Predictive factors for acute kidney injury and amputation in crush injuries from the Kahramanmaras earthquakes.

BACKGROUND: Crush syndrome (CS) is characterized by high morbidity and mortality due to severe electrolyte disorders, circulatory dysfunction, and multiple organ failure, secondary to severe rhabdomyolysis and reperfusion injuries. Acute kidney injury (AKI) related to crush syndrome is one of the life-threatening complications and is the most frequent cause of death following earthquakes, other than trauma. We conducted a retrospective study to identify predictive parameters from clinical and laboratory data that aid in recognizing CS, assessing its severity, and evaluating acute kidney injury and amputation indications in patients. METHODS: We retrospectively evaluated the clinical data and laboratory follow-up of 33 patients treated for crush syndrome within the first two weeks following the February 6, 2023 earthquake. Patients who underwent surgery for crush syndrome but could not be followed post-surgery were excluded. Laboratory parameters were analyzed upon admission and then daily over an average seven-day follow-up. A p-value of <0.05 was considered statistically significant. Data analysis was performed using IBM SPSS Statistics 26.0 and R Studio software. RESULTS: Of the 33 patients, 17 were male and 16 were female. The incidence of AKI was 35.7%, 66.7%, and 100% in patients with injuries to one, two, and three extremities, respectively. A significant correlation was observed between total entrapment time and the duration of required dialysis days; AKI risk significantly increased with more than six hours of total entrapment time. Regarding the initial blood values upon hospital admission, a myoglobin level exceeding 2330 mg/dL demonstrated the highest sensitivity for predicting AKI. An initial uric acid level (>6.36 mg/dL) on admission had the highest specificity for predicting AKI. The initial myoglobin level (>3450 mg/dL) showed the highest sensitivity in predicting the need for amputation. Meanwhile, the mean creatine kinase (CK) level (>34800 U/L) exhibited the highest specificity but the lowest sensitivity for amputation prediction. CONCLUSION: The study analyzed the effectiveness and predictability of clinical and laboratory findings concerning amputation and acute kidney injury in crush syndrome resulting from earthquakes. Effective amputation management is a crucial factor influencing prognosis and survival in patients with earthquake-induced crush syndrome.

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.

Clinical features and outcomes of orthopaedic injuries after the kahramanmaras earthquake: a retrospective study from a hospital located in the affected region.

BACKGROUND: The purpose of this retrospective, single-institutional study was to report the clinical features and outcomes of orthopaedic injuries after the Kahramanmaras earthquake. METHODS: An institutional database review was conducted to evaluate the results of patients who applied to our hospital's emergency department after the Kahramanmaras earthquake. Trauma patients referred to orthopaedics and traumatology were identified. Patient records were checked for injury type, fracture site, treatment type (conservative or surgical), surgical technique, and outcome. Diagnosis with crush syndrome and the need for haemodialysis were also noted. Bedside fasciotomy was undertaken based on the urgency of the patient's condition, number of patients and the availability of the operating theatre. A team consisting of a trauma surgeon, a plastic surgeon, a board-certified physician in infectious disease, a reanimation specialist, a general surgeon and a nephrologist followed up with the patients. RESULTS: Within the first 7 days following the earthquake, 265 patients were admitted to the emergency department, and 112 (42.2%) of them were referred to orthopaedics and traumatology. There were 32 (28.5%) patients diagnosed with acute compartment syndrome. Fasciotomy was performed on 43 extremities of 32 patients. Of these extremities, 5 (11.6%) were upper and 38 (88.4%) were lower extremities.The surgeries of 16 (50%) of the patients who underwent fasciotomy were performed in the emergency department. There was no significant difference in terms of complications and outcomes between performing the fasciotomy at the bedside or in the operating theatre (p = 0.456). CONCLUSIONS: Fasciotomy appears to be a crucial surgical procedure for the care of earthquake causalities. Fasciotomy can be safely performed as a bedside procedure based on the urgency of the patient's condition as well as the availability of the operating theatre.

The prevalence of double- and multiple crush syndromes in patients surgically treated for peripheral nerve compression in the upper limb.

OBJECTIVE: The double crush syndrome describes a condition characterized by multifocal entrapment of a nerve. In the upper limb, the high prevalence of carpal tunnel syndrome makes it a common diagnosis of assumption in the setting of median neuropathy. More proximal compressions may tend to be overlooked, under-diagnosed and under-treated in the population. This study aims to map the prevalence of peripheral upper limb nerve compressions among patients undergoing peripheral nerve decompression. METHODS: A prospective case series was conducted on 183 patients undergoing peripheral nerve decompression in a private hand surgery clinic. Level(s) of nerve compression in the median, ulnar and radial nerves were determined by history and physical examination. The prevalence of each nerve compression syndrome or combination of syndromes was analyzed. RESULTS: A total of 320 upper limbs in 183 patients were analyzed. A double crush of the median nerve at the levels of the lacertus fibrosus and carpal tunnel was identified in 78% of upper limbs with median neuropathy, whereas isolated lacertus syndrome and carpal tunnel syndrome were present in only 5% and 17% of affected limbs respectively. Cubital tunnel syndrome affected 12.5% of upper limbs, and 80% of these had concomitant lacertus and carpal tunnel syndromes, compared to only 7.5% with isolated cubital tunnel syndrome. CONCLUSION: A high prevalence should prompt clinicians towards more routine assessment for double crush syndrome to avoid misdiagnosis, inadequate treatment, recurrence, and revision surgeries.

6 February 2023, orthopedic experience in Kahramanmaras 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 Kahramanmaras 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.

Evaluation of the 2023 Kahramanmaras earthquake from the perspective of Plastic Surgery Department: A single-center experience.

OBJECTIVES: The aim of this study was to evaluate the treatment management and demographic data of earthquake victims admitted to Plastic Surgery Department of our center after the 2023 Kahramanmaras earthquake. PATIENTS AND METHODS: Between February 6th, 2023 and February 15th, 2023, a total of 120 patients (65 males, 55 females; mean age: 36.3±17.3 years; range, 85 to 88 years) who were consulted to the Plastic Surgery Department of our center were included. Demographic data of the patients, time to admission to the emergency room, removal time under the rubble, type of injury, emergency operation requirement, fasciotomy requirement, hyperbaric oxygen therapy administration, and length of stay in the intensive care unit were evaluated. After the first intervention, patients with compartment syndrome underwent emergency fasciotomy immediately. Perioperative laboratory values of the patients were followed closely to prevent the development of crush syndrome. RESULTS: Due to stay under the rubble, upper extremity soft tissue injury was seen in 46.2% of the patients. The pelvic and abdominal region were the least affected soft tissues in 1.7% patients. Fasciotomy was performed in 75 patients who stayed under the rubble. Hyperbaric oxygen therapy was applied to 21 of 75 patients who underwent fasciotomy. Amputation was performed in four patients, three of which were in the upper extremity and one in the lower extremity, during follow-up after fasciotomy. A total of 10.83% of the patients were treated conservatively and 11.67% of them were reconstructed with free flaps. Totally 7.5% of the patients who stayed under the rubble were hospitalized in our clinic for maxillofacial injuries. A total of 66.6% of these patients were treated surgically, while 33.3% of them were further treated conservatively. CONCLUSION: Proper triage, proper fasciotomy, and appropriate surgical interventions reduce the amputation rate, yielding clinically satisfactory results.

Double Crush Syndrome of the Upper Extremity.

¼: The double crush hypothesis originally proposed that compression of a peripheral nerve at a proximal site increases its susceptibility to additional distal lesions. ¼: The etiology of double crush syndrome is likely multifactorial as mechanical, systemic, pharmacologic, or environmental factors may increase a patient's susceptibility to this syndrome. ¼: To date, there remains no standardized definition of double crush syndrome, and there is no consensus on its exact pathophysiology or diagnostic criteria. ¼: Patients with double crush syndrome should be counseled that surgical repair may produce inferior outcomes compared with those who are treated for isolated entrapment neuropathies.

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.

How I do it? Uniportal full endoscopic contralateral approach for lumbar foraminal stenosis with double crush syndrome.

BACKGROUND: Evolution of endoscopic surgery provides equivalent results to open surgery with advantages of minimal invasive surgery. The literature on technique Uniportal Full endoscopic contralateral approach is scarce. METHODS: The endoscopic contralateral approach technique applies for patients presenting with double crush syndrome with foraminal and extraforminal stenosis. The key steps focus on contralateral ventral overriding superior articular process decompression, foraminal and extraforaminal discectomy, and lateral vertebral syndesmophyte decompression leading to enlargement of the contralateral foramen and extraforamen size. CONCLUSION: The Uniportal Full endoscopic contralateral approach is a good alternative to open surgery or minimally invasive microscopic surgery through direct endoscopic visualization of the entire route of exiting nerve with no neural retraction allowing both lateral recess and foraminal and extraforaminal decompression all in one approach.

Double crush syndrome caused by cervical spondylosis and vertebral artery loop.

PURPOSE: The purpose of this article is to report a successful treatment experience in a rare case of simultaneous cervical nerve root compression by spondylotic cervical foraminal stenosis and a vertebral artery loop. METHODS: 51-year-old man presented with a 4-year history of left-sided cervical pain radiating to the left shoulder with progressive exacerbation of weakness on left shoulder girdle muscles for 7 months. The patient had no history of trauma. The patient's CT and MRI revealed impingement of the left C6 cervical nerve root by a tortuous vertebral artery loop and also by narrowed left C5-6 cervical foramen that had undergone spondylotic changes. The patient underwent left C5-6 hemilaminectomy, facetectomy and C5-6 fusion. The procedures were uneventful, and the patient recovered with complete resolution of symptoms. RESULTS: The patient continued to be asymptomatic at a 2-year follow-up examination, and the muscle mass of his left girdle returned normal. CONCLUSIONS: This report illustrates the first phenomenon of a double crush syndrome caused by vertebral artery loop and cervical spondylotic changes. When patients with cervical spondylosis present with unexplainably severe pain and weakness, additional underlying pathologies should be considered when making differential diagnoses. The investigation planning should involve electromyography, computed tomography angiography, and magnetic resonance imaging.

[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.

Double Crush Syndrome.

Double crush syndrome is a distinct compression at two or more locations along the course of a peripheral nerve that can coexist and synergistically increase symptom intensity. In addition, dissatisfaction after treatment at one site may be the result of persistent pathology at another site along a peripheral nerve. Double crush syndrome is a controversial diagnosis; some scientists and surgeons believe it is an illness construction that may do more harm than good because it emphasizes an objective pathophysiologic explanation for unexplained symptoms, disability, and dissatisfaction that may be more psychosocially mediated. However, peripheral neuropathy may coexist with compressive neuropathy and contribute to suboptimal outcomes following nerve decompression. To better manage patients' expectations, treating practitioners should be aware of the possibility of concomitant cervical radiculopathy and carpal tunnel syndrome, as well as the presence of underlying systemic neuropathy.

[Invasive emergency techniques - In-field-amputation]. / Invasive Notfalltechniken - Notamputation.

On-scene invasive emergency procedures, such as Cricothyroidotomy, chest drain, intraosseous puncture or even in-field-amputation, are often unavoidable, when indicated, and present a major challenge for the emergency physician. Personal, temporal or local conditions are often unsuitable. Even with regular intervention by the Emergency Medical Service, "last resort" measures occur very infrequently, particularly in relation to paediatric emergencies. As well as theoretical training, practice-oriented course concepts are essential in order to achieve high quality in these procedures. This article presents the use of in-field-amputation, with reference to indication, implementation, problems and risks. It is part of a series of four articles on the subject of invasive emergency techniques.

Forklift-Related Crush Injuries of the Foot and Ankle.

BACKGROUND: Forklift-related crush injuries of the foot and ankle are relatively common in cities with shipping and construction industries. There is a paucity of literature on the incidence and sequelae of such injuries. We aimed to describe the incidence, patterns of injuries, sequelae, and morbidity associated with this type of injury. METHODS: A retrospective review of all patients with forklift-related crush injuries of the foot and ankle for 4 years was conducted. Patients' demographics, mechanisms and patterns of injury, fracture type, compartment syndrome, number of reconstructive operations, operative details, length of hospital stay, medical leave, repeat evaluation in emergency room, and complications were recorded and analyzed. RESULTS: There were 113 (2.17%) patients with forklift-related crush injuries out of 5209 patients seen in our institution for injuries of the foot and ankle. Crush injury from the wheels of the forklift truck was the most common mechanism at 71 (62.8%) patients. The forefoot was the most commonly injured region, followed by the midfoot, hindfoot, and ankle, with almost one-third (28.3%) of the patients having multiple injuries to the foot. Nine (8%) had open fractures, while 5 (4.4%) had compartment syndromes. Forty (35.4%) patients required hospitalization, and 35 (87.5%) of those hospitalized required operative intervention. Those who had surgery were more likely to have complications compared with those who did not require operative intervention (16 [45.7%] of 35 patients vs 7 [9%] of 78 patients; P < .05) and more likely to require longer medical leave (mean, 183 vs 30 days, P < .05). CONCLUSION: Forklift-related crush injuries of the foot and ankle are increasingly common in industrialized cities. The forefoot is commonly affected with involvement of multiple regions. Up to one-third of affected patients required hospitalization and multiple operative interventions resulting in loss of productivity, income, and significant morbidity. The possibility of residual disabilities must be clearly defined to the patients and their employers to manage potential workplace limitations and long-term expectations. LEVEL OF EVIDENCE: Level IV retrospective case series.

Efeitos da laserterapia na regeneração nervosa periférica / Effects of laser therapy in peripheral nerve regeneration

OBJETIVO: Analisar o efeito do laser nas doses de 5, 10 e 20J/cm2 na reparação do nervo fibular de ratos após esmagamento. Os resultados foram avaliados por meio da análise funcional da marcha e de parâmetros morfométricos.MÉTODOS: Lesão por esmagamento controlado do nervo fibular comum direito e submetidos a intensidades crescentes (G1: sem irradiação; G2: sham; G3: 5J/cm2; G4: 10J/cm2; G5: 20J/cm2) de irradiação do laser diretamente sobre o local da lesão por 21 dias consecutivos. A análise funcional da marcha foi realizada a intervalos semanais, tendo sido medido o índice funcional do fibular (IFF). Os animais foram sacrificados nos 21º dia pós-operatório para remoção do nervo fibular, que foi preparado para a análise morfométrica.RESULTADOS: Não houve diferença significativa (p>0,05) dos valores da análise de marcha (IFF) entre os grupos em qualquer momento de avaliação para o parâmetro. A área total da secção transversal do nervo foi significantemente maior no grupo 2 do que nos grupos 3 e 4, enquanto a densidade de fibras foi significantemente maior no grupo 4 do que no demais grupos.CONCLUSÃO: A irradiação com o laser AsGaAl de baixa potência não acelerou a regeneração do nervo fibular com nenhuma das doses utilizadas. Nível de Evidência I, Estudos terapêuticos - Investigação dos Resultados do Tratamento.

OBJECTIVE: The influence of dose of low power lasertherapy (AsGaAl, 830 nm) on the regeneration of the fibular nerve of rats after a crush injury was evaluated by means of the functional gait analysis and histomorphometric parameters.METHODS: Controlled crush injury of the right common fibular nerve, immediately followed by increasing doses (G1: no irradiation; G2: simulated; G3: 5 J/cm2; G4: 10 J/cm2; G5: 20 J/cm2) laser irradiation directly on the lesion site for 21 consecutive days. Functional gait analysis was carried out at weekly intervals by measuring the peroneal/fibular functional index (PFI). The animals were killed on the 21st postoperative day for removal of the fibular nerve, which was prepared for the histomorphometric analysis.RESULTS: The PFI progressively increased during the observation period in all groups, without significant differences between them (p>0.05). The transverse nerve area was significantly wider in group 2 than in groups 3 and 4, while fiber density was significantly greater in group 4 than in all remaining groups.CONCLUSION: The low power AsGaAl laser irradiation did not accelerate nerve recovery with any of the doses used. Level of Evidence I, Therapeutic Studies Investigating the Results of Treatment.