A crushing experience: The spectrum and outcome of soft tissue injury and myonephropathic syndrome at an Urban South African University Hospital

Abstract

Introduction: Crush syndrome may follow soft-tissue injury with rhabdomyolysis and renal failure. The study assessed: the level of creatinine kinase (CK) associated with significant renal dysfunction; the correlation between body surface area (BSA) involved and CK level; correlation between BSA injury and renal dysfunction to identify at risk patients. Methods: Retrospective review of patients Tygerberg Hospital Trauma Service between January 2003 and December 2005 with a screening CK level >500 U/L. Data were captured on a proforma. BSA was scored charting body surface bruising using a rule-of-nines. The study was approved by the Departmental Research Committee. Results: Three hundred and thirty-four records were reviewed. The majority (89%) were men, mean age 30 years and average Revised Trauma Score 7.5 (SD = 0.35). Blunt trauma constituted 75%, combined 15% and penetrating injury 10%, with blunt force assault 64% of the total. CK of >8500 U/L predicted renal failure (p 18% predicting renal impairment. CK >5000 U/L had a worse outcome compared with the CK = 500–5000 U/L, with higher peak urea (17.2 vs. 12 mmol/L) and peak creatinine (2836 vs. 140 mmol/L) and rate of renal failure (20% vs. 8%). The penetrating group included vascular injuries with increased CK due to ischaemia–reperfusion injury but low BSA, due to mainly gunshot wounds (70%). Three patients (10%) developed renal failure and had abnormal CK levels (range 538–32,540 U/L). Conclusion: Screening CK accurately stratify patients at risk for myonephropathic syndrome. Early aggressive fluid loading can prevent renal failure. Adjunctive measures have not improved outcome or decreased the need for dialysis. Patients sustaining vascular and severe extremity injury from penetrating wounds may develop rhabdomyolysis and should be routinely screened with CK levels, urea and creatinine.

Keywords

• Soft tissue
• Myoglobinuria
• Crush injury
• Myonephropathic syndrome
• Body-surface