The guidelines provided by the New York State Workers Compensation Board offer fundamental principles for addressing Crush Injuries and Compartment Syndrome. These directives are designed to assist healthcare professionals in determining appropriate interventions for these conditions within the context of a comprehensive assessment.
Healthcare experts specializing in managing Crush Injuries and Compartment Syndrome can depend on the guidance outlined by the Workers Compensation Board to make well-informed decisions about the most suitable therapeutic approaches for their patients.
It is crucial to emphasize that these guidelines are not meant to replace clinical judgment or professional expertise. The final decision regarding interventions for Crush Injuries and Compartment Syndrome should involve collaboration between the patient and their healthcare provider.
Crush Injuries and Compartment Syndrome
Crush injuries, including compartment syndrome, typically constitute surgical emergencies. Less severe cases, like contusions, may be managed similarly to general hand, wrist, and forearm pain, with a specific focus on RICE (rest, ice, compression, elevation).
Physical Exam
The physical examination spans from mild abnormalities in the case of minor injuries (e.g., contusions) to severe presentations involving fractures, restricted range(s) of motion, and neurovascular compromise.
Medical History
Compartment syndrome necessitates urgent evaluation and is characterized by a cool extremity in instances of vascular compromise. Crush injuries exhibit clear mechanisms of injury in the patient’s history. However, various factors can cause compartment syndrome, including trauma, excessive traction from fractures, tight casts, bleeding disorders, burns, snakebites, intra-arterial injections, infusions, and injuries from high-pressure injections.
Initial Assessment
Patients with more severe injuries experience intense pain and may show signs of vascular compromise. Recognizing compartment syndrome as an emergency, the initial assessment aims to determine the severity of the injury and whether urgent surgical evaluation and treatment are necessary. While milder injuries may be managed non-operatively, a low threshold for surgical consultation is maintained. Patients with less severe injuries should be closely monitored for potential neurovascular compromise.
Diagnostic Studies
X-Rays
Recommended for evaluating patients with crush injuries or compartment syndrome. The rationale behind this recommendation lies in the essential role of X-rays in assessing the extent of injuries and identifying fractures.
MRI/CT
Recommended for select patients with crush injuries or compartment syndrome. The initial evaluation typically does not require MRI or CT, but in certain cases, these imaging modalities may be necessary to assess symptoms and determine the extent of the injury.
Medications
For most patients, ibuprofen, naproxen, or other older generation NSAIDs are recommended as first-line medications. Acetaminophen (or its analog paracetamol) may be a reasonable alternative to NSAIDs for patients who are not suitable candidates for NSAIDs, although the prevailing evidence suggests that acetaminophen is modestly less effective. There is evidence indicating that NSAIDs are as effective in pain relief as opioids (including tramadol) and are less impairing.
NSAIDs for Treatment of Acute, Subacute, or Chronic Crush Injuries and Compartment Syndrome
Recommended for the treatment of acute, subacute, or chronic crush injuries and compartment syndrome. Indications include the recommendation for NSAIDs for the treatment of acute, subacute, or chronic crush injuries and compartment syndrome.
Over-the-counter (OTC) agents may be sufficient and should be tried first. The frequency/duration of use may be reasonable for many patients, and indications for discontinuation include the resolution of symptoms, lack of efficacy, or the development of adverse effects.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding
Recommended for concomitant use of cytoprotective classes of drugs (misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors) for patients at high risk of gastrointestinal bleeding. Indications encompass patients with a high-risk factor profile who also require NSAIDs, with consideration for cytoprotective medications, especially if longer-term treatment is contemplated.
At-risk patients include those with a history of prior gastrointestinal bleeding, the elderly, diabetics, and cigarette smokers. The frequency/dose/duration includes the recommendation of proton pump inhibitors, misoprostol, sucralfate, and H2 blockers, with no substantial differences in efficacy for preventing gastrointestinal bleeding. Indications for discontinuation involve intolerance, development of adverse effects, or discontinuation of NSAID.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should discuss the risks and benefits of NSAID therapy for pain. Acetaminophen or aspirin is recommended as the first-line therapy, appearing to be the safest regarding cardiovascular adverse effects.
If needed, non-selective NSAIDs are preferred over COX-2 specific drugs. For patients receiving low-dose aspirin for primary or secondary cardiovascular disease prevention, minimizing the potential for the NSAID to counteract the beneficial effects of aspirin is recommended, with the NSAID taken at least 30 minutes after or 8 hours before the daily aspirin.
Acetaminophen for Treatment of Crush Injuries and Compartment Syndrome Pain
Recommended for the treatment of pain associated with crush injuries and compartment syndrome, particularly in patients with contraindications for NSAIDs. Indications encompass all patients with pain from crush injuries and compartment syndrome, including acute, subacute, chronic, and post-operative cases.
The dose/frequency follows the manufacturer’s recommendations and may be utilized on an as-needed basis. There is evidence of hepatic toxicity when exceeding four grams per day, and indications for discontinuation include the resolution of pain, adverse effects, or intolerance.
Opioids for Pain from Acute, Subacute, Chronic, or Post-Operative Crush Injuries
Recommended for limited use of opioids (not to exceed seven days) for the treatment of select patients with severe pain related to acute, subacute, or chronic crush injuries. Limited use of opioids for a few days (not to exceed seven days) is also recommended for select patients who have undergone recent surgical intervention.
The frequency/dose/duration should align with the manufacturer’s recommendations, taken scheduled or as needed, generally for short courses of a few days, with subsequent weaning to nocturnal use if needed, then discontinuation.
The total length of treatment usually ranges from a few days to one week. Opioids should be utilized to supplement pain relief in addition to an NSAID or acetaminophen to reduce the total need for opioids and consequent adverse effects. Indications for discontinuation include sufficient pain management with other methods such as NSAIDs, resolution of pain, intolerance, adverse effects, lack of benefits, or failure to progress over a couple of weeks.
Rehabilitation
Rehabilitation (supervised formal therapy) necessitated by a work-related injury should concentrate on restoring the functional ability required for the patient’s daily and work activities, aiming to return the injured worker to their pre-injury status as much as feasible.
Active therapy demands internal effort from the patient to complete specific exercises or tasks. In contrast, passive therapy involves interventions that do not require the patient’s exertion but depend on modalities delivered by a therapist. Generally, passive interventions are seen as a way to facilitate progress in an active therapy program, simultaneously achieving objective functional gains. Emphasis should be placed on active interventions over passive ones.
Patients should be instructed to continue both active and passive therapies at home to extend the treatment process and maintain improvement levels. Assistive devices may be included as an adjunctive measure in the rehabilitation plan to facilitate functional gains.
Therapy: Active
Therapeutic Exercise
Recommended for the treatment of acute, subacute, chronic, or post-operative crush injuries. The rationale for this recommendation is that exercise is generally not indicated acutely; however, it may be necessary in the recovery or post-operative phases. Functional goals should encompass increased grip strength, key pinch strength, range of motion, and advancing work abilities.
The frequency/dose/duration may involve as few as two to three visits for patients with mild functional deficits, or up to 12 to 15 visits for those with more severe deficits, along with documentation of ongoing objective functional improvement. If ongoing functional deficits persist, more than 12 to 15 visits may be indicated, given documentation of improvement towards specific objective functional goals. As part of the rehabilitation plan, a home exercise program should be developed and performed in conjunction with therapy.
Therapy: Passive
Elevation and Relative Rest
Recommended for the treatment of acute crush injuries without compartment syndrome.
Self-Application of Ice
Recommended for the treatment of acute crush injuries without compartment syndrome.
Immobilization
Splinting
Recommended after initial treatment for moderate or severe acute and subacute crush injuries when compartment syndrome has been ruled out. The type of splint required depends on the injury type and subsequent debility. Splints are particularly recommended for patients with moderate to severe injuries when compartment syndrome has been ruled out.
Surgery
Recommended for the treatment of acute or subacute crush injuries or compartment syndrome, depending on the nature of the injury. This often includes emergency fasciotomy for releasing tension from compartment syndromes and other surgical procedures to address fractures and other correctable defects.
The rationale for this recommendation is that fasciotomies are especially essential for treating significant neurovascular compromise from compartment syndrome and represent a surgical emergency. Other procedures may be necessary based on correctable defects such as fractures, ligament tears, or other injuries.
