Reviving the Grasp: A Case Report on a Pioneering Approach to Managing Crush Syndrome and Unveiling the Occult Compartment Syndrome

A crush injury results directly from a crushing force, while crush syndrome, or traumatic rhabdomyolysis, manifests as systemic consequences stemming from the breakdown of muscle cells. Hand crush injuries present intricate challenges involving damage to multiple structures, tissue loss, and potential digit amputation, often caused by high-energy trauma. Each case demands a unique management plan, with the critical decision between limb salvage and amputation. Early intervention to restore vascularity is pivotal for preserving hand function. The complexity is heightened by the occult compartment syndrome, characterized by increased pressure causing neurovascular compromise without external signs. A patient with an insensate limb due to ipsilateral pan brachial plexus injury (BPI) adds an additional layer of complexity to the management journey, emphasizing the need for a multidisciplinary approach. This case is unique and underscores the importance of prioritizing reconstruction, identifying crush syndrome and the occult compartment syndrome, and employing a strategic, decisive approach that includes various surgical techniques for optimal outcomes in complex hand injuries.

Use of Integra® as a Temporizing Measure Before Definitive Flap Surgery in Mangled Extremities Requiring Revascularization

Complex palm defects with devascularized digits often require vein grafts. This may need to be followed by a free or pedicled flap to resurface the tissue lost and also cover the vein grafts and the anastomosis. However, if the anastomosis fails, or there is marginal wound necrosis, the existing flap would be redundant and a different flap would be needed for coverage.

In such situations, a novel approach would be to temporarily cover the anastomotic site with Integra® (Integra LifeScience Corporation, Plainsboro, NJ), until the digit and skin margin vascularity stabilize. This technique can be used to buy time and potentially lessen the need for pedicled or free flap coverage in the first instance. This should be taken into consideration as a viable alternative during revascularization in such cases.

In this case report, we present two cases in which we used Integra® as a temporary cover over exposed vein grafts until vascularization was established and a more definitive flap coverage was done. We were able to place the flap directly over the Integra®. This allowed time to determine additional necrosis of the wound margins and the final size of the defect that required coverage. Other advantages of this technique are that Integra® is readily available, there is no donor site morbidity, and the silicone layer which is not directly in contact with the vein graft can be easily peeled off without any traction. A flap or skin graft can be done directly over the collagen layer of the Integra®. Also, having a collagen layer integrated over the vein graft can potentially obviate the need for a flap.