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Trauma Case Rep
Trauma Case Rep
Trauma Case Reports
2352-6440
Elsevier

S2352-6440(24)00121-3
10.1016/j.tcr.2024.101098
101098
Case Report
Comprehensive management of severe crush injury in a pediatric patient: A case report
Nguyen Phi Duong nguyenduongphi1311@gmail.com
⁎
Nguyen Tien Minh
Mai Phuoc Thien
Truong Dinh Quang
City Children's Hospital, Ho Chi Minh City, Viet Nam
⁎ Corresponding author at: City Children's Hospital, 15 Vo Tran Chi Street, Tan Kien ward, Binh Chanh district, Ho Chi Minh City, Viet Nam. nguyenduongphi1311@gmail.com
14 9 2024
12 2024
14 9 2024
54 10109812 9 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
This case report presents the management of a severe crush injury in a 7-year-old male patient. The injury occurred following entrapment in a concrete mixer, resulting in extensive soft tissue trauma and vascular compromise. Prompt surgical intervention, including meticulous debridement and vascular reconstruction, was undertaken to optimize outcomes. Postoperative care involved serial debridement, negative pressure wound therapy, and subsequent skin grafting. Reconstructive procedures aimed to enhance hand function, yielding satisfactory outcomes at the three-month follow-up. This case underscores the importance of a multidisciplinary approach in managing pediatric crush injuries and highlights the role of collaborative care in optimizing outcomes.

Keywords

Crush injury
Pediatric patient
Vascular compromise
Surgical intervention
Multidisciplinary approach
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pmcIntroduction

Crush injuries resulting from traumatic incidents pose significant challenges in pediatric care, often necessitating prompt and comprehensive management to optimize outcomes [1]. In this report, we present the case of a 7-year-old male patient who sustained a severe crush injury to his forearm while playing. The patient's injury occurred when his hand became entrapped in a concrete mixer, leading to extensive soft tissue trauma and vascular compromise. Prompt initial stabilization measures were undertaken at a local hospital before the patient was transferred to our pediatric facility for further management. Through a multidisciplinary approach involving surgical intervention, vascular reconstruction, and meticulous postoperative care, the patient's functional and cosmetic outcomes were assessed. This case highlights the complexities associated with crush injuries in pediatric patients and underscores the importance of timely intervention and collaborative care in achieving favorable patient outcomes.

Case presentation

A 7-year-old male patient was admitted to our pediatric facility following a traumatic crush injury sustained while playing. The incident occurred when the patient inadvertently inserted his upper limb into a concrete mixer, resulting in entrapment and subsequent crush injury to his upper limb. Upon arrival at our institution, the patient presented with extensive soft tissue trauma involving the entire anterior aspect of his arm and forearm, with exposed tendons and nerves (Fig. 1).Fig. 1 The patient's wound.

Fig. 1

Clinical examination revealed signs of vascular compromise, including absent pulses and coldness in the affected fingers. Radiographic imaging of the forearm revealed no evidence of bony injury, while Doppler ultrasound failed to detect vascular flow in the wrist and forearm.

Emergency surgical intervention was promptly initiated to address the severe soft tissue trauma and vascular compromise. Meticulous exploration and debridement of the crushed tissues were undertaken, revealing significant damage to a segment of the brachial artery measuring 15 cm (Fig. 2).Fig. 2 Significant damage to a segment of the brachial artery.

Fig. 2

Urgent repair of the vascular injury was performed, along with management of multiple nerve lacerations identified during the procedure. Vascular reconstruction was achieved using a harvested greater saphenous vein graft (from his right leg) measuring 17 cm, followed by meticulous vascular anastomosis to restore blood flow to the affected limb (Fig. 3). The donor site was managed with appropriate care to prevent complications, and no significant issues were reported.Fig. 3 Vascular anastomosis using vein graft.

Fig. 3

Due to the extent of soft tissue trauma and compromised vascular supply, amputation of the thumb and distal phalanx of the middle finger was deemed necessary to optimize functional outcomes and wound healing. Following surgical intervention, the patient underwent multiple debridement procedures and was managed with negative pressure wound therapy (VAC) to promote wound granulation and tissue healing (Fig. 4).Fig. 4 Using VAC therapy.

Fig. 4

Subsequent skin grafting (Fig. 5) was performed to facilitate wound closure, and the patient was discharged home with appropriate postoperative care instructions.Fig. 5 After skin graft.

Fig. 5

Three months post-injury, the patient underwent a pollicization using the middle finger to optimize hand function (Fig. 6). The middle finger was chosen because its distal phalanx was amputated, making it a suitable candidate for this procedure. Despite some residual functional limitations, including reduced grip strength and joint stiffness, the patient demonstrated acceptable upper limb function as shown in Supplementary video.

Long-term follow-up and rehabilitation will be essential to monitor the patient's progress and optimize his overall recovery and quality of life. This case highlights the challenges associated with severe crush injuries in pediatric patients and underscores the importance of prompt intervention and comprehensive management to achieve favorable outcomes.Fig. 6 Pollicization using middle finger.

Fig. 6

Discussion

Crush injuries in pediatric patients present a multifaceted clinical scenario, often arising from high-energy trauma and involving a complex interplay of soft tissue damage, vascular compromise, and neurological deficits [2].

The case highlights the profound impact of crush injuries on pediatric patients, with the injury occurring due to entrapment in a concrete mixer during recreational play. Upon presentation, the patient exhibited alarming signs of vascular compromise, including absent distal pulses and coldness in the affected fingers, suggestive of severe ischemia [3]. Radiographic imaging and Doppler ultrasound further elucidated the extent of the injury, revealing the absence of bony injury and vascular flow, respectively, thus underscoring the severity of the vascular compromise.

In response to the grave clinical presentation, prompt surgical intervention was imperative to address the multifaceted nature of the injury and mitigate the risk of complications. Meticulous exploration and debridement of the crushed tissues were undertaken to remove devitalized tissue and minimize the risk of infection. Vascular reconstruction using a harvested greater saphenous vein graft was pivotal in restoring blood flow to the affected limb, as demonstrated by Chuong et al. [4]. The decision to use the greater saphenous vein was based on its suitable length and diameter, and its relatively low morbidity at the donor site. No significant complications were observed at the donor site postoperatively.

The postoperative management of the patient was characterized by a comprehensive and multidisciplinary approach, emphasizing the collaborative efforts of surgical, vascular, and rehabilitation specialists. Multiple debridement procedures, negative pressure wound therapy (VAC), and subsequent skin grafting played integral roles in promoting wound healing and facilitating rehabilitation. Negative pressure wound therapy (NPWT), commonly known as Vacuum-Assisted Closure (VAC), is a widely used adjunctive therapy in the management of complex wounds, including those resulting from severe crush injuries. In the presented case, VAC therapy played a crucial role in promoting wound healing and facilitating rehabilitation.

VAC therapy involves the application of controlled negative pressure to a wound site through a sealed dressing system connected to a vacuum pump. This creates a microenvironment that promotes wound healing by facilitating wound drainage, reducing edema, increasing blood flow, and promoting the formation of granulation tissue. Additionally, VAC therapy helps to remove excess exudate and infectious material from the wound, thereby reducing the risk of infection and promoting a favorable wound healing environment [5].

In the case of severe crush injuries, where extensive soft tissue trauma and compromised vascular supply are often present, VAC therapy can help to promote tissue perfusion and prevent wound complications such as infection and necrosis. By applying negative pressure to the wound site, VAC therapy helps to remove fluid and cellular debris, thereby reducing tissue edema and promoting the formation of healthy granulation tissue. VAC therapy has garnered considerable attention in the literature due to its demonstrated superiority over conventional wound care methodologies, as elucidated by several authors [[6], [7], [8]].

Furthermore, VAC therapy can aid in the preparation of wounds for subsequent surgical interventions, such as skin grafting, by promoting wound bed preparation and optimizing the conditions for successful graft take. In the presented case, VAC therapy likely facilitated the subsequent skin grafting procedure by promoting wound healing and providing a favorable environment for graft integration.

Additionally, three months post-injury, the patient underwent a reconstructive procedure involving pollicization using the middle finger to optimize hand function. Pollicization is a well-established technique in reconstructive hand surgery, offering the potential to restore key functions such as opposition, grasp, and fine motor control. During the pollicization procedure, the middle finger was surgically detached from its original location and repositioned to function as the thumb, ensuring adequate blood supply and sensation through careful preservation and reconstruction of the neurovascular structures. The middle finger was chosen over the index finger due to the distal phalanx amputation, making it a more suitable candidate. Despite some residual limitations, the procedure significantly improved the patient's hand function and quality of life. While pollicization can significantly improve hand function and quality of life for patients with thumb deficiencies, it is not without limitations. Patients may experience residual limitations in thumb function, such as reduced range of motion or decreased strength, particularly when compared to the native thumb. Additionally, the reconstructed thumb may have a different appearance and size compared to the original thumb, which can impact cosmetic outcomes [9].

The successful management of severe crush injuries in pediatric patients necessitates a multifaceted approach encompassing prompt surgical intervention, meticulous vascular reconstruction, and comprehensive postoperative care. Collaboration among various specialties is paramount to mitigate the risk of complications and optimize functional outcomes. Long-term follow-up and rehabilitation remain crucial in monitoring progress and ensuring optimal recovery in pediatric patients with crush injuries.

Conclusion

In conclusion, the presented case illustrates the complexities associated with crush injuries in pediatric patients and underscores the importance of a multidisciplinary approach in achieving favorable outcomes. Through prompt intervention, meticulous surgical technique, and comprehensive postoperative care, optimal functional and cosmetic outcomes can be achieved, highlighting the importance of collaborative and patient-centered care in the management of traumatic injuries in pediatric populations.

The following is the supplementary data related to this article.Supplementary Video 1

Patient's Final Functional Outcome.

Supplementary Video 1

CRediT authorship contribution statement

Phi Duong Nguyen: Writing – review & editing, Writing – original draft, Validation, Supervision, Methodology, Investigation, Data curation, Conceptualization. Tien Minh Nguyen: Data curation, Conceptualization. Phuoc Thien Mai: Investigation, Funding acquisition. Dinh Quang Truong: Supervision.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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