What are the potential complications and management strategies for crush injuries of the femur without fracture?

From the Guidelines

Crush injuries of the femur without fracture require immediate attention to prevent serious complications, with a focus on early detection and management of compartment syndrome and rhabdomyolysis. The most concerning complication is compartment syndrome, where increased pressure within muscle compartments compromises blood flow, potentially causing tissue necrosis and permanent disability if not treated within 6-8 hours 1. Rhabdomyolysis is another significant risk, where damaged muscle releases myoglobin into the bloodstream, potentially causing acute kidney injury 1.

Management Strategies

Management begins with immediate assessment of neurovascular status, including checking pulses, sensation, and motor function in the affected limb.

• Intravenous fluid resuscitation with normal saline at 1-2 L initially, followed by maintenance fluids, helps prevent acute kidney injury from myoglobin 1.
• Pain control typically involves opioid analgesics such as morphine (2-4mg IV every 2-4 hours) or hydromorphone (0.5-1mg IV every 2-4 hours).
• Laboratory monitoring should include creatine kinase (CK) levels, renal function tests, and electrolytes every 4-6 hours initially.
• If compartment syndrome is suspected, compartment pressure measurements should be performed, with fasciotomy indicated for pressures within 30 mmHg of diastolic pressure or absolute pressures above 30-40 mmHg 1.
• Deep vein thrombosis prophylaxis with low molecular weight heparin (e.g., enoxaparin 40mg subcutaneously daily) should be initiated once bleeding risk is controlled.
• Early physical therapy and rehabilitation are essential to prevent muscle atrophy and joint stiffness, typically beginning with gentle range of motion exercises within 24-48 hours if the patient's condition allows.

Preventive Infection Strategies

Preventing infectious complications is crucial in limb trauma management, with antibiotic prophylaxis recommended as soon as possible and for a maximal duration of 48 h to 72 h in patients with open fracture 1.

Timing and Modalities for Fracture Fixation

In the absence of severe visceral injury, circulatory shock, or respiratory failure, an early definitive osteosynthesis of diaphyseal fractures is recommended within the first 24 hours to reduce the incidence of local and systemic complications 1. However, in the presence of severe visceral injuries, circulatory shock, or respiratory failure, a delayed definitive osteosynthesis of diaphyseal fractures is probably recommended within the first 24h to reduce the incidence of systemic complications.

From the Research

Potential Complications of Crush Injuries of the Femur without Fracture

• Crush injuries of the femur without fracture can lead to severe systemic manifestations, including cardiac failure, kidney dysfunction, shock, systemic inflammation, and sepsis 2
• Patients with crush injuries can develop life-threatening systemic effects such as hypovolemic shock, hyperkalemia, metabolic acidosis, and disseminated intravascular coagulation 2
• Compartment syndrome, hypotension, and organ injury (including acute kidney injury) are also potential complications of crush injuries 3

Management Strategies for Crush Injuries of the Femur without Fracture

• Early, aggressive resuscitation is recommended in prehospital settings to reduce complications from crush injuries 2
• Continuous administration of massive amounts of fluid, diuresis, and hemodialysis may be necessary to manage crush syndrome 2
• Care at the incident scene should focus on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport 3
• Initial stabilization and trauma evaluation, as well as treatment of any complication (e.g., compartment syndrome, hyperkalemia, rhabdomyolysis, acute kidney injury), are essential in the healthcare facility 3

Importance of Prompt Treatment

• Immediately beginning treatment is the single most important factor in reducing the mortality of disaster-situation crush syndrome 2
• Delayed diagnosis and treatment of crush injuries can lead to high on-site mortality 2
• Prehospital providers and emergency clinicians should maintain a comprehensive understanding of crush injuries and syndrome to optimize patient care 2, 3