From the Guidelines
A crush injury to the thumb requires immediate medical attention to prevent long-term complications and promote optimal recovery. The management of a crush injury to the thumb involves several key steps, including cleaning the wound with mild soap and water, applying gentle pressure with a clean cloth to control bleeding, and taking over-the-counter pain relievers like acetaminophen (500-1000mg every 6 hours) or ibuprofen (400-600mg every 6-8 hours) for pain management 1. It is also essential to apply ice wrapped in a towel for 15-20 minutes every 1-2 hours during the first 48 hours to reduce swelling and elevate the hand above heart level when possible.
For minor crush injuries, a splint may help immobilize the thumb to promote healing. However, it is crucial to seek emergency medical care if there is severe pain, significant deformity, numbness, inability to move the thumb, exposed bone, or signs of infection (increasing redness, warmth, swelling, or pus) 1. Crush injuries can damage underlying structures, including bones, tendons, nerves, and blood vessels, potentially leading to compartment syndrome or long-term complications if not properly treated.
The risk of developing compartment syndrome is increased in patients with severe limb trauma, including fracture, crush injury, hemorrhagic injury, or reperfusion of an ischemic lesion, and hypotension 1. Experts suggest investigating repetitively for clinical signs of compartment syndrome, such as pain, tension, paresthesia, paresis, and an increase in compartmental pressure monitoring.
In patients with established compartment syndrome, early fasciotomy is the treatment of choice, involving a wide incision of the skin, subcutaneous tissue, and fascia 1. The volume of fluid to be administered remains debated, but most retrospective studies report that patients who eventually developed acute kidney injury had a longer time to initiate volume resuscitation compared to those who did not 1.
Key considerations in the management of a crush injury to the thumb include:
- Prompt medical attention to prevent long-term complications
- Gentle wound cleaning and bleeding control
- Pain management with over-the-counter medications
- Ice application and elevation to reduce swelling
- Immobilization with a splint for minor injuries
- Emergency medical care for severe injuries or signs of infection
- Monitoring for compartment syndrome and prompt fasciotomy if necessary
- Aggressive fluid resuscitation to prevent acute kidney injury 1.
From the Research
Crush Injury Thumb
- A crush injury thumb is a type of injury that occurs when the thumb is subjected to a compressive force, causing damage to the bones, blood vessels, nerves, and soft tissues 2.
- The management of crush injuries of the hand, including the thumb, requires a planned and decisive approach, with accurate assessment of the injury and creation of a reconstructive plan by structures 3.
- The essential components of primary surgery for crush injuries of the hand include precise and complete debridement, skeletal stabilization, vascular repair, and soft tissue cover 3.
- Secondary surgery may include procedures to enhance the function of the hand or to improve the aesthetics of the hand, such as bone grafting, fusion, tendon and nerve reconstruction, flap de-bulking, and toe to hand transfers 3.
Systemic Manifestations
- Crush injuries can lead to systemic manifestations, including crush syndrome, which is a severe systemic manifestation of trauma and ischemia involving soft tissue, principally skeletal muscle, due to prolonged crushing of tissues 4, 5.
- Crush syndrome can result in cardiac failure, kidney dysfunction, shock, systemic inflammation, and sepsis, and can have a high mortality rate if not treated promptly and effectively 4, 5, 6.
- The treatment of crush syndrome includes maintaining fluid electrolyte and acid-base balance, application of dialysis, and prevention and treatment of complications 6.
Emergency Management
- Emergency clinicians play a critical role in the evaluation and treatment of patients with crush injuries, including those with thumb injuries 4, 5.
- Care at the incident scene is essential and focuses on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport 5.
- Early aggressive resuscitation is recommended in prehospital settings to reduce complications from crush syndrome 4.