Emerging role of physiotherapy in management of crush injury over forearm

INTRODUCTION

Crush injuries to the forearm and hand are devastating phenomenon with poor outcomes.^1,2 A compressive force, usually caused by a motor vehicle and industrial accident. Crushes and transiently increases the pressures within the hand and leads compartment syndrome.

That causing damage to bones, blood vessels, nerves, and soft tissues.³ These injuries can lead to compartment syndrome, vascular damage, infection, neurological injury, and tissue necrosis.⁴

Crush injuries with skin disruption can be challenging to accurately diagnose and manage. This case- report provides initial evaluation of forearm crush injuries as well as short- and long-term physiotherapy management strategies.

CASE REPORT

A 37 years old male had history of crush injury over right forearm because of the gas cylinder blast in 2021. At that time; his forearm was managed by multiple surgeries. Wound debridement and multiple flexors and extensor tendon repair, open reduction internal fixation with nailing / K-wire and skin grafting were done over affected forearm. After that, his arm was immobilised for 2 months. After completing immobilization phase, Physiotherapy reference was given.

He came for hand rehabilitation in our institute. At that time, he had complained of pain, swelling, restricted range over affected side, muscle weakness over right forearm, wrist and hand, reduced grip strength on right hand, and difficulties in ADL’S over right-hand following crush injury over right forearm.

Our musculoskeletal assessment revealed dull aching pain noted during right hand movement. Swelling was present over dorsal surface of forearm. Scar was present over right dorsal aspect of forearm which was healed. ROM examination revealed grossly restricted range of motion over right wrist and hand. The power in the muscle of hand, wrist and forearm on right side was grade 3 at available ROM. Grip strength of right hand was 4.6 kg and 23 kg over left hand.

Baseline neurological testing, dermatomes, SD curve and Deep tendon reflexes were performed and provided no helpful diagnostic information. Dermatomes were equal bilaterally and circumferential sensory testing was unable to determine any nerve root involvement. Lastly, reflexes were normal. In order to determine functioning skill level, “Sollerman Hand Function” Test was taken. The eight normal grip patterns can be divided into total 20 subtests, each involving hand ADL task. Each subtest is scored on a scale of 0-4 points. The total score of this test is 80. The patient got 40 scoring out of 80 at beginning of physiotherapy programme.

Physiotherapy management

Taking into account the most frequent manifestations, the goals of physiotherapy interventions include reduce pain, swelling, increasing of ROM, muscular strength and facilitation of hand function and hand grips and prevent contracture and deformity. The objective of physical therapy is to preserve and recover the patient’s autonomy, reduce dependence and improve quality of life. The exercise programme is described in table 1.

All exercises were started with few repetitions and they were progressed gradually according to patient’s ability to perform. Exercises were progressed gradually according to X- ray findings. Physiotherapeutic exercises were given 40 min/day, 6 days a week for 11/2 month. After 11/2 month of follow up, dull aching pain and swelling were subsiding. Patient showed good improvement in ROM and muscle strength as well as in grip strength. Patient showed good improvement in ADLs also. After range of motion was restored, a home exercise program was initiated. The home exercise program included a return to ADLs and occupational related activity and active, resistive, gripping activities of the hand. However the patient was satisfied with the outcome of the operation and physiotherapy treatment and was able to use his hand with a reasonable strength for the daily activities.

DISCUSSION

Early involvement of a hand rehabilitation by physiotherapist will minimize posttraumatic contractures following crush injuries.⁵ Physiotherapy interventions include patient education and exercises like passive, active-assisted, and active range of motion exercises, as well as customizing an intrinsic-plus splint.⁶ Immediately after injury, the hand assumes an intrinsic-minus position for prolong time can lead to edema over the dorsum of the hand in the loose subcutaneous and sub tendinous space.^6,7 If the hand is allowed to stay in this suboptimal position for longer time, the joints become stiffen and also causes interstitial adhesions.⁷

CONCLUSION

Physiotherapy plays significant role in the elimination of pain, improving range; muscle strength and hand function and also reduces the risk of stiffness, contracture and deformity in crush injuries.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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