Crush and Pinch Injuries

Why this matters

Field-service work is full of things that close on hands: garage door sections, fan blades, compressor mounts being lowered, a water heater rocked onto a dolly, a condenser sliding off a pad. Most pinches are bruised fingers and a bad afternoon. A smaller number are crush injuries, where tissue has been squeezed hard enough or long enough that the damage keeps developing after the load comes off. The trouble is that the two can look alike in the first minutes, and the worse one often looks better.

This card covers freeing the person, the first actions, and how to tell which kind you have. Bleeding control is owned by its own card; see related: Severe Bleeding and the Tourniquet. This is not training, and a hands-on first aid course is what makes a responder. The guidance here follows the American Red Cross and the American Heart Association first aid guidelines.

First: stop whatever is still pushing

Before anyone touches the injured person, take the energy out of the thing that caught them. A crush injury gets worse in seconds if a second cycle runs.

• Motorized equipment: kill it at the disconnect or unplug it, then make sure it cannot restart. For a garage door opener, pull the plug; the wall button and a remote can both cycle it. For a blower, a fan or a compressor, open the disconnect and keep a hand on it or lock it until the person is free.
• Spring-loaded equipment: a garage door is held by springs carrying a large amount of stored energy. Never wind, unwind or cut a spring to free a hand. The springs are not what is pinching; the section is. Lift the section with enough people, and clamp locking pliers on the track just below the bottom roller so the door cannot drop again.
• A load: an appliance, a pallet, a condenser. Lift it with enough people or a lever and slide blocking (cribbing: short lengths of lumber stacked under the load) in as you go, so that if a grip slips it drops onto wood instead of back onto the person. Never put a hand or foot under a load to hold it.

Then call 911 if the injury is anything beyond a finger that was caught and released in a second or two. Have someone else call while you work.

The gate: what was crushed, and for how long

Two questions sort crush injuries far better than how the injury looks:

1. What was crushed? A fingertip, a whole hand, a forearm, a leg, the chest or pelvis.
2. How long was it under the load? Seconds, minutes, or longer.

Removing the load. Current first aid guidance favors freeing a trapped person as soon as it can be done without risk of dropping the load back onto them. The exception is a person pinned for a long time, where releasing the pressure can let damaged-muscle byproducts flood the bloodstream suddenly, a condition called crush syndrome. That is a decision for the dispatcher and the paramedics, not a bystander, so tell the dispatcher how long the person has been pinned and follow their direction. If the load is still pressing on the chest or blocking breathing, it comes off now; nothing waits on a breathing problem.

Why a crushed limb can look better than it is

A cut bleeds and you can see it. A crush injury can leave the skin intact, the color nearly normal and the person saying it is not too bad, while the real injury is underneath.

Compartment syndrome. Muscles in the forearm, hand, lower leg and foot sit in tight compartments wrapped in tough tissue that does not stretch. A crush makes the muscle swell, and the swelling has nowhere to go, so pressure inside the compartment rises and starts cutting off the blood supply to the muscle and nerves. It builds over hours, not seconds. The early warning is pain that is out of proportion to what the injury looks like, and pain that gets worse when the fingers or toes are gently stretched. Later signs (numbness, tingling, a tight, shiny limb, weakness) mean it has progressed. It is a surgical emergency.

Hidden fractures and internal injury. Small bones in the hand and foot break under a crush without obvious deformity. A crush of the chest, abdomen or pelvis can cause internal bleeding with nothing visible at all.

That is why a crushed limb gets evaluated even when it looks fine at the scene, and why the person should not be the one deciding they are okay to finish the job.

What you do while waiting

• Control bleeding with firm, direct pressure on any open wound. A limb that is bleeding heavily and not controlled by pressure is a tourniquet case.
• Do not squeeze or massage the injured area. Support it in the position of comfort.
• Remove rings, watches and gloves from an injured hand early, before swelling locks them on.
• Cool, do not freeze. A cold pack wrapped in cloth on a pinched finger helps pain and swelling. Do not ice a limb that was under a heavy load for a long time; leave that to responders.
• Keep them warm and still and watch for shock: pale or gray skin, cold sweat, fast breathing, confusion. Lay them down if they are faint.
• Nothing by mouth for anyone you have called 911 for.

One gate, two outcomes: two doors, one week

A garage door shop sends two techs to replace a cracked bottom section on a 16-foot double door. Both cases below happened to the same shop in the same week.

Case one: the fingers. At 2:10 pm, the newer tech, Luis, is guiding the new section into place by hand when the lead lowers the door on the opener to check alignment. Luis's left middle and ring fingers are between the new section and the one above it as the hinge line closes. The lead releases the button within about a second and the door stops; he pulls the opener plug before anyone moves, and they lift the section by hand to free the fingers.

Gate: fingers, under load for about a second. On-site first aid. The skin over the middle fingernail is split and bleeding; the ring finger is red with no cut. Gloves on, firm pressure with gauze for 10 minutes stops the bleeding. Luis's rings come off right away. A cold pack wrapped in a shop towel goes on.

Then the decision about care, and this is where the gate's second half matters. The blood under the middle fingernail is spreading, the finger is swelling, and Luis says the pain is "a lot worse than it looks." Pain out of proportion to the visible injury, after a crush, is the cue to get it seen. The lead drives him to an urgent care clinic within the hour rather than letting him finish the install. The clinic finds a fracture of the fingertip bone under the nail. A tech who had wrapped it and kept working would have been back the next morning with a finger twice the size.

Case two: the section. Three days later, on another section replacement, the lead is taking the old cracked section to the truck on a dolly, it tips on the driveway lip and falls flat across the lead's right shin as he goes down with it. The section is heavy, awkward and pinning his leg to the concrete. His helper on that job, Sam, is the only other person there.

Gate: a whole lower leg, under load. Call 911 now. Sam calls on speaker and tells the dispatcher a garage door section is on the lead's lower leg, that he can lift one end, and that the leg has been under it for about a minute. The dispatcher tells him to lift it off if he can do it without dropping it back. Sam, using a pry bar from the truck, raises one end and the homeowner slides two lengths of 2x4 under it, then they walk it off the leg. Elapsed time pinned: about three minutes.

The shin has a scrape and looks only mildly bruised. The lead says he wants to stand up and see if he can walk. That is the trap. The lower leg is exactly where compartment syndrome happens, and the mechanism (a heavy section, edge-on, onto a shin against concrete) is the kind that causes it. Sam keeps him sitting, leg supported, no ice, and waits for the ambulance. At the emergency department the lead is held for observation because of rising pain in the calf over the next several hours.

What the two cases teach together. Both injuries looked minor at the scene. The finger case went to urgent care because the pain was out of proportion; the shin case went by ambulance because of what was crushed, not how it looked. The gate decided both, and the look of the injury decided neither.

What changes the answer

A torsion spring or cable, not a section, caused the injury. A failed spring or a cable that snaps under tension can strike with great force. Treat any strike to the head, chest or abdomen as a 911 call even if the person is talking, and do not let anyone near the remaining spring until a qualified door tech has secured it.

The person is pinned in a confined place. A tech pinned under equipment in a crawlspace or an attic cannot be freed by one rescuer, and the air in that space is part of the hazard. See related: Rescuing Without Becoming the Second Victim, and Fainting and Collapse in Attics and Crawlspaces.

The fingertip came off. That is an amputation, with its own handling for the part. See related: Amputations and Saving the Part.

After the event

A crush injury that sends someone to a hospital is reportable to OSHA within 24 hours if the employee is admitted as an inpatient, under 29 CFR 1904.39 (federal rule; state plans run their own process). A fracture treated at urgent care is likely recordable on the OSHA 300 log, if your shop is required to keep one. Write it up the same day; see related: Accident and Incident Reporting SOP. Then fix the cause: on this job, a rule that nobody runs an opener while a hand is on a section, and two people on a dolly carrying a door section.

References

• American Red Cross and American Heart Association Guidelines for First Aid, crush injuries and compartment syndrome
• 29 CFR 1904.39 and 29 CFR 1904.7, OSHA reporting and recordkeeping
• See related: Severe Bleeding and the Tourniquet
• See related: The First Five Minutes After Someone Is Hurt
• See related: Calling 911 From a Job Site So They Find You