Crush injuries of the hand are those that involve

varying degrees of tissue loss; this can include

skin, tendons, nerves, vessels or bone

These are mostly open injuries with risk of

infection and interruption of the healing process
Systems approach is the easiest way to evaluate
complex injuries

Consider each individual system involved, stage

of injury and necessary precautions for
treatment
Systems to be considered:

•Skin
•Tendons
•Nerves
•Blood vessels
•Bones
•Pain and edema
Two primary functional uses of the hand :
Pinch between thumb and fingers – affected by
radial side hand injury, influences prehension and
fine motor coordination

Grip is affected by ulnar side hand injury,

diminishes complex grip and stability
Treatment
1. Restoration of blood flow
2. Prevention of infection
1. Antibiotics
2. Wound debridement
3. Wound care
3. Restoration of skeletal stability
4. Wound closure
5. Reconstruction
Therapeutic priorities
• Acute phase, 0-3 weeks after surgery

• Manage and protect repairs

• Prevent joint stiffness in uninvolved joints
• Control edema
• Wound management
• Manage pain
• Client education
• Psychological support
Intermediate phase, 3-6weeks after surgery

Increasing ROM of involved strutures

Managing scarring
Wound care and protection
Initiating functional use of UE
Later phases

Maximizing ROM
Endurance
Strength
Function
1. Restoration of blood flow
Signs of arterial insufficiency:
Pallor
Decreased temperature
Increased pain
Loss of pulse

Re vascularization - First consideration in the

management of crush injury
Extreme edema is often sign of compartment
syndrome should be monitored – decompression
2. Prevention of infection
a) Intravenous antibiotics and tetanus immunization

b) Wound debridement -
Involves cleansing of the wound and removal of
foreign bodies and devitalized tissue
c) Wound care –
Following debridement wound is closed with bulky
dressing extending from elbow to tip of the fingers

Hand is held in “position of function”

Careful wound management is integral to prevent

infection and controlling scar formation

In case of grafts or flaps, pressure and shearing

forces are avoided for the first 2 postoperative

weeks
3. Restoration of skeletal
stability
Skeleton must be stabilized as soon as possible so

that movement can be initiated

Reduction of fractures and dislocations – ideally

within hours or days of injury, before edema and

fibrosis make reduction difficult
In direct traumatic bone loss or severe
comminution – primary corticocancellous bone
grafting will be necessary

Fixation – K-wires, rigid internal fixation with

plates, screws
4. Wound closure
Timing will depend on – condition of the wound,
soft tissue availability and reconstructive
considerations

Risk of infection is decreased when

reconstruction is deferred in case of
contaminated wound
Planned skin coverage with pedicled flap or soft
tissue transfer can be undertaken when wound is
considered ready
5. Reconstruction
Includes -
Muscle tendon reconstruction
Tendon transfer
Nerve grafting
Flap debulking

Performed when maximum soft tissue and joint

mobility have been achieved
Hand therapy
Complex injury characterized by – adhesion
formation and joint stiffness

Pain relief should be provided to enable the

patient to co-operate

Treatment program should be tailored to meet

individual needs
Principles and aims of hand therapy will include

1. Uncomplicated wound healing

2.Early movement
3.Restoration of function
Oedema control
Gross edema may persist which will lead to soft
tissue fibrosis and joint stiffness

Elevation and active motion should commence,

unless contraindicated

Gentle compression bandaging initiated in the

absence of vascular compromise, grafting or flaps
Early active motion
Uninvolved joints - ROM exercises regularly
throughout the day

Early protected active motion after tendon repair

In absence of tendon repair where there is

skeletal stability – vigorous active movements
Differential tendon gliding exercise

Composite fist making exe

Frequency and repetition increased with

improvement
Muscle strengthening and endurance training
begun after 6th week

Resisted exercises – exercise putty

Splinting
Initially static splints are used to immobilize,
support and protect the hand

After sufficient healing – corrective splint used

for correction and remodelling scar tissue
Force applied should be negligible –

1. Excess force can damage healing structures

2.Response to corrective splinting should be

carefully monitored – undue pain, swelling or
inflammatory response
Commonly used splints :

C splint – thumb web space contracture

Dynamic capener splint for PIP flexion deformity
Dynamic extension outriggers for PIP joint
flexion deformity
Serial wrist casting into extension
Scar management
Gentle scar massage - to soften scar prior to
exercise and for desensitization

Intensity of massage increased as skin tolerance

improves

Compression – pressure glove, silicone gel

sheeting, neoprene garment
Scar maturation continues for many months so
compression therapy is maintained for 3 to 4
months
Functional activity
Use for hands for light self care tasks at the
earliest

Modification of equipment's

Vocational rehabilitation
Patient education
Exercise, splinting, scar management and
functional activity

Understanding the rationale, sequence and

frequency of use of various therapy measures

Regular review – modification of programme

Psychological consideration
Encouragement and reassurance

Formal counselling