Imaging in crush injury: a spectrum of findings in survivors of the twin earthquakes on February 6, 2023.

On February 6, two major earthquakes with magnitudes of 7.8 and 7.7 on the Richter scale hit Turkey and Northern Syria causing more than 50,000 deaths. In the immediate aftermath of the earthquakes, our major tertiary medical referral center received dozens of cases of crush syndrome, presenting with a variety of imaging findings. Crush syndrome is characterized by hypovolemia, hyperkalemia, and myoglobinuria that can lead to rapid death of victims, despite their survival of staying under wreckage for days. The typical triad of crush syndrome consists of the acute tubular necrosis, paralytic ileus, and third-space edema. In this article, we focus primarily on characteristic imaging findings of earthquake-related crush syndrome and divided them into two distinct subsections: myonecrosis, rapid hypovolemia, excessive third-space edema, acute tubular necrosis, and paralytic ileus, which are directly related to crush syndrome, and typical accompanying findings of earthquake-related crush syndrome. Lower extremity compression in earthquake survivors results in the typical third-space edema. In addition to the lower extremities, other skeletal muscle regions are also affected, especially rotator muscles, trapezius, and pectoral muscles. Although it may be relatively easy to better detect myonecrosis with contrast-enhanced CT scans, changing the windowing of the images may be helpful.

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.

Application of contrast-enhanced ultrasonography in the diagnosis of skeletal muscle crush injury in rabbits.

OBJECTIVE: To explore the diagnostic value of quantitative contrast-enhanced (CE) ultrasonography for crush injury in the hind limb muscles of rabbits. METHODS: A total of 120 New Zealand white rabbits were randomized to receive compression on the left hind limb for either 2 h (n = 56) or 4 h (n = 56) to induce muscle crush injury. Another eight animals were not injured and served as normal controls. CE ultrasonography parameters such as peak intensity (PI), ascending slop, descending slop and area under curve (AUC) were measured at 0.5, 2, 6 and 24 h and 3, 7 and 14 days after decompression. RESULTS: Compared with the uninjured muscles, reperfusion of the injured muscles showed early and high enhancement in CE ultrasonography images. The time-intensity curve showed a trend of rapid lift and gradual drop. The PI and AUC values differed significantly among the three groups and were positively correlated with serum and tissue biomarkers. Rabbits of the 4-h compression group showed significantly higher PI and AUC values, and serum and tissue parameters than the 2-h compression group at each time points. CONCLUSION: CE ultrasonography can effectively detect muscle crush injury and monitor dynamic changes of the injured muscles in rabbits. PI and AUC are promising diagnostic parameters for this disease. ADVANCES IN KNOWLEDGE: CE ultrasonography might play an important role in the pre-hospital and bedside settings for the diagnosis of muscle crush injury.

Contrast-enhanced ultrasound assessment of muscle blood perfusion of extremities that underwent crush injury: an animal experiment.

BACKGROUND: This research aimed to study the assessment of local muscle microcirculation perfusion of extremities that underwent crush injuries by using contrast-enhanced ultrasonography (CEUS). METHODS: A total of 28 New Zealand rabbits were anesthetized by using intramuscular pentobarbital sodium (30 mg/kg). A balloon cuff device was used to create crush injuries to the left hind leg of each rabbit with a force of 18.6 kPa. CEUS was performed at the 0.5th, 2nd, 6th,24th, and 72nd hour after the release of the crush pressure. Peak intensity (PI) of the crushed regions was compared with those of the uncrushed regions and before the creation of crush injury. Receiver operating characteristic analysis was used to determine the diagnostic value of PI for the crushed region. RESULTS: During the 72nd hour after the release of the crush pressure, 5 of the 28 rabbits died, and thus, their statistics were eliminated from the experiment. At different time points after the release of the crush pressure, the crushed regions in all 23 survivals showed quick and high enhancement, and their intensities were higher than those of the un crushed region in the arterial phase. The time-intensity curves of the crushed regions all appeared as rapid lift-gradual drop. PIs were obviously higher in the crushed regions than in the uncrushed regions and than those before the creation of crush injury ( p G 0.001). Receiver operating characteristic curves showed that extremity crush injury was diagnosed by using PI value. CONCLUSION: CEUS presents that the microcirculation perfusion of the crushed muscle increased obviously after the release of the crush pressure.PIs evaluated quantitatively the microcirculation perfusion changes. It may suggest a potential alternative for evaluating microcirculation abnormality of the muscle crush injury to the extremities.

Muscle crush injury of extremity: quantitative elastography with supersonic shear imaging.

The aim of this study was to determine the characteristic of muscle crush injury at quantitative ultrasonographic elastography using supersonic shear imaging (SSI). Twenty-three New Zealand rabbits underwent crush injury to left hind leg caused by a special balloon cuff device. Conventional ultrasonography and SSI quantitative elastography were performed at both crushed and uncrushed regions of the left hind legs. Quantitative lesion elasticity was measured using the Young's modulus (in kilopascals) at 0.5 h, 2 h, 6 h, 24 h and 72 h after the release of the crushing pressure. Compared with those from the uncrushed regions, both the maximum and mean elasticity values at these time points from the crushed regions were significantly higher (p < 0.001). A receiver operating characteristic (ROC) analysis was employed to assess diagnostic performance. ROC curves showed that extremity crush injury was diagnosed using elasticity value and the greater the elasticity value, the greater the diagnostic value. SSI provides quantitative elasticity measurements, thus, adding complementary information that potentially could help in crush injury characterization with conventional ultrasonography.

Complex extrication and crush injury.

An unusual motor vehicle collision case is presented involving a complex, prolonged extrication with crush injury. While crush injury and crush syndrome are often considered to be in the realm of disaster medicine and urban search and rescue, more typical single-patient or few-patient incidents such as industrial accidents and vehicular crashes can involve these clinical entities. All emergency medical services (EMS) personnel should have a basic working familiarity with the operational and clinical issues involved in crush injury and crush syndrome. Crush syndrome is reviewed here from the perspective of prehospital management.

Crush thoracic trauma in the massive Sichuan earthquake: evaluation with multidetector CT of 215 cases.

PURPOSE: To determine the multidetector computed tomographic (CT) features of crush thoracic traumas resulting from the massive Sichuan earthquake. MATERIALS AND METHODS: This study was approved by the ethics committee of the medical school, and informed consent was waived. A retrospective review was undertaken of 215 multidetector chest CT scans of 112 male and 103 female patients who sustained crush thoracic injuries in the Sichuan earthquake at 2:28 pm Beijing time, May 12, 2008, and were rescued in the authors' hospital. Multidetector chest CT studies were performed between May 12, 2008, and June 7, 2008. The authors looked for injuries to the thoracic cage, pulmonary parenchyma, and pleura. RESULTS: One hundred forty-three patients (66.5%; 95% confidence interval [CI]: 60.2%, 72.8%) had at least one rib fracture; the mean number of rib fractures per patient was 6 [corrected]. Forty-five of these patients (31.5% of 143 patients; 95% CI: 23.9%, 39.1%) had flail chest, with a total of 288 ribs fractured. There were 46 patients (21.4%; 95% CI: 15.9%, 26.9%) with at least one vertebral fracture. There were 77 vertebral fractures total; 36 of these fractures were in T1 through T10. Twelve patients (5.6%; 95% CI: 2.5%, 8.7%) had sternal fractures, and 48 patients (22.3%; 95% CI: 16.7%, 27.9%) had either scapular or clavicular fractures. There were 117 patients (54.4%; 95% CI: 47.7%, 61.1%) with pulmonary parenchymal injuries and 146 (67.9%; 95% CI: 61.7%, 74.1%) with pleural injuries. CONCLUSION: Crush thoracic trauma resulting from the massive Sichuan earthquake was a life-threatening injury; this type of injury has the potential for multiple fractures and pulmonary parenchymal injuries.

Ultrasonic appearance of rhabdomyolysis in patients with crush injury in the Wenchuan earthquake.

BACKGROUND: On May 12, 2008, a major earthquake hit Wenchuan County in Sichuan Province of China. The number of cases of crush injury following this event was high. Ultrasonic appearance of rhabdomyolysis (RM) caused by crush injury in the Wenchuan earthquake was observed to evaluate the diagnostic value of ultrasound for detection of rhabdomyolysis. METHODS: We analyzed clinical and ultrasonic manifestations of 50 cases of RM and 18 cases of RM with osteofascial compartment syndrome (OCS). All cases were caused by crush injury in the Wenchuan earthquake. For these RM patients, we also evaluated the correlations between creatine kinase (CK) and the scope of the muscle lesions as observed by ultrasound. RESULTS: There were differences in clinical symptoms, physical signs and ultrasonic appearance between the two groups of patients. The ultrasonic characteristics of the RM were as follows: the striated muscle in the lesions thickened with good overall continuity, and the muscle texture was vague; the strength of the echo was uneven and the echo was cloudy or ground glass-like. Liquid dark zones appeared between muscles and were spindle-like or irregular in shape. There were no blood flow signals in the liquid dark areas. The volume of the striated muscle increased in patients with OCS; the fascia wrapping the muscle showed arched protrusions and significant displacement. The flow velocity of the distal arteries decreased and the spectrum was abnormal. The muscle lesion scope of RM group and RM and OCS group was (7.8 +/- 2.0) cm and (13.6 +/- 3.1) cm, respectively. The correlation coefficient (r) between the muscle lesion scope and the CK was 0.681 for the RM group (P < 0.05) and 0.516 for the RM and OCS group (P < 0.05). CONCLUSIONS: The ultrasonogram of RM has characteristic manifestations and can provide important information for clinical diagnosis and treatment of rhabdomyolysis.

The clinical and technical evaluation of a remote telementored telesonography system during the acute resuscitation and transfer of the injured patient.

BACKGROUND: Ultrasound (US) has an ever increasing scope in the evaluation of trauma, but relies greatly on operator experience. NASA has refined telesongraphy (TS) protocols for traumatic injury, especially in reference to mentoring inexperienced users. We hypothesized that such TS might benefit remote terrestrial caregivers. We thus explored using real-time US and video communication between a remote (Banff) and central (Calgary) site during acute trauma resuscitations. METHODS: A existing internet link, allowing bidirectional videoconferencing and unidirectional US transmission was used between the Banff and Calgary ERs. Protocols to direct or observe an extended focused assessment with sonography for trauma (EFAST) were adapted from NASA algorithms. A call rota was established. Technical feasibility was ascertained through review of completed checklists. Involved personnel were interviewed with a semistructured interview. RESULTS: In addition to three normal volunteers, 20 acute clinical examinations were completed. Technical challenges requiring solution included initiating US; audio and video communications; image freezing; and US transmission delays. FAST exams were completed in all cases and EFASTs in 14. The critical anatomic features of a diagnostic examination were identified in 98% of all FAST exams and a 100% of all EFASTs that were attempted. Enhancement of clinical care included confirmation of five cases of hemoperitoneum and two pneumothoraces (PTXs), as well as educational benefits. Remote personnel were appreciative of the remote direction particularly when instructions were given sequentially in simple, nontechnical language. CONCLUSIONS: The remote real-time guidance or observation of an EFAST using TS appears feasible. Most technical problems were quickly overcome. Further evaluation of this approach and technology is warranted in more remote settings with less experienced personnel.

Double crush syndrome evaluation in the median nerve in clinical, radiological and electrophysiological examination.

Double crush syndrome (DCS) was first described by Upton and McComas who proposed that focal compression of an axon often occurs at more than one level. The aim of the study was to support the hypothesis of DCS of the median nerve on the basis of available diagnostic methods. 30 patients (25 F and 5 M aged 33-73, mean 54.6+/-8.2 years) with coexisting carpal tunnel syndrome (CTS) and cervical radiculopathy (CR) were examined. Control group included 40 healthy volunteers (27 F and 13 M aged 17-82, mean 43.1+/-11 years). Medical evaluation comprised clinical examination, X-ray and MR imaging of the cervical spine, electroneurography (ENG) with F-wave and somatosensory evoked potentials (mSEPs) of median nerves. In clinical examination 96.6% of patients suffered from cervical spine pain and nocturnal paresthesies of at least one hand. Muscular atrophy was present in 43.3% in the proximal and in 70% in the distal part of the upper extremity. 30.3% of patients presented with a thoracic scoliosis. On X-ray examination, all patients showed cervical discopathy, mostly C5-C6 (70%) and C6-C7 (53.3%). Using MR investigation, the narrowing of intervertebral foramina was present in 81.25% and narrowing of vertebral canal in 37.5%. On ENG all patients presented with CTS, bilaterally in 73.3%. The F wave was abnormal in 73.3% and mSEPs in 66.7% of patients. Coincidence of MR and mSEPs in view of lateralization was observed in 71.4%. Results supported the DSC hypothesis. DCS evaluation requires both structural and functional diagnosis of peripheral neurones using MRI and electrophysiological examination.

Temporary bridge plating of the medial column in severe midfoot injuries.

Severe crush injuries to the midfoot often involve comminuted cuneiform or tarsal navicular fractures. Treatment principles for the bony injury of the crushed midfoot include maintenance of the medial column length and alignment, as well as appropriate stable fixation after open or closed fracture reductions. This is especially important because outcomes after midfoot injuries are related to the stability of the medial longitudinal arch of the foot. Treatment options include closed reduction and isolated K-wire fixation, limited open reduction and internal fixation with K-wires, screw fixation directed from the navicular to the cuneiforms, spanning external fixation between the talus and the first metatarsal, or combinations of these techniques. Limited internal fixation combined with external fixation may be difficult or impossible in comminuted fractures secondary to the small size and large number of bony fragments. Also, the external fixator is a potential source of pin tract infections. We propose a temporary internal bridge plating technique of the medial column of the foot using an 8- to 10-hole, 2.7-mm reconstruction plate between the talar neck and the first metatarsal, which may provide adequate temporary internal stabilization until bony healing occurs.

Evaluation of the severity of traumatic rhabdomyolysis using technetium-99m pyrophosphate scintigraphy.

A quantitative scoring method was designed to assess the extent of muscle damage. Technetium-99m pyrophosphate (99mTc-PYP) scintigraphy was performed for 9 patients experiencing crush injury in the Chichi (Taiwan) earthquake. The magnitude of muscle uptake of 99mTc-PYP was graded as follows: grade 0, less than bone radioactivity (BRA); grade 1, equal to BRA; grade 2, higher than BRA; or grade 3, greatly higher than BRA. The area of muscle injury was estimated according to the rule of nines. The sum of the muscle injury size multiplied by its corresponding grading was defined as the anterior or posterior score according to the anterior or posterior images. Each image was interpreted by two physicians and average anterior and posterior scores were calculated. The muscle score was defined as the geometric mean of the average anterior and posterior scores. Significant correlations were obtained between the muscle score and duration of time trapped (r = 0.868, p < 0.01), peak serum creatine kinase level (r = 0.866, p < 0.01), peak serum phosphorus level (r = 0.877, p < 0.01) and number of hospital days (r = 0.875, p < 0.01). A negative correlation between the muscle score and blood pH (r = -0.706, p < 0.01) was also observed. We concluded that this scoring method may be used as an adjunct for evaluating the locations of trauma and the severity of crush syndrome, and for predicting the duration of hospital stay.

Shear syndrome: the worst case scenario of crush syndrome.

Shear syndrome is described as a complication of crush syndrome. In addition to compression of and injury to the electrode, complete transection occurs. In this case, the free end migrated to the pulmonary artery with the potential for further complications.

[Changes in the lymphatic system in the crush syndrome]. / Izmeneniia limfaticheskoi sistemy pri sindrome dlitel'nogo sdavleniia.

In vivo indirect electrolymphoroentgenography was conducted to study the reaction of lymphatics during prolonged compression syndrome (PCS). The studies were made on white rats, Wistar-line, males. It was found out that the early period of clinical course of PCS was characterized by lymphostasis. The intermediate period of PCS corresponds to the stage of the collateral lymphokinesis. At the edge of intermediate and late period of PCS the electrolymphoroentgenogram shows the removal of lymphostasis and recovery of main lymphokinesis.