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Severe Crush Injury to the Forearm and Hand the Role of Microsurgery

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Severe Crush Injury to the Forearm and Hand the Role of Microsurgery Severe Crush Injury to the Forearm and Hand The Role of Microsurgery Francisco del Piñal, MD, PhDa,*, Esteban Urrutia, MDa,b, Maciej Klich, MDa,c KEYWORDS Crush syndrome Hand Compartimental syndrome Free flap Hand revascularization Microsurgery KEY POINTS Microsurgery changes the prognosis of crush hand syndrome. Radical debridement should be followed by rigid (vascularized) bony restoration. Finally, bringing vascularized gliding tissue allows active motion to be restored. INTRODUCTION discusses the pathology and treatment of injuries involving the distal forearm, wrist, or metacarpal Severe crush injuries to the hand and fingers area and fingers separately. often carry an unavoidably bad prognosis, resulting in stiff, crooked, and painful hands or fingers. In follow-up, osteoporosis is often ACUTE CRUSH TO THE DISTAL FOREARM, times seen on radiographs. A shiny appearance WRIST, AND METACARPAL AREA OF THE of the skin and complaints of vague pain may HAND lead the surgeon to consider a diagnosis of re- Clinical Presentations and Pathophysiology flex sympathetic dystrophy,1 to offer some “explanation” of the gloomy prognosis that a Two striking features after a severe crush injury are crush injury predicates. Primary or secondary 1. The affected joints tend to stiffen and the amputations are the common end options of affected tendons tend to stick. treatment. 2. The undamaged structures distal to the area of In the authors’ experience, the prompt and injury usually get involved. precise application of microsurgical techniques can help alter the often dismal prognosis held The trauma appears to have a “contagious” ef- by those suffering from severe crush injuries. fect that spreads distally, similar to a fire spreading To avoid the progression of a severely crushed to the higher floors in a skyscraper. There is no hand to a useless hand, one should understand satisfactory explanation as to why normal anatomy that the pathophysiology involved in the distal seemingly spared during the initial traumatic event forearm, wrist, and metacarpal area is different should convert to abnormality. To most, the from that in the fingers. Therefore, this article consequence, a frozen hand, is more devastating The authors have nothing to disclose. a Instituto de Cirugı´a Pla´ stica y de la Mano, Private Practice, Hospital La Luz and Hospital Mutua Montan˜ esa, Madrid/Santander, Spain; b Department of Orthopaedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile; c Department of Traumatology and Orthopedics, Clinical Hospital, Warsaw, Otwock, Poland * Corresponding author. Calle Serrano 48-1B, E-28001-Madrid, Spain. E-mail addresses: [email protected]; [email protected] Clin Plastic Surg 44 (2017) 233–255 http://dx.doi.org/10.1016/j.cps.2016.11.002 0094-1298/17/Ó 2016 Elsevier Inc. All rights reserved. plasticsurgery.theclinics.com 234 del Pin˜ al et al than the original injury, that is, a focal trauma in the In exploring the pathophysiology, the following forearm (Fig. 1). questions can be posed: What causes a healthy This traumatic event will cause localized devas- tendon to be unable to glide? Or a normal joint to cularization in the forearm and result in healing by stiffen? Or an uninjured finger to deviate? Several fibrosis locally. These facts, however, do not factors can shoulder some of the blame: insuffi- explain the end result of a frozen hand, which often cient debridement, the presence of dead space is very painful. The authors attempted to reveal that fills with debris or hematoma, unstable mysterious pathophysiology of the crush syn- fixation, and poor coverage. The underlying com- drome of the hand, but such attempts have not monality with these factors is that they contribute been fruitful.2 to the formation of an enormous amount of fibrotic Fig. 1. An example of a frozen hand as discussed. (A) This 44-year-old man was referred 4 months after sustaining a crush injury to his forearm and wrist by a press. Parts of the wounds were left to heal by secondary intention for fear of losing the whole hand. (B) Malunion is pre- sent in several areas of the radius, ulna, and carpal bones. It is notable that his fingers became stiff and immobile despite being practically unin- volved. (C) The patient is unable to make a fist. (D) The patient is unable to extend the fingers. (Copyright Ó 2015, Francisco del Pin˜ al, MD.) Microsurgery in Crush Injury to the Hand 235 and scarred tissue. All of them are responsible for minimal variations, management focuses on a delay in the commencement of active motion, addressing the 4 pillars in the listed order: which leads to the loss of tendon gliding and joint stiffness. Muscle contracture, secondary to diag- 1. Debridement nosed or undiagnosed compartment syndrome, 2. Bone management would drag the fingers into dysfunctional 3. Neurovascular structures damaged positions. 4. Soft tissue defect Within this chaotic milieu of diminished blood supply, hematoma, unstable fractures, and poor Radical Debridement soft tissue coverage in severe crush injuries, it is easy to foresee that any contaminant could lead In the setting of a severe crush to the forearm and to one of the most dreaded complications— the hand, there is a large amount of devitalized or deep space infections. Fibrosis and contamina- threatened tissue. The devitalized tissue is a nidus tion with or without infection result in the dismally for an inflammatory response, creating a wound functionless “frozen” hand. Furthermore, chronic, bed that heals primarily through the means of unremitting pain is a common component of this fibrosis. This results in a massive amount of scar- syndrome in its later stage. Although a handy ring. Reducing the burden of dead or dying tissue acronym “CRPS1” (complex regional pain syn- is paramount to promoting the revascularization of drome) could offer an easy explanation to the bone as well as for aiding tendon gliding. onset of pain, a more logical and clearer explana- When the crush injury involves the metacarpals, tion is that the nerves are either unable to glide one has to consider debriding the interosseous and thus causing pain without movement (neu- muscles should they be devascularized and/or rodesis) or ischemic in the confines of heavy scar- denervated. Most of the blood supply to the inter- ring. The discomfort is exhausting for the patient osseous muscles enters proximally,3 and an injury both physically and psychologically, and amputa- to the carpal arch unavoidably impairs the arterial tion may be needed as the endpoint treatment inflow into the deep muscles of the hand. In addi- (Fig. 2). tion, compartment syndrome in the hand may occur with minimal clinical symptoms and remains difficult to diagnose.4 Such compartment release MANAGEMENT should occur with low suspicion to preempt future dysfunction. With the diligent and quick application of the When the crush injury occurs at the carpal level, appropriate techniques, a surgeon can halt the severe derangement of the carpal architecture— progression from crush injury to frozen hand, illus- including floating carpal bones, disruption of the trated in Fig. 2. It is hoped that aggressive opera- deep carpal arches, and potentially hand devascu- tive management will result in a better functioning larization—can be expected. Acute hand amputa- hand in the setting of an admittedly devastating tion is not rare,5 and late amputation due to deep injury. Management keys are to address each of hand infection is unfortunately common. Amputa- the factors that lead to the poor results. Because tion is not surprising in this scenario, because of the complexity in the decision-making process the entire central portion of the hand is deprived and the technical expertise required in the treat- of its arterial inflow, and potential interosseous ment, it is crucial that the utmost care be under- muscle necrosis may occur if revascularization is taken by a skilled team of surgeons. With needed.2 Fig. 2. Flowchart showing the nat- UNYIELDING JOINTS ural progression in mismanage- STUCK TENDONS ment of complex injuries. CRPS1, NONUNIONS INSUFFICIENT DEBRIDEMENT complex regional pain syndrome. UNFILLED DEAD SPACE MINOR POOR COVERAGE COMPLICATIONS UNSTABLE FIXATION MAJOR POOR INFLOW FROZEN HAND DEEP INFECTION “CRPS1” AMPUTATION 236 del Pin˜ al et al Fig. 3. (A, B) Massive crush injury at the central portion of the hand. Debridement and primary stabilization were carried out as an emergency. Notice that the first web space and thenar musculature (arrows) suffered hydraulic extrusion. The radial side of the hand had marginal blood supply, with Doppler signals in the dorsum of the thumb only. (C, D) Three days after the injury, secondary to hematoma and edema, a massively swollen “balloon” Microsurgery in Crush Injury to the Hand 237 Interestingly, simple debridement of this central functional recovery, it is best to replace the joint. devitalized tissue can lead to further problems This especially applies when the joint injury occurs because the dead space created may fill with in the setting of severe soft tissue injury (Fig. 5). blood upon release of the tourniquet.6 This central Although this approach seems very aggressive, hematoma might become secondarily infected, the reward is often a much better end result with and if not infected, it may still lead to the formation overall less patient suffering and faster healing of densely fibrotic tissue, with both carrying an times. One should bear in mind that early rehabili-
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