volumes have been written and practiced in relation to the crush injuries involving hands , over the decades . mutilated hand and its treatment demands a thorough knowledge of rehabilitative techniques , and an in depth knowledge about the anatomy of hand , in order to achieve successful outcomes in its treatment .
we present three cases of mutilated hand due to being crushed in a sugarcane machine .
all three patients were males , with the age of 14yrs , 30yrs and 34yrs respectively .
mutilated hand injuries must be treated aggressively and efficiently which is essential to achieve good functional results .
reid defined mutilated hand as the one that  has suffered a severe injury involving loss of substance and has been left lacking in prehension  . these complex injuries with composite soft tissue loss and functional compromise require re - establishment ofbony and soft tissue continuity , not only because of the significant loss of soft tissue cover which causes exposure of the deeper structures of hand , but also due to the fact that without such interventions a mutilated hand would remain functionless .
the sugarcane machines commonly used in our country have two rollers with irregular surfaces , opposed to each other that are turned either by a handle or an electric motor [ fig .
the sugarcane is kept in - between the two rollers and is churned amongst the rollers .
these mutilating hand injuries due to sugarcane machines often occur , when the person is cleaning the machine and this machine is suddenly turned on unknowingly , thus churning the hand in - between its mechanical rollers .
the same injury can also occur , if the cloth being used for cleaning the machine gets entrapped amongst the rollers when machine is turned on , therefore , subsequently dragging the hand along with it .
the hand gets caught by a force and pulled at a low velocity in - between the rollers of the machine .
the irregular surfaces of the roller help the machine onto a firm grip on the hand , in turn pulling the finger tips between the rollers followed by the hand , thus , creating multiple burst lacerations over the fingers .
the high energy force leads to fractures , opening of joint capsule , and severe soft tissue injuries .
we report three cases with crush injury of hand while using sugarcane machine , which presented to us within a period of six months , i.e. march 2015 to august 2015 .
case 1 : 14-year - old child , who presented to us within two hours of injury involving his left hand , which he sustained while cleaning the sugarcane machine .
2 : a ) pre - operative image of the injured hand b ) post - operative image of the injured hand after skin grafting ] a ) pre - operative image of injured hand b ) post - operative image of injured hand after skin grafting . case 2 : 30-year - old man , who presented to us within 1 hour of injury involving his left hand , which he sustained while grinding the sugarcane pulp in the machine .
3 : a ) pre - operative image of the injured hand b ) pre - op x - rays of injured hand c)post - operative image of the injured hand d ) image after skin grafting d ) image at 6 weeks follow - up f ) image at 6 months follow - up ] a ) pre - operative image of injured hand ; b ) pre - operative x - rays of injured hand ; c ) post - operative image of injured hand d ) post - operative image of injured hand after skin grafting e ) follow - up image after 6 weeks of injury .
f ) follow - up image after 6 months ofinjury showing function of the hand after rehabilitation .
a ) pre - operative image of injured hand b ) post - operative image of injured hand1 .
palmar aspect of hand c ) follow - up image at 4 weeks of injury .
case 3 : 34-year - old man , who presented within 3 hours of injury to the right hand , sustained while grinding the sugarcane pulp . [ fig .
2 : a ) pre - operative image of injured hand b ) post - operative image of the injured hand c ) image at 4 weeks follow - up ] the two of the three patients sustained injuries to the non - dominant hand .
the thumb being shorter than all the fingers is rarely involved in the cascade of the injury .
all injured fingers had macerations along the margins of the skin , possibly due to the roller blades being wet at the time of injury .
there were longitudinal lacerations over the fingers , both on the dorsal and volar sides , with the nail complex involved sparingly .
the proximal interphalangeal joints were exposed with the avulsion of the central slips and loss of continuity of the covering capsules , whereas , the flexor tendons were in continuity with loss of the flexor tendon sheath in the region of the volar skin laceration .
these injuries were managed with debridement under anesthesia . on receiving the patients , wounds were washed and covered with sterile dressings , with broad spectrum antibiotics being started . within the operation room ,
the principles ofwound care were followed with an attempt at restoring the bony stability and soft tissue coverage to allow early mobilization of the fingers . wound debridement and lavage with 6 liters of normal saline
the vertical midline slits in the extensor expansion were stitched using interrupted 4 - 0 nylon sutures .
the skin was approximated over tendons to provide them with a biological coverage using sutures i.e. nylon 3 - 0 .
the fractures , sustained by case ii were fixed using k - wires , whereas , mini fixators were used in case iii .
two of these patients required split thickness skin grafting over the dorsum of hand , which was undertaken after the three days of sustaining the injury .
the hand was immobilized in using a dorsal plaster slab for pain relief , and the patients were allowed to flex their fingers within the slab .
the patients were administered analgesics to reduce the pain and promote active flexion of fingers .
the slab was removed in the second week and the k - wires in case 2 were removed after confirming union at three weeks .
the patient is assessed for the post - traumatic stiffness , which is clinically apparent in inter - phalyngeal , meta - phalyngeal and wrist joints .
the patient undergoes rehabilitation under the supervision of a physiotherapist , where he practices passive , active - assisted and active stretching of the involved joint .
the score was 0 in two patients and 1 patient ( case 3 ) was lost to follow - up .
the mutilating injuries of hand have a seasonal incidence ; being more common during the spring and summer months , during which the harvest of sugarcane is reaped throughout india .
nail complex is usually injured and the fingers ( usually the index to little finger ) have multiple lacerations of the dorsal and palmar aspect .
the expansion is longitudinally split along its entire length , up to the meta - carpophalangeal joint .
the central slip is usually avulsed from the base of middle phalynx , exposing the pipj to the exterior leaving its capsule torn .
the flexor tendons are found in continuity with extensive damage to the flexor tendon sheath in the region of the volar laceration .
the digital nerves and vessels usually escape injury , likely due to the longitudinal nature of lacerations .
the rollers of the sugarcane machine have gaps between them , thus leaving some space unlike the press injuries where the entire finger is crushed , including the bones . in the patients managed by us , the bony injuries were less severe compared to the soft tissue injuries which may be due to the explanation offered above .
early debridement and removal of sugarcane fibers along with intravenous antibiotics should be undertaken and if the tissue are mutilated beyond salvage , amputation with reconstruction of the hand should be undertaken .
these injuries are likely to develop significant stiffness and loss of function due to the following reasons a ) injury to both the flexor tendon sheath and extensor tendons leading to stiffness on both sides of the fingers
b ) extensive lacerations with thin skin bridge and loss of skin over some areas c ) high risk of infection due contamination by vegetable material d ) chance of developing boutennier s deformity due to injury to the central slip e ) fractures , even when less severe , may cause delay in mobilization . the sugar cane machine injury , even though timely intervened , seemingly leaves a partially deformed hand , but the function of the hand returns to near normal after physiotherapy and intervention , primarily by an orthopaedic surgeon .
 introduction : volumes have been written and practiced in relation to the crush injuries involving hands , over the decades . mutilated hand and its treatment demands a thorough knowledge of rehabilitative techniques , and an in depth knowledge about the anatomy of hand , in order to achieve successful outcomes in its treatment.case presentation : we present three cases of mutilated hand due to being crushed in a sugarcane machine . 
 all three patients were males , with the age of 14yrs , 30yrs and 34yrs respectively.conclusion:mutilated hand injuries must be treated aggressively and efficiently which is essential to achieve good functional results . 
 any delay in effective management may lead to stiffness and very poor functional results . 
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Case Presentation:
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Introduction
Case Presentation
Discussion
Conclusion