Demographic and clinical features of extremity crush injuries resulting from entrapment under the rubble: An orthopedic perspective

doi:10.21203/rs.3.rs-4896356/v1

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Demographic and clinical features of extremity crush injuries resulting from entrapment under the rubble: An orthopedic perspective

https://doi.org/10.21203/rs.3.rs-4896356/v1

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Background:

We aimed to contribute to the literature by reporting the demographic and clinical characteristics of patients who suffered extremity crush injuries as a result of being trapped under rubble following the earthquake that occurred in Turkey on February 6, 2023.

Methods:

In total, 65 patients, including 33 females and 32 males, were enrolled. The mean age of the patients was 32.2 ± 20.45 years. Patients were categorized into four treatment groups, including nonoperative (n = 13), fasciotomy/debridement (n = 20), fracture fixation (n = 5), and amputation (n = 27) groups. Demographic and clinical information were analyzed.

Results:

The lower extremities were the most frequently affected anatomical regions. Upon hospital admission, all patients exhibited significant elevations in serum potassium and creatinine kinase levels; however, these levels decreased significantly within 24 h of the initiation of operative or nonoperative treatment (p < 0.05). The rate of crush syndrome development was 54%, 60%, and 59% in the nonoperative, fasciotomy/debridement, and amputation groups, respectively. Similarly, the rate of hemodialysis was 15%, 35%, and 22% in the nonoperative, fasciotomy/debridement, and amputation groups, respectively. The reoperation rate was 75% and 30% in the fasciotomy/debridement and amputation groups, respectively. Furthermore, the incidence of infection was 40% in fracture fixation group, 40% in the fasciotomy/debridement group, and 33% in the amputation group. The mortality rate was 5% in the fasciotomy/debridement group and 7% in the amputation group. The mean duration of hospitalization for all treatment groups was 10.9 ± 10.41 days, with the fasciotomy/debridement group having the longest duration of hospitalization (14.5 ± 9.8 days).

Conclusion:

During the acute treatment phase, a significant increase in crush syndrome and wound infection rates, accompanied by a greater need for hemodialysis and prolonged hospitalization, were frequently observed. We hypothesize that the findings of studies on earthquake-related experience could provide a reference for future investigations.

Earthquake

earthquake-related injury

crush injury

Approximately 800 million people worldwide reside in regions with a high risk of earthquakes [1,2]. Türkiye has experienced numerous devastating earthquakes throughout its history due to its location along active faults and the high prevalence of significant seismic activity [3,4]. On 6 February 2023, the southern and southeastern regions of Türkiye experienced the most devastating earthquakes in its modern history [5]. Consequently, orthopedic surgeons operating near these earthquake zones frequently encounter patients with injuries resulting from being buried under the rubble (Fig. 1). Prolonged entrapment under the rubble results in crush injuries or crush syndrome, in which can cause loss of extremities or even death [6–9]. Crush injury is defined as the direct physical compression of muscular tissues. Crush syndrome, also known as traumatic rhabdomyolysis, is characterized by a succession of metabolic changes caused by severe musculoskeletal injury, undermining cellular integrity and resulting in the release of cellular contents into the circulatory system [10]. Crush syndrome manifests in 40–70% of individuals afflicted with crush injuries [7,11

Crush injuries affecting the extremities pose a significant challenge for orthopedic surgeons. The optimal approach to manage such injuries remains uncertain. Orthopedic surgeons consider treatment options such as fasciotomy and debridement, amputation, and nonoperative follow-up based on the severity of the injuries [12,13]. We reported the demographic and clinical features of patients with extremity crush injuries due to entrapment under the rubble following the earthquake of 6 February 2023. Moreover, we evaluated the impact of orthopedic interventions performed during the acute phase.

This research has been approved by the IRB (institutional review board) of the authors(2023/238). We performed a retrospective analysis of 79 patients entrapped under the rubble following the earthquake. Patients who underwent initial surgery at a different center or were transferred to another center during the treatment course were excluded, as were those with insufficient laboratory or clinical data. Consequently, 65 patients were included in the study.

Data included baseline demographic information, the extent of crush injuries, concurrent extremity fracture, and the treatments administered along with their indications and outcomes.

Patients were categorized into four treatment groups: nonoperative (n = 13), fasciotomy/debridement (n = 20), fracture fixation (n = 5), and amputation (n = 27). Table 1 presents the indications for each treatment modality. These indications were based on factors such as extremity perfusion status, evidence of compartment syndrome and hemodynamic instability, fractures, and the mangled extremity severity score (MESS).

Table 1

Treatment approaches for crush injuries during the disaster phase
Non-operative treatment	Fasciotomy and Debridement	Amputation		Fracture Fixation Solely
Non-operative treatment	Fasciotomy and Debridement	Upper Limb	Lower Limb	Fracture Fixation Solely
• Without any fracture • Pulsatile extremity • No signs of ischemia • No signs of hemodynamic instability • No pain with passive movement of the fingers	• With or without any fracture • Pulsatile extremity • No signs of ischemia • No signs of hemodynamic instability • Clinical signs of increased compartment pressure*	• With or without any fracture • Pulseless extremity with prolonged and obvious signs of ischemia • Uncontrollable/refractory hemodynamic instability	• With or without any fracture • MESS score > 7	• With fracture • No clinical signs of increased compartment pressure*
*Pain with passive movement of fingers, poikilothermy, paralysis and paresthesia were assessed, Compartment pressures were not measured routinely due to disaster conditions.

The evaluation of treatment outcomes involved various parameters, including changes in serum potassium and creatinine kinase levels, the rate of crush syndrome development, the necessity for hemodialysis and reoperations, the incidence of infections in the affected area, the duration of hospital stay, and the mortality rate.

Serum potassium (mEq/L) and creatine kinase (U/L) levels were measured before and 24 h after the initial orthopedic intervention; however, for non-surgically managed patients, these values were assessed upon admission and 24 h after hospitalization.

Patients with tachycardia (heart rate > 120/min), dark-colored urine, and serum creatine kinase levels > 1,000 U/L were diagnosed with crush syndrome [10].

Statistical Analyses

Statistical analyses were performed using SPSS software (version 18.0; IBM Corp., Armonk, NY, USA). Continuous data are presented as means ± standard deviations, whereas categorical data are presented as numbers and percentages. Non-parametric variables were compared using the chi-squared test or Fisher’s exact test. Parametric variables were compared using one way-analysis of variance or the t-test. P-values < 0.05 were considered statistically significant.

We enrolled 33 female (50.8%) and 32 male (49.2%) patients with a mean age of 32.2 ± 20.45 years. Regarding anatomical injury sites, the unilateral thigh, cruris, foot, arm, forearm, and hand were affected in 7 (11%), 14 (22%), 7 (11%), 6 (9%), 5 (7%), and 2 (3%) patients, respectively. Furthermore, the unilateral cruris and thigh were affected in 4 (6%) patients, the unilateral arm and forearm in 6 (9%) patients, the hand and contralateral thigh in 1 (2%) patient, the bilateral cruris in 3 (5%) patients, and the bilateral cruris and thigh in 10 (15%) patients. Of the 13 (20%) patients with single fractures, 6 had combined tibia and fibula, 2 femur shaft, 2 humerus shaft, 1 metatarsal, 1 phalanx, and 1 radius distal fractures. Furthermore, multiple lower limb fractures were observed in 3 (5%) patients, whereas open fractures were observed in 4 (6%) patients.

Upon hospital admission, all patients exhibited significant elevations in serum potassium and creatinine kinase levels; however, these levels decreased significantly within 24 h of the initiation of operative or nonoperative treatment (p < 0.05) (Table 2).

Table 2

Mean serum potassium and creatine kinase levels in different treatment groups
	Pretreatment (mean ± SD)	Posttreatment (mean ± SD)	p
Non-operative Group
K (mEq/L)	4.54 ± 0.8	3.81 ± 0.3	0.005
CK (U/L)	17587.61 ± 20975.57	10023.53 ± 12723.68	0.58
Only fracture fixation Group
K (mEq/L)	4.04 ± 0.4	3.34 ± 0.35	0.013
CK (U/L)	3581.3 ± 2819.3	2098 ± 1840.4	0.302
Fasciotomy/Debridement Group
K (mEq/L)	4.37 ± 0.72	3.79 ± 0.78	0.002
CK (U/L)	53827.42 ± 96014.16	15509.36 ± 23081.86	0.041
Amputation Group
K (mEq/L)	4.8 ± 0.95	3.9 ± 0.88	0.000
CK (U/L)	46852.11 ± 49171.53	18361.26 ± 27969.37	0.000
Total
K (mEq/L)	4.56 ± 0.84	3.81 ± 0.74	0.005
CK (U/L)	39598.03 ± 63256.13	14489.96 ± 22909.29	0.022

SD: Standard deviation, K: Potassium, Ca: Calcium, CK: Creatine Kinase, p < 0.05 was significant

Table 3 presents the rates of crush syndrome development, hemodialysis and reoperations, infections in the affected area, and mortality. In total, three patients died during the acute treatment phase.

Table 3

Baseline characteristics of the study participants
	Non-Operative (n = 13)	Only fracture fixation (n = 5)	Fasciotomy-debridement (n = 20)	Amputation (n = 27)	Total
Age (mean ± SD)	29.8 ± 17.2	43.4 ± 21.7	27 ± 16.6	35.2 ± 23.6	32.2 ± 20.45
Gender (n, %)
Male	10 (76.9%)	4 (80%)	8 (40%)	13 (48.1%)	35 (53.8%)
Female	3 (23.1%)	1 (20%)	12 (60%)	14 (51.9%)	30 (46.2%)
Crush Syndrome (n, %)
Presence	7 (53.8%)	0 (0%)	13 (60%)	16 (59.3%)	36 (55.4%)
Absence	6 (46.2%)	5 (100%)	7 (35%)	11 (40.7%)
The need of hemodialysis (n, %)
Yes	2 (15.4%)	0 (0%)	7 (35%)	6 (22.2%)	15 (23.1%)
No	11 (84.6%)	5 (100%)	13 (65%)	21 (77.8%)	50 (76.9%)
The number of surgeries (n, %)
0	13 (100%)	0 (0%)	0 (0%)	0 (0%)	13 (20%)
1	0 (0%)	5 (100%)	5 (25%)	19 (70%)	29 (45%)
> 1 - ≤3	0 (0%)	0 (0%)	12 (60%)	8 (30%)	20 (31%)
> 3 - ≤5	0 (0%)	0 (0%)	2 (10%)	0 (0%)	2 (3%)
> 5	0 (0%)	0 (0%)	1 (5%)	0 (0%)	1 (1%)
Wound Site Infection (n, %)
Presence	0 (0%)	2 (40%)	8 (40%)	9 (33%)	19 (29.2%)
Absence	13 (100%)	3 (60%)	12 (60%)	18 (66%)	46 (71.8%)
The rate of mortality (n, %)
	0 (0%)	0 (0%)	1 (5%)	2 (7.4%)	3 (4.6%)
The duration of hospital stays (mean ± SD)
	4.15 ± 4.2	13 ± 6.2	14.5 ± 9.8	11.2 ± 12	10.9 ± 10.41
n = number, SD = standard deviation
].

The mean duration of hospitalization for all treatment groups was 10.9 ± 10.41 days. Notably, the nonoperative group exhibited the shortest duration of hospitalization (4.15 ± 4.2 days), whereas the fasciotomy/debridement group had the longest hospital stay (14.5 ± 9.8 days) (Table 3).

Earthquake-related injuries can manifest in various ways, commonly occurring as individuals attempt to escape or become trapped under the rubble [14]. Most people trapped under the rubble lose their lives immediately, and those successfully rescued frequently sustain serious injuries [15]. Although multiple studies have evaluated earthquake-related injuries, only one investigated injuries caused by being trapped under the rubble. This study [16] conducted a comparison between survivors rescued from collapsed buildings and a control group comprising individuals with varying injury mechanisms during the same earthquake; a higher incidence of multiple fractures and severe soft tissue injuries, including rhabdomyolysis, was observed in patients who were rescued from under the rubble. Considering the significance of understanding this specific type of injury, we investigated the demographic and clinical characteristics of patients with extremity crush injuries caused by building collapses.

The lower extremities, the most affected anatomical site in earthquake-related injuries, account for approximately 36% of the body surface area [15–19]. Consistent with previous studies, we observed that the cruris and thigh regions are the most commonly affected. Li et al. [16] demonstrated a higher incidence of multiple and axial bone fractures in patients rescued from collapsed buildings. Notably, we observed a multiple fracture rate of 5%, with the combined tibia and fibula fractures being the most common. Considering the catastrophic nature of earthquakes affecting extensive geographic areas and the population, we found that a significant number of severely injured patients with axial bone or multiple fractures lost their lives before being rescued from under the rubble.

The decision for limb amputation following crush injuries poses a considerable challenge. Previous studies have demonstrated that amputation should be considered for patients with a MESS score > 7 [20]. However, the applicability of this scoring system to upper extremity injuries remains uncertain [21]. Nayar et al. [22] emphasized that hemodynamic instability and prolonged ischemia time are pivotal factors influencing the decision for upper extremity amputations. Therefore, we used the MESS score to guide decision-making regarding the lower extremity, whereas prolonged ischemia signs and hemodynamic instability were used for the upper extremity.

Fasciotomy is performed to reduce compartmental pressure, particularly in patients with compartment syndrome. Previous studies have demonstrated the pivotal role of fasciotomy in preserving limb function and improving overall survival during the initial phase of compartment syndrome management. Furthermore, the applicability of fasciotomy in delayed compartment syndrome remains limited; therefore, few patients with delayed compartment syndrome underwent this procedure [6,23]. In our study, fasciotomy was performed in 20 patients with clinical signs of increased compartment pressure without limb ischemia (Table 1).

Surgery is not recommended for all patients with crush injuries. Greaves et al. [24] demonstrated that patients who underwent fasciotomies for crush injuries are at elevated risk for uncontrolled bleeding, sepsis, and wound infections. Therefore, the optimal management approach in patients with crush injuries involves reduction of intracompartmental pressure through the administration of intravenous fluid and mannitol [24,25]. In our study, 13 patients with injured limbs were managed nonoperatively by nephrologists and intensivists. These injured limbs were monitored twice daily by orthopedic surgeons to determine the need for surgery.

Crush injury causes cellular damage and myonecrosis, releasing myoglobin, potassium, phosphorus, and uric acid into the bloodstream [6,7,10]. These parameters play a pivotal role in diagnosing and monitoring crush injuries. Considering the limitations of performing comprehensive blood tests in adverse conditions, our study focused solely on evaluating serum potassium and creatine kinase levels. A significant reduction was observed in these two parameters within 24 h of initiation of treatment, providing evidence for the effectiveness of the preferred treatment modalities.

Crush syndrome, although commonly associated with extensive damage to major muscle groups, can manifest regardless of the severity of the trauma. Therefore, all patients with crush injuries are at risk of developing crush syndrome [7,9,10]. Clinicians should be able to diagnose and manage this syndrome effectively. Integral components of effective management, essential for preventing fatal complications, include assessing serum potassium levels, monitoring urine output, and avoiding nephrotoxic medications [13]. Notably, 10–40% of patients with rhabdomyolysis progress to acute kidney injury [26]. Li et al. [16] reported the incidence of crush syndrome in 12 of 31 victims of building collapses; of these, acute kidney injury manifested in 5 patients, whereas 1 required hemodialysis. Similarly, in our study, of the 34 patients (56%) with crush syndrome, 15 (23.1%) needed hemodialysis. The 6 February 2023 earthquake inflicted substantial damage across all healthcare facilities within the affected zone. Consequently, victims had to be transferred to distant hospitals. Moreover, due to a significant number of individuals sustaining injuries, some victims had to travel independently to hospitals located beyond the earthquake zones, resulting in significant delays in the initiation of treatments such as fluid resuscitation and alkalization. Consequently, in our study, an elevated incidence of crush syndrome was observed, thereby increasing the demand for hemodialysis.

The incidence of wound infection is significantly elevated following crush injuries. The compromised structural integrity of the affected tissue and its diminished perfusion render the tissue susceptible to infectious agents [27,28]. In our study, wound infection manifested in 29.2% of the patients. Furthermore, an elevated incidence of infection was associated with an increased probability of reoperation. Our study demonstrated a high incidence of wound site infections and reoperations among patients who underwent fasciotomy/debridement or amputation (Table 3). Therefore, we recommend extreme caution concerning wound infection and the potential need for reoperation when treating patients with crush injuries.

Our study demonstrated an overall mortality rate of 4.6%, with significant elevation thereof observed in the amputation group. This increased mortality rate among patients requiring amputation for crush injuries can be attributed to the greater severity of their injuries.

The severity of injuries related to earthquakes can lead to prolonged hospitalization. Previous studies have demonstrated prolonged hospitalization in patients with earthquake-related injuries compared to those with injuries of other origins [29]. Notably, the mean hospitalization duration for the Wenchuan earthquake victims was 7 days [30]. In our study, the mean duration of hospitalization was 10.9 days, with a prolonged stay observed in patients who underwent surgeries compared to those treated non-surgically (Table 2). The prolonged hospital stay was attributed to affected individuals originating from distant regions and a lack of suitable accommodations.

Nonoperative follow-up, fracture fixation only, fasciotomy/debridement, and amputation are not interchangeable modalities within the treatment regimen for patients with crush injuries; therefore, a comparative analysis of the outcomes of these treatment modalities was not performed. We presented a concise overview of the initial treatment phase for this challenging clinical condition. Few studies have been conducted in this domain, resulting in a lack of consensus regarding the indications for various treatment strategies. Furthermore, a lack of comprehensive data exists to facilitate a comparative evaluation of treatment outcomes. We hypothesized that the collective findings of studies based on earthquake-related experience could provide a reference for future studies.

This study had several limitations. First, the retrospective study design introduces inherent biases and limitations in data collection and analysis. Second, the high-magnitude earthquake exerted its impact across a large geographical region involving a substantial population. Therefore, important parameters such as the duration of being trapped under the rubble, intra-compartmental pressure level, and levels of blood biomarkers such as phosphorus and uric acid could not be evaluated.

In conclusion, we treated a significant number of patients with extremity crush injuries resulting from entrapment under the rubble following the earthquake of 6 February 2023. The orthopedic interventions included amputation, fasciotomy/debridement, and fracture fixation. During the acute treatment phase, a significant increase in crush syndrome and wound infections, accompanied by a greater need for hemodialysis needs and prolonged hospitalization, were frequently observed. The treatments administered during this unfortunate experience, along with the clinical outcomes, can contribute to the development of a structured algorithmic framework for the evaluation and treatment of similar clinical conditions.

IRB: institutional review board

MESS: mangled extremity severity score

Ethics approval and consent to participate: Mersin University Ethics Committee of Clinical Research approved the study protocol (2023/238). The patients and/or their families were informed that data from the research would be submitted for publication, and gave their consent.

Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request

Competing interests: The authors declare that they have no competing interests

Funding: Not applicable

Authors' contributions: EG: Data collection, data analysis and writing the manuscript, ZMA: Data collection, data analysis and writing the manuscript, MME: Conceptualization, supervision and critical review of the manuscript. All authors provided critical review of the manuscript and approved the final draft for publication

Acknowledgements: We would like to express our endless gratitude to Abtullah Milcan, Cengiz Yılmaz, İrfan Ayan and Mehmet Çolak, who work in the department of orthopedics and traumatology, for their contributions during the earthquake period.

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No competing interests reported.

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Demographic and clinical features of extremity crush injuries resulting from entrapment under the rubble: An orthopedic perspective

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Abstract

Background:

Methods:

Results:

Conclusion:

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BACKGROUND

METHODS

Statistical Analyses

RESULTS

DISCUSSION

CONCLUSION

Abbreviations

Declarations

References

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Status:

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