Crush wounds as an interdisciplinary problem: a description of two clinical cases

Introduction

The most common cause of chronic wounds located in the lower limbs are disorders in the vascular system: venous (60–80%) [1, 2], arterial (10–15%) [3] or arteriovenous (20%) [3–5]. Post-traumatic wounds constitute a much smaller percentage of lower limb ulcers. They are listed in the “other” group together with ulcers resulting from, among other causes: infectious disease, metabolic disease, and reaction to drugs [6]. They constitute 5.4% of the reasons for reporting to hospital emergency departments and are one of the most common reasons for visits [7]. In the United States, they are the cause of as many as 4.7% of hospitalizations [8]. Post-traumatic ulcers may be the result of accidental or intentional (self-inflicted) trauma or a complication after a procedure, e.g. surgery. Among the causes of accidental injuries, we can distinguish road accidents, accidents at work, or e.g. being hit by a trolley in a supermarket, by an umbrella/heel/kick in crowded places or unintentional self-harm, such as hitting the edge of a bed. Post-traumatic wounds are divided depending on the mechanism of injury and classified according to the severity of the injury, e.g. the Mangled Extremity Severity Score (MESS) classification [9, 10]. Injuries can be superficial or deep, and the differentiation criterion is the level relative to the subcutaneous tissue. Another classification of post-traumatic wounds distinguishes simple wounds (skin layers, small size), complex wounds (with damage to tendons and/or bone and joint structures, nerves, vessels, body cavities, internal organs) and complicated wounds, in which there is a wound infection, abscess or phlegmon [11]. Crushing injuries constitute a significant group among post-traumatic wounds. Crush injuries, in addition to extensive tissue damage, especially muscle damage, are often accompanied by bone fractures and impaired circulation. Lower limbs are most often at risk of such injury [12]. Regardless of the causative factor, in accordance with the current recommendations [13], it is first important to implement diagnostic measures, start causal and general treatment, and then local treatment in accordance with the latest standards.

Case 1 report

A 29-year-old man was admitted to the Chronic Wound Treatment Clinic due to a difficult-to-heal wound on the left lower limb. The patient was brought in a wheelchair with the left lower limb placed in a plaster splint. Three months earlier, the man had suffered a crush injury when a forklift ran over his foot.

Data from medical records

On the day of admission to the Hospital Emergency Department, the blood supply and innervation of the lower limb were preserved. The wound was located on the lateral and external part of the metatarsus, and there were numerous abrasions and petechiae on the shin. Deformation of the ankle joint area was visible. Radiological examination revealed numerous fractures of the metatarsus, and under inhalation anesthesia an attempt was made to reposition the foot. Computed tomography revealed numerous fractures: explosion fractures of the navicular bone with its fragmentation, with destruction of the Chopart joint with subluxation of the fragments forming its surface, multi-fragment fractures of the anterior calcaneus, the anterior part of the talus, the distal part of the third metatarsus body without displacement, the base of the second metatarsus without displacement, and others. The patient was admitted to the Department of Orthopaedics and Traumatology of the Musculoskeletal System for surgery (Figs. 1, 2). On the second day of the patient’s hospital stay, while waiting for the orthopedic procedure, the innervation and blood supply of the lower limb were preserved, but a decrease in the warmth and bruising of the toes of the left foot were observed (Fig. 3). Bloody ecchymoses were visible along the entire lower limb. The mobility of the fingers was preserved, and the limb was not swollen. After consultation with a vascular surgeon, CT angiography was performed. The angiographic examination revealed critical stenosis of the popliteal artery and up to 40% stenosis of the dorsalis pedis artery. The patient was transferred to the Department of Vascular Surgery and Angiology, where percutaneous angioplasty of the popliteal artery was performed. In the following days, a decision was made to postpone the patient’s planned orthopedic procedure until the clinical condition of the limb improved and the difficult-to-heal wound healed (Fig. 4). For this purpose, the patient was referred to the Chronic Wound Treatment Clinic.

Clinical description of the wound and surrounding skin

Multiple wounds were located on the anterior, lateral and inner side of the shin and on the metatarsus. The toes were in the process of demarcation. The wound with the largest surface area (approximately 240 cm2) was located on the anterior and medial surface of the shin and extended through the dorsal part of the metatarsus to the plantar part of the foot (Figs. 5, 6). Its entire surface was covered with black, strongly adherent necrosis. On the outer side of the foot there were numerous small wounds, also covered with black necrotic tissue. The skin on the entire shin had many small abrasions, bruises and ecchymoses. Around the largest defect, the skin was bruised and small blood vessels were visible underneath.

Therapeutic and nursing procedures implemented

First, actions related to the hygiene of the wound and the surrounding skin were performed. Then, after mechanical cleaning of the wound, material for micro­biological examination was collected from its surface. The study revealed the presence of Enterococcus faecalis 10² CFU/ml and Staphylococcus epidermidis 10⁴ CFU/ml. Due to the large amount of dead tissue, the wound was treated as at risk of developing infection; therefore a broad-spectrum antiseptic was applied to all affected areas. Attention was also paid to the fingers, which were washed with lavaseptic and separated from each other with dry gauze. After mechanical cleaning of the largest wound and partial removal of dead tissue from its bed, a hydrating gel and hydrocolloid dressing were applied to its surface (Fig. 7). The remaining minor defects were secured with a mesh dressing. An emollient was applied to the skin around the ulcers, omitting the interdigital spaces. For the first three weeks, visits to the clinic took place once a day. After separation of the black necrosis from the wound bed, blood vessels, tendons and bone fragments were exposed (Fig. 8). The surface of the ulcer was cleaned with a Wound Pad sponge, removing biofilm, dead tissue and remnants of exudate from its bed. In the following weeks, depending on the clinical condition of the wound and the amount of exudate produced, local treatment and the frequency of visits to the clinic were modified. During several weeks of therapy, minor defects healed, and the surface of the largest wound was covered with granulation tissue, which was gradually decreasing. Throughout the therapy, the patient consumed specialist products with protein, arginine and macro- and microelements. During the therapy, the limb remained immobilized in a plaster splint and the patient did not put any weight on the foot. The patient was educated on how to perform exercises to strengthen the muscles of the lower limb, especially the quadriceps femoris muscle. In the following days, despite the reduction of the wound surface, increasingly exposed bone fragments were observed, which damaged the granulation tissue and caused bleeding (Fig. 9). During a follow-up visit to the orthopedic clinic, the patient underwent a radiological examination, which did not show any signs of bone union.

Obtained effect

Despite effective local treatment and a significant reduction in the wound area, the presence of internal damage in the skeletal system did not allow the defect to heal. Due to the chronic wound, the presence of which increased the risk of postoperative complications, and also due to the high probability of not obtaining a stable walking surface and the dysfunction of the foot, a decision was made together with the patient to amputate the limb at the level of the shin.

Case 2 report

A 33-year-old patient was admitted to the Chronic Wound Treatment Clinic with an ulcer on her right lower limb.

Subject data

The wound had been caused five months earlier as a result of a crush injury – the patient fell down the stairs and “hung” on her lower limb. As a result of the fall, the cruciate ligaments were torn – orthopedic surgery was planned for after the wound had healed. The patient moved using orthopedic crutches. The patient had grade III obesity; on the day of the accident her body weight was 218 kg, with a height of 172 cm (body mass index (BMI) = 73.89). The patient had no other health problems. Until now, the patient has been under the care of various specialists. The surface of the wound was cleaned surgically and dressed with specialist dressings. The patient reported very severe pain – VAS 9 points.

Description of the wound and surrounding skin

The wound was located on the lateral surface of the limb, slightly below the knee joint (Fig. 10). The wound surface area was 730 cm² and it was 3 cm deep. The bed was covered with a large amount of yellow necrosis. The edges of the wound were thick and undermined over its entire surface, covered with necrotic tissue. The skin around the ulcer was significantly macerated and contaminated with, among other things, remnants of the glue securing the gauze, remnants of the ointment and exudate. The exudate from the wound was very abundant and had an unpleasant smell.

Therapeutic and nursing procedures implemented

Due to obesity and significant swelling of the limb, the patient was referred for a Duplex scan, which showed insufficiency of the perforating vein system. Local treatment first consisted of washing and cleaning the wound and the surrounding skin. Then, after careful removal of dead tissue from the wound surface, material was collected for microbiological examination (Fig. 11). Based on the obtained result (Morganella morganii 10⁴ CFU/ml), targeted antibiotic therapy was initiated. The patient received negative pressure dressings and multilayer compression therapy (31–40 mm Hg) for two weeks (Figs. 12, 13). After consultation with a plastic surgeon, the patient was deemed eligible for skin graft application.

Obtained result

During three weeks of therapy and interdisciplinary activities, it was possible to apply the graft (Fig. 14).

Discussion

Crush injuries of the lower limbs pose a serious challenge for therapeutic teams. They often involve damage to the musculoskeletal system, soft tissues, blood vessels and nerves. Limb salvage after blunt lower limb trauma is an extremely difficult process, and the salvage rate is lower than in penetrating injuries [12]. Many scales have been developed to assess clinical status and predict the success of treatment of traumatic wounds, including crush injuries [10, 14, 15]. Recent meta-analyses and retrospective studies suggest that although popular scales such as MESS and the Gustilo-Anderson classification are commonly used and accepted in risk stratification, they are often used incorrectly and may have poor predictive value [14, 15]. In our first case, we presented a young man who sustained a complex crush injury to the foot at work. Forklift-related foot and ankle injuries are relatively common in industrialized cities. There is little literature on the incidence and outcomes of such injuries. Hong et al. [16] reported that their institution had 113 (2.17%) patients with forklift-related foot and ankle injuries. Crushing injury by the forklift wheels was the most common mechanism in 71 (62.8%) patients. The forefoot was the most commonly injured area, followed by the midfoot, hindfoot, and ankle, with almost one third (28.3%) of patients having multiple foot injuries. Crushing injuries to the foot are more severe than simple foot fractures. These wounds are usually very complicated and include multiple fractures and soft tissue injuries. The main symptoms are pain, severe muscle and tissue damage, and extreme swelling. For this reason, the treatment of a crush injury to the foot can be quite difficult and often requires the cooperation of orthopedists, vascular surgeons, plastic surgeons, wound care specialists, physiotherapists, and others [17]. The patient we described suffered a crush injury to the soft tissues of the foot, multiple fractures of most of the bone structures of the metatarsus, and damage to the arteries. Despite the significant destruction of the musculoskeletal system in the foot, an attempt was made to save it. On the second day of hospitalization, the patient developed symptoms of lower limb ischemia and underwent percutaneous angioplasty of the popliteal artery. Repair procedures in the blood vessels are a common procedure performed in patients with crush injuries [12, 18]. Deja [19] reported that over a period of 5 years at the Department and Clinic of Trauma Surgery in Gdańsk, 64 patients with crush injuries of the limbs required repair surgery within the vascular system. In as many as 35 patients, the crush injury affected the lower limb, and in 12 patients, it was necessary to repair the popliteal artery. In his work, the author assessed early treatment results, at the time of the patient’s discharge from the hospital, based on the examination of the pulse and the degree of warmth on the periphery, possible neurological disorders and limb mobility. A very good result was considered to be a well-perceptible pulse and normal warmth on the periphery of the operated limb comparable to the healthy side, no neurological disorders and full mobility in the joints. A good result was assessed as normal warmth with a less perceptible pulse on the periphery compared to the healthy side, a slight degree of sensory disturbance or a slight degree of limitation of mobility (after bone fixation surgery or after conservative treatment). He considered the absence of a palpable pulse, with worse circumferential warmth, but without signs of chronic ischemia or with significant neurological deficits or significant limitation of limb mobility limiting the patient’s efficiency as a satisfactory result. He defined a poor result as cases requiring amputation. In the case presented by us, on the day of discharge, the innervation and blood supply of the lower limbs were preserved, being more pronounced on the right side, while on the operated limb the pulse was weaker and the fingers less warm. The foot reconstruction procedure was temporarily abandoned due to the clinical condition of the limb, and an attempt was made to treat the chronic wound locally. The patient reported to the Chronic Wound Treatment Clinic 3 months after the injury and within 11 weeks of the first visit; a significant reduction of the wound surface was achieved, from an area of 240 cm² to 12 cm². Unfortunately, bone fragments penetrating the wound surface in the area of the ankle joint prevented its effective healing. Due to the ulceration and the associated high risk of postoperative infection, as well as the lack of bone union after 4 months of immobilization, and the highly probable lack of functionality of the foot and ankle after reconstructive surgery, the decision was made to amputate the limb. Currently, the main goal of limb salvage is to restore and maintain stability and the ability to walk. The success of treatment is no longer measured solely by the restoration of viability, but also by the functional results of the limb [17]. An important aspect to consider before surgery is whether the injury occurs in the weight-bearing area of the foot. The role of the midfoot in the weight-bearing function and its relationship with the forefoot and rearfoot emphasize the importance of proper treatment of midfoot injuries. It is necessary to prove that the patient will be able to walk with a fairly normal gait [17]. Although our patient ultimately required a transfemoral amputation, we believe that the interventions we performed likely helped prevent an above-knee amputation and could potentially be more beneficial if initiated early in the patient’s treatment.
Our second case involves a 33-year-old woman who sustained a crush injury to her lower extremity. The patient was morbidly obese, and the weight of her body and the force of gravity likely contributed to the severity of her injuries. In addition to soft tissue damage, both cruciate ligaments were also torn. In our review of the current literature, we were unable to find any studies reporting a similar cause of crush injury. Lower limb injuries often occur in accidents related to transport, such as car accidents, or large objects falling on the limb. Crush injuries are characterized by pain, bruising and swelling, ranging from mild to severe [12]. In the described case, due to the extensive damage to soft tissues and cruciate ligaments, we planned to prepare the wound for transplant application. During 3 weeks of conservative treatment, the wound surface was systematically cleansed and negative pressure dressings and multilayer compression therapy were used. Compression therapy in patients with perforator vein insufficiency should exert pressure in the ankle area in the range 21–30 mm Hg [20, 21]. However, due to the presence of edema and considering that in obese people with BMI above 30 [22], venous pathology may worsen, we used a higher degree of compression between 31and 40 mm Hg. On the other hand, Davini et al. [23] presented an interesting report on the analysis of medical records of 9 patients with lower limb edema and a post-traumatic wound in the Achilles tendon area. In all patients with normal limb blood supply, in addition to negative pressure dressings, multi-layer compression therapy was used. No adverse effects were observed during negative-pressure wound therapy and compression therapy. In the next stage, the patient described by us was admitted to the Plastic Surgery Clinic for skin graft application. Skin graft is one of the most commonly used techniques in plastic and reconstructive surgery, including in post-traumatic wounds [24, 25]. He et al. [26] analyzed the medical records of 72 consecutive patients hospitalized due to crush injuries, treated with skin grafts. In all patients, the wound surfaces were extensive, and in 41 patients the wounds were located on the lower leg. A similar case description was presented by authors from China [27], describing a young woman who suffered an extensive crush injury of the left lower limb. The patient was treated with aggressive debridement of the wound surface and negative pressure therapy. After 19 days of local treatment, the patient underwent an autologous skin graft, which ensured skin continuity.

Conclusions

Most crush injuries pose a serious challenge to the therapeutic team. In patient care, an interdisciplinary approach is often required, including nurses, orthopedists, vascular and plastic surgeons, physiotherapists and psychologists.

Disclosures

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References