A Tragic Hand Injury

Are you still in shock? 

… Because I am. Do you feel like Mark and Lexie's deaths hit you like a freight train carrying thousands of steel bricks? Because I do. And even though I work on the show and am privileged to know the events that will be happening for the next several months, I still feel shaken by what transpired in Episodes 824 and 901. Shaken and really, really sad. I'm really sad not only for the beloved characters that we have lost, but I'm also distressed about the injuries of those who survived the crash.

What if Derek Shepherd, world-renowned neurosurgeon, can't ever operate again?

Derek suffered a devastating crush injury to his left hand.

When Derek regained consciousness after the crash, his left hand was not only entrapped in a piece of the wreckage, but it was severely injured. At this point, he already had multiple hand fractures, damage to his median nerve, and a laceration to his forearm. Then, when he freed himself, he made this all worse and also fractured his thumb. Until help arrived, our doctors could do little for Derek, except close the forearm laceration with a safety pin in order to decrease the amount of blood loss and exposure that might lead to infection.

A crush injury occurs as a result of several different forces happening simultaneously such as shearing, contusion, stretching, and pressure. Examples of crush injuries to the hand and forearm include:

• Getting the hand/forearm caught between two heavy objects that are compressed together.

•Getting the fingers, hand, or forearm caught in machinery.

•A motor vehicle accident in which the car flips and crushes an extremity.

Crush injuries to the hand can be very difficult to treat due to the broader area of injury.

These injuries do not just affect the bone and joints – They can also involve the skin and subcutaneous tissue, muscles, tendons, nerves, and blood vessels. Unfortunately, the risk of long-term disability after a crush injury can be high, so it is extremely important to perform a thorough initial assessment of the injury in order to develop an appropriate treatment plan to ensure the most optimal recovery.

The physical examination should concern the following factors:

• Check the appearance of the skin (for blisters, open wounds, elevated areas, foreign material, other noticeable abnormalities).

• Test the circulation to the hand (palpable pulses in arteries, capillary refill in the fingers).

• Perform a neurologic exam (detect tingling, numbness, ability to move fingers).

• Order radiographic studies to confirm the presence of fractures.

• Examine for deformity to determine possible bone or joint injury.

After examination and diagnosis, doctors then begin their treatment plan. They first need to debride (clean out) any dead or severely contaminated tissue in order to prevent infection or heavy scarring. Next, surgeons must make sure the extremity has adequate blood supply. However, one should be cautious of closing the wound too tightly and increasing the pressure in the tissues because it could lead to compartment syndrome. Compartment syndrome forms when increased pressure builds within tissue; if left untreated, the syndrome can lead to tissue death and loss.

After compartment syndrome has been ruled out, surgeons then reduce any fractures and perform the necessary fixation. After repairing the bony injuries, doctors will then assess whether any of the tendons have been damaged. In order to restore the patient's range of motion, surgeons may need to do tendon grafts or transfers. And then, they arrive at the nerve injuries, usually reserving their repair for a later date because often these deficits cannot be adequately assessed in the beginning of treatment.

Derek dropped the instrument due to the injury on his median nerve.

Located in the upper limb, the median nerve runs down the arm and connects with the thumb and all fingers in the hand (except for the pinkie finger). It originates with the cervical spine, specifically C5 and C6, and is then routed to the arm and forearm. Not only does the median nerve control sensation in the hand, but it also provides sensation and function to the palm side of the thumb, index and middle finger, and half of the ring finger. The nerve is also responsible for sensation to the nail bed of the thumb and those three fingers.

An injury to the median nerve can cause a variety of deficits. Depending on the specific location of the lesion or compression, patients could struggle with flexing the wrist, turning the hand over, and suffer the inability to move the thumb across the palm. The injury could also cause tingling or numbness in the forearm and wasting of the muscles at the thumb base. And lastly, particular to Derek's case, an injury to the median nerve could severely affect one's grip. Even after surgical repair, Derek still struggles with prehension (the ability to grasp or seize) – a vital skill for holding instruments, retracting tissue, and performing meticulous brain or spinal surgery.

For more information on median nerve injury, please visit the following link:

http://www.nlm.nih.gov/medlineplus/ency/article/000691.htm