Double entrapment neuropathy of the ulnar nerve at the elbow and the wrist : double crush syndrome?

BACKGROUND: Double crush syndrome refers to a nerve in the proximal region being compressed, affecting its proximal segment. Instances of this syndrome involving ulnar and cubital canals during ulnar neuropathy are rare. Diagnosis solely through clinical examination is challenging. Although electromyography (EMG) and nerve conduction studies (NCS) can confirm neuropathy, they do not incorporate inching tests at the wrist, hindering diagnosis confirmation. We recently encountered eight cases of suspected double compression of ulnar nerve, reporting these cases along with a literature review. METHODS: The study included 5 males and 2 females, averaging 45.6 years old. Among them, 4 had trauma history, and preoperative McGowan stages varied. Ulnar neuropathy was confirmed in 7 cases at both cubital and ulnar canal locations. Surgery was performed for 4 cases, while conservative treatment continued for 3 cases. RESULTS: In 4 cases with wrist involvement, 2 showed ulnar nerve compression by a fibrous band, and 1 had nodular hyperplasia. Another case displayed ulnar nerve swelling with muscle covering. Among the 4 surgery cases, 2 improved from preoperative McGowan stage IIB to postoperative stage 0, with significant improvement in subjective satisfaction. The remaining 2 cases improved from stage IIB to IIA, respectively, with moderate improvement in subjective satisfaction. In the 3 cases receiving conservative treatment, satisfaction was significant in 1 case and moderate in 2 cases. Overall, there was improvement in hand function across all 7 cases. CONCLUSION: Typical outpatient examinations make it difficult to clearly differentiate the two sites, and EMG tests may not confirm diagnosis. Therefore, if a surgeon lacks suspicion of this condition, diagnosis becomes even more challenging. In cases with less than expected postoperative improvement in clinical symptoms of cubital tunnel syndrome, consideration of double crush syndrome is warranted. Additional tests and detailed EMG tests, including inching tests at the wrist, may be necessary. We aim to raise awareness double crush syndrome with ulnar nerve, reporting a total of 7 cases to support this concept.

Factors predicting kidney replacement therapy in pediatric earthquake victims with crush syndrome in the first week following rescue.

Crush syndrome due to traumatic rhabdomyolysis is one of the most significant problems to occur following earthquakes. On February 6, 2023, millions of people in Turkey were affected by two consecutive Kahramanmaras earthquakes. The present study reports the analysis of clinical and laboratory findings of crush syndrome in pediatric earthquake victims admitted to our hospital from our region where the earthquake had a devastating effect. Clinical and laboratory findings concerning earthquake victims with crush syndrome were analyzed within the first week to determine what factors are predictive of kidney replacement therapy (KRT). The data of patients were retrospectively collected from medical records. A total of 310 children were admitted as earthquake victims to the pediatric emergency department. Ninety-seven (31%) of these patients had crush syndrome. Fifty-three (55%) of those with crush syndrome were female. The mean age was 10.9 ± 4.7 years, and the mean time under the rubble was 30.6 ± 23.8 h. Twenty-two patients (23%) required KRT. Hemodialysis was applied to 16 (73%) of them, and hemodiafiltration was applied to the other six (27%) in the pediatric intensive care unit. Regarding creatine kinase (CK) levels, the area under the receiver operating characteristic (ROC) curve (AUC) for predicting KRT was 0.905 (95% confidence interval [CI] 0.848-0.963; p < 0.001). The optimal cut-off value was 40,000 U/L with a sensitivity of 86% and a specificity of 83%. In terms of the percentage of body area crushed, the AUC for predicting KRT was 0.907 (95% CI 0.838-0.976; p < 0.001). The optimal cut-off value was 30% with a sensitivity of 86% and a specificity of 88%. Multiple logistic regression analysis showed that each 10% increase in body area crushed (OR 4.16, 95% CI 1.58-10.93, p = 0.004) and 1 mg/dl increase in the serum phosphorus level (OR 4.19, 95% CI 1.71-10.28, p = 0.002) were significant risk factors for dialysis treatment. CONCLUSIONS: Crush syndrome and kidney problems are common following disasters like earthquakes. Clinical and laboratory findings at admission can predict dialysis requirement in earthquake victims. While CK elevation, body area crushed percentage, and increased phosphorus level were predictive of dialysis treatment, time under the rubble was not. Even if the patients were under the rubble for a short time, acute kidney injury (AKI) may develop as a result of severe hypovolemia due to crush injuries, and patients may need KRT. WHAT IS KNOWN: •Crush syndrome after earthquakes needs to be treated carefully in victims and can cause AKI and mortality when not treated timely and appropriately. WHAT IS NEW: •CK level elevation, body area crushed percentage, and increased phosphorus level are predictive of dialysis treatment. •The time under the rubble may not be predictive of dialysis requirement.

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.

Crush injury and syndrome: A review for emergency clinicians.

INTRODUCTION: Primary disasters may result in mass casualty events with serious injuries, including crush injury and crush syndrome. OBJECTIVE: This narrative review provides a focused overview of crush injury and crush syndrome for emergency clinicians. DISCUSSION: Millions of people worldwide annually face natural or human-made disasters, which may lead to mass casualty events and severe medical issues including crush injury and syndrome. Crush injury is due to direct physical trauma and compression of the human body, most commonly involving the lower extremities. It may result in asphyxia, severe orthopedic injury, compartment syndrome, hypotension, and organ injury (including acute kidney injury). Crush syndrome is the systemic manifestation of severe, traumatic muscle injury. Emergency clinicians are at the forefront of the evaluation and treatment of these patients. Care at the incident scene is essential and focuses on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport. Care at the healthcare facility includes initial stabilization and trauma evaluation as well as treatment of any complication (e.g., compartment syndrome, hyperkalemia, rhabdomyolysis, acute kidney injury). CONCLUSIONS: Crush injury and crush syndrome are common in natural and human-made disasters. Emergency clinicians must understand the pathophysiology, evaluation, and management of these conditions to optimize patient care.

CRUSH SYNDROME IN EARTHQUAKES - STAY AND PLAY OR LOAD AND GO?

Earthquakes are unpredictable natural disasters accompanied by material damage and many victims. In the case of a person remaining trapped under the collapsed material, the development of crush syndrome can occur. Crush syndrome is the result of traumatic rhabdomyolysis and is present in 2%-15% of all injured persons in an earthquake. It is not easy to recognize, and proper treatment is challenging. Persons who have a clear crush injury and/or have been immobilized for more than four hours should be considered potential victims of crush syndrome. Therefore, knowledge about crush syndrome must be comprehensive and accessible to all parties involved. In this paper, the management of crush syndrome victims, which includes the principles of triage, and medical and logistic principles as well, is presented. Triage principles are presented at the level of triage priorities, places, and diagnoses. Medical principles, crucial for crush syndrome, are presented regarding the duration of compression and time before or after extraction of the patient. Logistic principles provide an overview of the priorities and modes of transport in relation to distance of health institutions, and the importance of management and education associated with crush syndrome. Each country with recognized disasters (natural or man-made) in which crush-related victims are expected, will benefit if the knowledge about triage, medical and logistic principles for crush syndrome is incorporated in their educational programs and regularly updated.

Management of Severe Crush Injuries in Austere Environments: A Special Operations Perspective.

Crush injuries present a challenging case for medical providers and require knowledge and skill to manage the subsequent damage to multiple organ systems. In an austere environment, in which resources are limited and evacuation time is extensive, a medic must be prepared to identify trends and predict outcomes based on the mechanism of injury and patient presentation. These injuries occur in a variety of environments from motor vehicle accidents (at home or abroad) to natural disasters and building collapses. Crush injury can lead to compartment syndrome, traumatic rhabdomyolysis, arrythmias, and metabolic acidosis, especially for patients with extended treatment and extrication times. While crush syndrome occurs due to the systemic effects of the injury, the onset can be as early as 1 hour postinjury. With a comprehensive understanding of the pathophysiology, diagnosis, management, and tactical considerations, a prehospital provider can optimize patient outcomes and be prepared with the tools they have on hand for the progression of crush injury into crush syndrome.

Crush syndrome in a case of severe infant physical abuse: a case report.

Crush syndrome, also known as traumatic rhabdomyolysis, is the result of the disruption of skeletal muscle fibers with the release of intracellular contents into the bloodstream. Although trauma is the main trigger for rhabdomyolysis in adults, in the pediatric population viral infections and inherited disorders seem to be the most frequent causes. Only a few reports in the literature mention rhabdomyolysis secondary to non-accidental pediatric trauma. We herein report an unusual case of traumatic rhabdomyolysis, following significant physical abuse in an infant. Rhabdomyolysis should be suspected in children presenting with a history of excessive blunt trauma, because a prompt diagnosis and treatment prevent from the potential life-threatening consequences.

Double crush syndrome: Epidemiology, diagnosis, and treatment results.

BACKGROUND: Double Crush Syndrome (DCS) is a clinical condition that involves multiple compression sites along a single peripheral nerve. The present study aims to describe the epidemiology of DCS and surgical results. METHODS: A retrospective observational analytic study included patients with clinical diagnosis of cervical radiculopathy and carpal tunnel syndrome who underwent surgery between January 2009 and January 2019. General demographic characteristics were noted, and 3 groups were distinguished: spinal surgery, carpal tunnel release, and bimodal decompression (BD); statistical differences were analyzed between them. RESULTS: The sample comprised 32 patients. DCS prevalence was 10.29%. Mean age at presentation was 59.25±10.98 years. There was female predominance (75%). Paresthesia was the main symptom (65.6%). Post-surgical results of BD showed significant improvement in sensory nerve conduction velocity, motor nerve conduction velocity (both P=0.008), and disability on Douleur Neuropathique 4 questions, Neck Disability Index, and Boston Carpal Tunnel Questionnaire (P=0.001, 0.004, 0.008, respectively). CONCLUSIONS: Diagnosis and management of DCS are a challenge. It is necessary to determine the site with maximal compression and risk of complications to decide on treatment. If first-line surgery is adequate, proximal and distal symptomatology can be improved. To maximize success, we recommend BD, according to the present results.

A novel method to assess the severity and prognosis in crush syndrome by assessment of skin damage in hairless rats.

PURPOSE: Crush syndrome (CS), a serious medical condition characterised by damage to the muscle cells due to pressure, is associated with high mortality, even when patients receive fluid therapy during transit to the hospital or admission to the hospital. There is no standard triage approach for earthquake victims with crush injuries due to the scarcity of epidemiologic and quantitative data. We examined whether mortality can be predicted based on the severity of skin damage so that assess the severity and prognosis in crush syndrome by assessment of skin damage in hairless rats because we have previously observed that CS results in oedema and redness of the skin in rats. METHODS: Anaesthetised rats were subjected to bilateral hind limb compression [1 kg (mild) and 2 kg (severe) loads] with a rubber tourniquet for 5 h. The rats were then randomly divided into three groups: sham, mild CS, and severe CS. RESULTS: The mild and severe CS groups had mortality rates of 20 and 90%, respectively. The severe CS group demonstrated higher rates of hyperkalaemia, hypovolemic shock, acidosis, and inflammation. Skin damage was significantly worse in the severe CS group compared to the mild CS group. Skin damage showed good correlation with pathological severity. CONCLUSIONS: Skin damage is a valid measure of transepidermal water loss and severity of CS. We suggest that these models may be useful to professionals who are not experienced in disaster management to identify earthquake victims at high risk of severe CS.

[Diagnosis and treatment of crush syndrome of chest and arm].

Objective: To investigate pathogenesis, diagnosis, and treatment of crush syndrome of chest and arm. Methods: Between January 2010 and January 2015, 5 cases of crush syndrome of chest and arm caused by pressing oneself in a coma after CO poisoning or alcoholic intoxication were treated. There were 4 males and 1 female with an average age of 36.7 years (range, 28-46 years). Two patients involved left upper limb and chest, while the other three patients involved right upper limb and chest. The crushed time ranged from 4 to 12 hours (mean, 7 hours). All 5 cases received emergency decompression and vacuum sealing drainage (VSD). After surgery, the patients were transferred to Intensive Care Unit to receive continuous renal replacement therapy (CRRT). The wounds were repaired with skin grafts after the patients' condition were stable. Results: The hospitalization time was 26-48 days (mean, 33 days). Necrosis of the skin graft occurred in 1 case, which cured after debridement and skin graft again. The skin graft survived in the other cases and the wounds healed by first intension. Five patients were followed up 12-18 months (mean, 15 months). At last follow-up, the results were excellent in all 5 cases according to the assessment criteria proposed by GU Yudong. The patients got full recovery of their upper limb activities and sensation. All the patients returned to the normal life and work. Conclusion: CO poisoning, drunkenness, and pressing oneself together will lead the crush syndrome to severe and rapid progress. The key of the treatment is a comprehensive therapy including a thorough and rapid tension reduction to save the limb function, CRRT, and correction of anemia and electrolyte imbalance.

Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome.

Double crush syndrome (DCS), as it is classically defined, is a clinical condition composed of neurological dysfunction due to compressive pathology at multiple sites along a single peripheral nerve. The traditional definition of DCS is narrow in scope because many systemic pathologic processes, such as diabetes mellitus, drug-induced neuropathy, vascular disease and autoimmune neuronal damage, can have deleterious effects on nerve function. Multifocal neuropathy is a more appropriate term describing the multiple etiologies (including compressive lesions) that may synergistically contribute to nerve dysfunction and clinical symptoms. This paper examines the history of DCS and multifocal neuropathy, including the epidemiology and pathophysiology in addition to principles of evaluation and management.

Canine model of crush syndrome established by a digital crush injury device platform.

OBJECTIVE: To establish a canine model of crush syndrome (CS). METHODS: A total of 16 healthy adult female Beagle dogs were randomly divided into the control group (n=8) and the experimental group (n=8). The crush injury was created in the left hind leg of each dog in the experimental group. RESULTS: The biochemical indexes in the experimental group changed significantly compared to the values before extrusion. And they were also significantly different from the values of the control group. The glomerular capillary dilation, renal tubular epithelial cell degeneration, and renal interstitial lymphocytic infiltration were found in the kidneys. CONCLUSION: The canine CS model established by the digital crush injury device platform was successful according with the diagnosis of CS. It is good for the investigation of the CS mechanism and treatment using this model.

Disaster nephrology: crush injury and beyond.

Disasters result in a substantial number of renal challenges, either by the creation of crush injury in victims trapped in collapsed buildings or by the destruction of existing dialysis facilities, leaving chronic dialysis patients without access to their dialysis units, medications, or medical care. Over the past two decades, lessons have been learned from the response to a number of major natural disasters that have impacted significantly on crush-related acute kidney injury and chronic dialysis patients. In this paper we review the pathophysiology and treatment of the crush syndrome, as summarized in recent clinical recommendations for the management of crush syndrome. The importance of early fluid resuscitation in preventing acute kidney injury is stressed, logistic difficulties in disaster conditions are described, and the need for an implementation of a renal disaster relief preparedness program is underlined. The role of the Renal Disaster Relief Task Force in providing emergency disaster relief and the logistical support required is outlined. In addition, the importance of detailed education of chronic dialysis patients and renal unit staff in the advance planning for such disasters and the impact of displacement by disasters of chronic dialysis patients are discussed.

The role of hyperbaric oxygen therapy in crush injuries.

Hyperbaric oxygen therapy has been approved for primary or adjunctive care in 14 indications. A hyperbaric environment exists when a patient's whole body is physically exposed to 100% oxygen and pressure that is greater than one atmosphere absolute. Hyperbaric oxygen therapy works through the ideal gas laws and is effective as an adjunctive therapy in the treatment of crush injuries. Oxygen is considered a drug and can have contraindications and adverse effects. Hyperbaric therapy works through several different mechanisms in the crush injury. Effects of hyperoxygenation, reduction of edema, infection control enhancement, blood vessel and collagen formation, and reduction of free radicals and reperfusion injury help in healing in patient with crush injuries.

The exploded hand syndrome: a report of five industrial injury cases.

The term 'exploded hand syndrome' refers to a specific type of crush injury to the hand in which a high compressive force excessively flattens the hand leading to thenar muscle extrusion through burst lacerations. Out of 89 crushed hands seen over a period of seven years, only five had exploded hand syndrome. They were all male industrial workers ranging in age between 24 and 55 years. All patients had thenar muscle extrusion. Other concurrent injuries included fractures/dislocations, compartment syndrome, and ischaemia. All patients were treated by excision of the extruded intrinsic muscles, as well as primary management of concurrent injuries. All patients had functional assessment including: motor power and sensory testing, range of motion of hand joints, and the quick DASH score. Objective testing showed reduced sensibility in the thumb, reduced grip strength (mean 52% of contralateral hand), reduced pinch strength (mean of 27% of contralateral hand), reduced thumb opposition (the mean Kapandji Score was 5 out of 10), and deficits in the range of motion of the metacarpophalangeal and interphalangeal joints of the thumb. The quick DASH score ranged from 11 to 49 and only two patients were able to go back to regular manual work.

Aortic injuries in crush trauma patients: different mechanism, different management.

BACKGROUND: The objective of this study is to report the clinical and radiological characteristics and early and long-term survival of a series of acute traumatic aortic injuries (ATAI) in crush trauma patients, and to compare such data with our last 30 years experience managing ATAI in deceleration non-crush trauma patients. METHODS: From January 1980 to December 2010, 5 consecutive ATAI in crush trauma and 69 in non-crush trauma patients were admitted at our institution. ISS, RTS and TRISS scores were similar in both groups. RESULTS: Overall in-hospital mortality was 24.3%. There was no in-hospital mortality in crush patients and 26.1% in non-crush patients (p=0.32). All aortic-related complications occurred in non-crush patients. Median follow-up was 129 months (range 3-350 months). Non-crush group survival was 76.8% at 1 year, 73.6% at 5 years, and 71.2%% at 10 years. There was no mortality during follow-up in the crush group. Mean (SD) peak creatine phosphokinase was significantly higher in crush group than in non-crush group: 7598 (3690) IU/L vs. 3645 (2506) IU/L; p=0.041. Incidence of acute renal injury was higher in crush trauma patients (100% vs. 36.2%; p=0.018). Low-severity injuries were more common in crush trauma patients (100% in crush patients vs. 43.5% in non-crush patients, p=0.04). CONCLUSIONS: Aortic injuries in crush thoracic trauma patients seem to present in a different clinical scenario from aortic injuries in high-speed thoracic trauma thus requiring distinct considerations. When planning the initial management of aortic injuries in crush trauma, the increased risk of rhabdomiolysis and subsequent acute renal failure, as well as a tendency to develop lower-risk aortic wall injuries, must be considered.

Effect of ginkgo biloba extract on recovery after facial nerve crush injury in the rat.

BACKGROUND AND OBJECTIVE: Many pharmacological agents have shown successful results in experimental crush injury of the peripheral nerve. To date, therapeutic effect of ginkgo biloba extract (GBE) on the peripheral nerve crush injury of rats has been rarely reported, moreover, neuroprotective effect on the facial nerve crush injury has not been reported. MATERIALS AND METHODS: Prospective functional recovery, using a vibrissae movement and electrophysiological analysis of recovery 4 weeks after the facial nerve crush in adult rats, and comparison with randomized intraperitoneal injection of either GBE or control phosphate buffered saline. RESULTS: Relative to the control group (26 days post operation), administration of GBE significantly accelerated the recovery of vibrissae orientation to 11.7 days post the operation. A significant functional recovery was observed by postoperative 2nd week in the experimental group. The recovery of threshold and conduction velocity, postoperative 4th week in the experimental group, showed statistically significant difference compared to that of the control group. CONCLUSION: From this result, intraperitoneal injection of GBE has been found effective in promoting the regeneration of the nerve in an experimental facial nerve crush rat model. Further studies, including morphological and molecular analyses, are necessary to clarify the mechanisms of GBE on the facial nerve crush.