of-eight (figure-8) protocol for the clinical assessment of finger and hand circumference. Methods and Results: Thirteen patients residing in a rehabilitation center were recruited. Inter- and intrarater reliability of the jeweler rings as well as the revised figure-8 protocol were assessed. Jewelers rings were used to assess the circumferences of the middle and ring finger of both hands. The figure-8 method was used to assess the circumference of both hands. Reliability analyses were performed in Statistical Package for the Social Sciences 26 and demonstrated an excellent reliability for the jeweler rings as well as the revised figure-8 protocol, represented by single random measure intraclass correlation coefficient_(2,1) values of at least 0.973 and Cronbach alpha of at least 0.99. Conclusions: Circumference measurements are valid to use; however, reliability issues do exist in clinical practice. Assessing the circumference of fingers with our new jeweler rings protocol and the circumference of the hand by means of a revised figure-8 protocol is highly reliable in a clinical setting.

Factors associated with limited hand motion after hand trauma

Hand injuries are common and have a significant impact on daily life. However, the factors associated with functional outcome after hand injuries are not well established. The purpose of this study was to identify factors that are independently associated with hand total active motion (TAM).A total of 50 patients with unilateral complex hand injury were included in this study. The associations between various demographic, injury-related, and clinical assessment factors and TAM were determined by univariate and multivariate linear regression analyses. Nerve injuries recognized during surgery and diagnosed with electrodiagnostic (EDX) studies were compared using Pearson chi-squared test.Among multiple injury-related and initial clinical assessment factors, nerve injury diagnosed with EDX studies, hospital stay length, elevated C-reactive protein, and skeletal injury were independently associated with TAM in the affected hand after adjusting for covariates. Nerve injuries diagnosed with EDX studies were not consistent with those recognized during surgery.Our results suggest that high-energy trauma leading to skeletal and nerve injury with inflammation is associated with limited hand motion after surgery and postoperative immobilization. A comprehensive EDX study may enable identifying occult or recovered nerve injuries, which would be helpful in understanding limitations in finger movements.