CURRENT CONCEPTS

Crush Injuries of the Hand

Avi D. Goodman, MD,* Christopher J. Got, MD,* Arnold-Peter C. Weiss, MD*

Crush injuries of the hand are a rare but devastating phenomenon, with historically poor
outcomes. A compressive force, usually caused by a high-energy mechanism such as a motor
vehicle or industrial accident, crushes and transiently increases the pressures within the hand.
This force acts on the incompressible blood in the vasculature and leads to a dramatic rise in
tissue pressures and damage to multiple tissue types, including bones, blood vessels, nerves,
and soft tissues. A wide zone of injury results from a delayed inflammatory reaction involving
the zone bordering the crushed cells, which may initially belie the severity of the injury. As
such, these injuries go on to produce tremendous inflammation and swelling, potentially
followed by compartment syndrome or other vascular damage, infection, neurological
injury, and tissue necrosis. Crush injuries with minimal skin disruptions can be particularly
challenging to accurately diagnose and manage. This paper provides a review of the
initial evaluation of hand crush injuries as well as short- and long-term management strate-
gies. (J Hand Surg Am. 2017;-(-):-e-. Copyright Ó 2017 by the American Society for
Surgery of the Hand. All rights reserved.)
Key words Crush injuries, hand compartment syndrome, contracture management, review, case
report.

C
RUSH INJURIES TO THE HAND ARE a rare but particularly challenging to accurately diagnose and
devastating phenomenon, with historically manage. This paper provides a review of the initial
poor outcomes.1,2 A compressive force, evaluation of hand crush injuries as well as short- and
usually caused by a high-energy mechanism such as a long-term management strategies.
motor vehicle or industrial accident, crushes and
transiently increases the pressures within the hand. DIAGNOSIS AND INITIAL MANAGEMENT
This force acts on the incompressible blood in Many such injuries are associated with high-energy
the vasculature and leads to a dramatic rise in tissue trauma, and Advanced Trauma Life Support princi-
pressures causing damage to bones, blood vessels, ples must be applied as necessary to preserve life over
nerves, and soft tissues.3 A wide zone of injury results limb. The patient must be evaluated in a systematic
from a delayed inflammatory reaction involving the fashion to avoid missed injuries.
bordering zone, which may initially belie the severity
of the damage. These injuries go on to produce History
tremendous inflammation and swelling, potentially Once the patient is stable, a pertinent medical history
followed by compartment syndrome, vascular damage, should be obtained with particular attention to injury
infection, neurological injury, and tissue necrosis.4 timing and mechanism; the former is crucial in
Crush injuries with minimal skin disruption can be determining salvage versus amputation because

From the *Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown Corresponding author: Avi D. Goodman, MD, Department of Orthopaedic Surgery, Warren
University, Providence, Rhode Island. Alpert Medical School, Brown University, 593 Eddy St., Providence, RI 02903; e-mail:
[email protected].
Received for publication January 7, 2017; accepted in revised form March 22, 2017.
0363-5023/17/---0001$36.00/0
No benefits in any form have been received or will be received related directly or indirectly http://dx.doi.org/10.1016/j.jhsa.2017.03.028
to the subject of this article.

Ó 2017 ASSH r Published by Elsevier, Inc. All rights reserved. r 1

2 CRUSH INJURIES OF THE HAND

devascularized muscle can only survive 4 to 6 hours neurovascular compromise, resulting in compartment
of warm ischemia.5 An understanding of the injury syndrome.
mechanism can help infer energy level of the crush- The surgeon must be vigilant for signs and symp-
ing force and raise suspicion for occult injuries. toms of compartment syndrome; with 10 separate
Learning the patient’s occupation, handedness, and muscular compartments, the hand poses a particular
comorbidities helps determine functional needs and challenge (Fig. 1). Profuse edema and inflammation
goals. Although several scoring systems attempt to increase the volume within the fascial compartments,
estimate outcomes, these do not accurately predict the decreasing perfusion to soft tissues and nerves. Of the
need for amputation over salvage in upper extremity classic “5 Ps” of compartment syndrome (pain, pallor,
crush injuries.4,6 paresthesias, pulselessness, and paralysis), only pain
(both out of proportion to clinical examination findings
Clinical examination and with passive stretch) is thought to present early
The examination begins with an inspection, looking enough to recognize and treat the pathology before
for wounds that may indicate open fractures, tendon deep tissue necrosis occurs.1,7 However, even this
or nerve injuries, or even an “exploded hand” as conventional wisdom may be unreliable, as a study by
described by Graham.3 In this constellation, the del Piñal et al1 investigating compartment syndrome
compressive force generates a predictable injury in crushed hands showed a significant proportion of
pattern, beginning with interosseous muscle extrusion patients had no pain with passive stretch, perhaps due
through a tension failure of the skin, commonly in to concomitant neurological injury or masked by
the first web space where the skin is weakest; this fractures. A rising analgesia requirement is a useful
portends a grave prognosis.3 Gross swelling and alternative in children and the unconscious. The classic
palmar convexity may be clues to impending intrinsic-minus position of hand compartment syn-
compartment syndrome or fracture-dislocations.1,3 A drome is also obscured by the significant swelling
thorough neurological examination should assess the associated with crush injuries. In all cases of hand
new baseline status of each nerve, including signs of compartment syndrome following a closed crush
acute carpal tunnel syndrome. In patients unable injury, del Pinal et al1 found that the thenar and first
to cooperate, look for dry, red skin as a sign of web space muscles were involved. In addition,
sympathetic paralysis; if present, this usually Ouellette et al8 showed that 15 of 17 patients (88%)
indicates more serious nerve damage (as opposed to were obtunded at the time of developing compartment
neurapraxia). Tendon function in all fingers and the syndrome. Because of the lack of reliability of clinical
thumb should be assessed, through both tenodesis symptoms and serious implications of a missed diag-
and active motion of each joint, if possible. Most nosis, the surgeon must have a low threshold for
importantly, assess the hand for perfusion through directly measuring compartment pressures.
pulses, capillary refill (especially dorsal paronychial Compartment pressures can be considered either
tissue), warmth/color, and Doppler signals because in absolute terms or relative to the diastolic blood
vascular compromise will often determine operative pressure. Whereas the value of absolute intra-
urgency. Acute bleeding should be controlled, most compartmental pressure needed for compartment syn-
frequently with direct pressure only because clamp- drome has been debated (often 30 mm Hg or more) the
ing can easily injure nearby nerves. relative pressure difference (DP) is accepted as more
Knowledge of injury patterns assists in prompt and accurate. A study did not find any evidence delineating a
appropriate methodical evaluation. Graham3 pro- particular DP causing reduced circulation in the upper
posed that the “exploded hand” suffers a sequential extremities, but using lower extremity data, it is
pattern, beginning with extrusion of the thenar accepted that a DP less than 30 mm Hg for longer than
musculature (noted previously) as the thumb becomes 2 hours compromises perfusion and is more sensitive
coplanar with the hand, in addition to thumb ray and specific than clinical signs.9 The complication rates
dislocation and/or fracture. As the arches of the with delayed diagnosis are high and include long-term
hand flatten, the force proceeds through metacarpal pain, dysfunction, and intrinsic contractures of
headelevel dissociation and carpometacarpal (CMC) the hand; thumb contractures are especially poorly
fracture-dislocation of rays II to V. The third stage tolerated.2,10 Edema and bleeding can evolve over time,
involves the pericapitate transmission of forces, and as such, it is important to perform serial examina-
manifested by intercarpal ligament disruption. The tions. To minimize ischemia, early recognition and
fourth stage sees characteristic longitudinal fractures judicious action to relieve the elevated pressures are
of the tubular bones. Finally, the fifth stage is critical, including removing extrinsic compression,

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 CRUSH INJURIES OF THE HAND 3

FIGURE 1: A, B A 3-year-old had an automobile wheel roll over his hand. The hand is swollen and the thumb is forced into extension
and abduction through the hydrostatic effects of swelling. C, D Multiple basilar metacarpal fractures. E, F First web space compartment
pressure taken in the operating room measures 97 mm Hg. G Treated by compartment releases and percutaneous K-wire fixations. (AeF
Clinical pictures courtesy of David Netscher, MD.)

elevating the extremity, and ultimately fasciotomizing MANAGEMENT OF CRUSH INJURIES

all involved compartments.7,8,11 Initial operative management
Given the complexities of such crush injuries, it is
Imaging and laboratory tests important to consider both short-term tactics and
Radiographs of the hand, wrist, and forearm can long-term strategies for management of each
identify for fractures, dislocations, and preexisting component: soft tissues, fractures, and neurovascular
bony conditions. If the clinical examination is fairly injuries. First, salvage versus amputation must be
benign and the mechanism is unknown, abnormal addressed, but given that no criteria exist for reliably
fracture patterns can indicate a crush mechanism, and accurately predicting the salvageability of the
especially longitudinal tubular bone fractures.3 A upper extremity, most surgeons lean heavily toward
computed tomography scan can also be obtained for initial salvage, while maintaining late amputation as
better characterization of intra- or periarticular frac- an option. If the patient is able to communicate, it is
tures and dislocations, although this should not delay crucial to assess and discuss handedness, occupa-
operative intervention. Basic laboratory tests as well tional and functional demands, and treatment goals.
as whole blood lactate, creatine kinase, and urinary After appropriate antibiotic administration, anes-
myoglobin can assess for blood loss anemia, meta- thesia, and tourniquet inflation, proximal vascular
bolic derangements, hypoperfusion, and muscle injuries should be addressed with a bypass, graft,
damage. Fluid resuscitation is often needed to or shunt. A careful evaluation is followed by
improve end-organ perfusion. Once the initial work- an aggressive debridement of all suspect tissue.
up is complete, the decision must be made to take Bernstein et al5 state that the goal of initial debride-
the patient to the operating room, and how quickly. ment is to achieve a clean wound that looks surgically

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4 CRUSH INJURIES OF THE HAND

created and ready for reconstruction. Pressure moni-

TABLE 1. Local Flap Coverage Options for Finger
toring and compartment releases are performed when Tissue Defects
necessary, as is provisional coverage over tendons
and neurovascular structures.a,b Conflicting data exist Local Flap Coverage
Injury Option
regarding the precise timing of coverage, but trends
suggest that the most important factor in preventing Smaller finger defects Cross-finger, thenar, dorsal
complications is the thoroughness of debridement. metacarpal artery, turnover
Skeletal management begins with debridement Larger finger defects Radial forearm, posterior
of devitalized bones, followed by stabilization of interosseous
fractures or dislocations (using K-wires, plates, or Thumb fingertip loss Homodigital flap
external fixation), with the goal of early motion and Thumb fingertip loss Moberg, V-Y advancement,
stiffness prevention. Extensive dissection associated (with bone exposure) dorsal metacarpal artery
with plate fixation should be avoided to preserve any Thumb pulp loss Free vascularized toe pulp,
bone-healing biology, especially in the acute phase. partial toe transfers
In addition to restoring blood flow, venous drainage
should be reestablished, with the selective addition of
heparin-soaked pledgets, nail plate removal, and Because stiffness is the rule rather than the
leeches. Nerve management is guided by the exami- exception, tenolysis is often indicated when rehabil-
nation, with exploration warranted if an injury is itation has plateaued.3 Because crush injuries often
suspected. If found in continuity, it should be gently include damage to the thenar musculature, an oppo-
cleaned, and if transected, should be either cut to the nensplasty may be needed to restore function to the
level of healthy tissue and repaired or tagged for later thumb, along with other tendon transfers as needed.
repair.5 The surgeon should have a low threshold for As the soft tissue improves, bony fixation should
decompression at Guyon canal and the carpal tunnel; progress from temporizing to definitive and address
the latter should always accompany compartment nonunion with bone grafting and malunion with
releases. osteotomy, as appropriate. If a digit or ray is detri-
Once the initial debridement and repair is mental to the functional outcome, then amputation is
completed, the tourniquet should be released to further warranted. Although the first subsequent debridement
address perfusion. Wound dressings are dictated by the may be too early, delayed management of neuro-
extent, quality, and cleanliness of the wound bed. vascular injuries can include grafting for segmental
Antibiotic beads may be considered in particularly deficits, neurolysis of adhesions, and sympathectomy
contaminated wounds. Negative pressure wound to improve perfusion. Depending on the level of
therapy can be a useful adjunct in temporary coverage, contamination, neurovascular damage, and soft tissue
minimizing swelling and the number of dressing loss, multiple trips to the operating room may be
changes, although the effect on bacterial load, infec- necessary.
tion, and time to closure is debated.12,c Alternatively,
damp-to-dry dressings remain the mainstay of treat- Complications and prognosis
ment. The hand should be treated with orthosis fabri- Literature regarding the complications and outcomes
cation, often in the intrinsic-plus position, and elevated of crush injuries to the hand is limited and varies based
to the level of the heart. Depending on coverage and on the extent of the initial injury.7,14 A systematic
vascular repairs, micro-precautions—with a goal of review of forearm compartment syndrome revealed
minimizing peripheral vascular constriction—may be that neurological deficits were the most common
advisable, including increased room temperature and/ complication (18%), followed by contractures and
or heating blanket, anticoagulants (including heparin muscle necrosis.14,15 Increased time to fasciotomies
and variants, aspirin, dextran, and others), and main- (> 6 hours after presentation) was found to be signif-
tenance of nothing-by-mouth status in case of vascular icantly associated with developing complications.10
repair failure.13 Functional outcomes of severe crush injuries are
notoriously poor, often from stiffness secondary to
Subsequent operative management contractures and neurodeficits.3,16 Data from lower
The second debridement should take place 2 to 3 extremity compartment syndrome demonstrated that
days after the first. With definitive coverage now a lower-energy injuries, shorter time to fasciotomy,
higher priority, a number of local flaps have been younger age, and absence of fractures is associated
successfully used (Table 1), as have distant options.13 with better outcomes.14 A retrospective evaluation of

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 CRUSH INJURIES OF THE HAND 5

22 patients with upper extremity compartment syn- treatment or serial casting for several months.16 A
drome demonstrated that, based on motor function, review of over 400 PIP joint flexion contractures
sensation, or stiffness, 17 (74%) reported excellent initially treated conservatively demonstrated that 87%
outcomes and 5 (22%) reported fair outcomes after a of these contractures were managed effectively non-
fasciotomy.17 surgically.19 If these fail, the checkrein ligaments are
carefully transected via a volar approach to the PIP
PREVENTION AND TREATMENT OF joint. If the contracture persists, a volar capsulotomy
COMPLICATIONS is performed to allow for a volar plate and accessory
In addition to neurological deficits, hand contractures collateral ligament release.
may result either from improper positioning of the Thumb adduction contractures should initially be
injured hand or from the ischemic effect of a missed managed with dynamic orthosis treatment, with
compartment syndrome. Contractures from each an abduction force to the thumb CMC joint.16 If
present, and are managed differently. conservative interventions are unsuccessful, the deep
Early involvement of a hand therapist to develop fascia is split longitudinally and the insertion of the
a rehabilitation plan will minimize posttraumatic adductor pollicis muscle is transected. If adduction
contractures.14 Early interventions include teaching contracture persists, a thumb CMC capsulotomy al-
and assisting with passive, active-assisted, and active lows release of the volar intermetacarpal and oblique
range of motion exercises, as well as customizing an CMC joint ligaments, while preserving the radial
intrinsic-plus splint.18 Immediately after injury, the CMC joint ligament to prevent instability. Correction
hand assumes an intrinsic-minus position as edema of the adduction contracture results in a skin deficit
develops at the dorsum of the hand in the loose that often requires coverage.
subcutaneous and subtendinous space.16,18 If the Ischemic hand contractures often result from
hand is allowed to stay in this suboptimal position, missed compartment syndrome and present with
the joints stiffen as the protein-laden exudate causes MCP flexion, PIP and DIP joint extension, and thumb
interstitial adhesions.16 adduction—opposite to the contractures seen with an
The 3 most common posttraumatic hand contrac- intrinsic-minus hand.16 Delayed hand compartment
tures, caused by allowing the crushed hand to rest syndrome can be detected while the hand is posi-
in an intrinsic-minus position, include meta- tioned in the intrinsic-plus position by passively
carpophalangeal (MCP) joint hyperextension, prox- extending the MCP joint daily. If this is painful,
imal interphalangeal (PIP) and distal interphalangeal fasciotomies should be performed early. Immediately
(DIP) joint flexion, and thumb adduction.16 If pre- after surgery, the hand should not be positioned in the
sent, MCP contractures should first be managed with intrinsic-plus position in order to minimize additional
either orthosis fabrication or serial casting for 1 to 2 ischemia.
months. If conservative interventions fail, operative If ischemic contractures develop, the goals of
release of the MCP includes splitting the extensor treatment are to prevent stiffness and deformity and
tendon, elevating the capsule, and performing a dor- to restore motion.11 Supervised stretching, mobiliza-
sal capsulectomy.16 Fibrosis of the thumb adductor is tion exercises, and orthosis treatment with a hand
at additional risk for inadequately treated compart- therapist are the first line of treatment. Littler’s
ment syndrome because it is the deepest muscle, technique involved releasing the extensor component
analogous to the “ellipsoid” infarct of the forearm; of the intrinsic muscles from the PIP joints and active
this can be particularly difficult to treat. Proximal and splinting.
distal tenolysis and excision of the dorsal fibers of the
collateral ligaments should be performed until 70 of Clinical adjuncts to surgery
flexion is achieved, followed by 2 to 3 days of The hands allow us to perform functions that define
orthosis treatment or 5 to 7 days of K-wire immobi- us as humans, including social interaction, self-care,
lization. It is important to minimize interventions to communication, and expression. Given the high
those strictly required because excessive collateral degree to which we rely on our hands in everyday
ligament disruption may cause joint instability, life, hand injuries can have a significant psycho-
thereby defeating the purpose of the surgery. After logical impact on ability to make adjustments and
this short immobilization, the patient must begin recover from injury.20 Although hand surgeons must
working to maintain these range of motion gains. understand and recognize the psychological conse-
Proximal interphalangeal joint flexion contractures quences of hand injury (such as posttraumatic stress
should initially be managed with dynamic orthosis disorder), hand therapists are in a unique position to

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6 CRUSH INJURIES OF THE HAND

FIGURE 2: A Preoperative clinical picture and B, C radiographs of the reported crushed hand.

FIGURE 3: A, B Immediate postoperative radiographs.

screen and monitor these consequences. Psycho- metacarpals, he had exposed metacarpal fractures and
logical distress can interfere with recovery if not lacerated extensor tendons (Fig. 2A). His sensory
appropriately recognized and addressed. Therefore, examination was variable, and his motor examination
patients should be screened by incorporating ques- was notable for an inability to fire most flexors
tions about changes in sleep patterns, mood, and (although flexor pollicis longus function was main-
behavior and, if positive, referred for additional tained). Despite a Doppler signal present at his
psychological support within 3 months after the palmar arch, no signals were found in the digits, and
initial injury. his digits were cool. Radiographs revealed fractures
of metacarpals I to V, including dislocations at the
base of the first and neck of the second (Fig. 2B, C).
CASE PRESENTATION His medical history was significant only for hyper-
A 66-year-old right-handed gentleman sustained an lipidemia and a 25-pack-year smoking history. In the
isolated injury to his right hand, which was crushed emergency department, the patient was provisionally
by a 250-ton press for approximately 10 seconds. In irrigated, supplied with an orthosis, and given
addition to a degloving injury about his carpus and appropriate antibiotics. He was then taken emergently

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 CRUSH INJURIES OF THE HAND 7

to the operating room for an attempt at salvage, 5. Bernstein ML, Chung KC. Early management of the mangled upper
extremity. Injury. 2007;38(Suppl 5):S3eS7.
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In the operating room, an irrigation and debride- The validity of the mangled extremity severity score in the assess-
ment cleaned the wounds of nonviable tissue. An ment of upper limb injuries. J Bone Joint Surg Br. 2005;87(11):
autologous vein graft (taken from the forearm) was 1516e1519.
7. Codding JL, Vosbikian MM, Ilyas AM. Acute compartment syn-
needed to restore blood flow from the superficial arch drome of the hand. J Hand Surg Am. 2015;40(6):1213e1216.
to the common digital artery to the middle and ring 8. Ouellette EA, Kelly R. Compartment syndromes of the hand. J Bone
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9. Ulmer T. The clinical diagnosis of compartment syndrome of the
fingers were noted to have segmental injuries. Each lower leg: are clinical findings predictive of the disorder? J Orthop
metacarpal was reduced and pinned with K-wires Trauma. 2002;16(8):572e577.
(Fig. 3), and the carpal tunnel was released; no further 10. Duckworth AD, Mitchell SE, Molyneux SG, White TO, Court-
Brown CM, McQueen MM. Acute compartment syndrome of the
compartment releases were needed given the extent forearm. J Bone Joint Surg Am. 2012;94(10):e63.
of the injury. After the wound was loosely approxi- 11. Leversedge FJ, Moore TJ, Peterson BC, Seiler JG. Compartment
mated and dressed, the arm was treated with an syndrome of the upper extremity. J Hand Surg Am. 2011;36(3):
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12. Krug E, Berg L, Lee C, et al. Evidence-based recommendations for
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was slower than expected. His examination stabilized compartment syndrome of the upper extremity in children: diagnosis,
with healed wounds, diminished but intact sensation in management, and outcomes. J Child Orthop. 2013;7(3):225e233.
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ACKNOWLEDGMENTS 1978;61(1):58e63.
20. Hannah SD. Psychosocial issues after a traumatic hand injury:
The authors thank Jeremy Raducha, MD, and Joseph facilitating adjustment. J Hand Ther. 2011;24(2):95e103.
A. Gil, MD, for their clinical care and preparation of
the manuscript. EDITOR’S SUGGESTIONS FOR MORE
INFORMATION
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