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Hand & Forearm Compartment Syndrome

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Topic updated on 11/12/15 5:29pm
Introduction
  • Increased osseofascial compartment pressure leads to  decreased perfusion
  • May lead to irreversible muscle and nerve damage
  • May occur anywhere that skeletal muscle is surrounded by fascia, but most commonly
    • leg
    • forearm (details below)
    • hand (details below)
    • foot
    • thigh
    • buttock
    • shoulder
    • paraspinous muscles
  • Pathophysiology
    • local trauma and soft tissue destruction> bleeding and edema > increased interstitial pressure > vascular occlusion > myoneural ischemia
  • Causes
    • trauma
      • fractures (most common)
        • distal radius fractures in adults
        • supracondylar humerus fracture in children
      • crush injuries
      • contusions
      • gunshot wounds
    • tight casts, dressings, or external wrappings
    • extravasation of IV infusion
    • burns
    • postischemic swelling
    • bleeding disorders
    • arterial injury
  • Outcomes
    • may lead to
      • loss of function
      • Volkmann ischemic contracture
      • neurologic deficit
      • infection
      • amputation
Anatomy
  • Forearm compartments
    • 3 in total
      • volar
        • most commonly affected
      • dorsal
      • mobile wad (lateral)
        • rarely involved
        • muscles
          • brachioradialis
          • extensor carpi radialis longus
          • extensor carpi radialis brevis
  • Hand compartments
    • 10 in total
      • hypothenar
      • thenar
      • adductor pollicis
      • dorsal interosseous (x4)
      • volar (palmar) interosseous (x3)
Presentation
  • Symptoms
    • pain out of proportion to clinical situation is usually first symptom
      • may be absent in cases of nerve damage
      • difficult to assess in
        • polytrauma 
        • sedated patients
        • children
  • Physical exam
    • pain w/ passive stretch of fingers
      • most sensitive finding
    • paraesthesia and hypoesthesia
      • indicative of nerve ischemia in affected compartment
    • paralysis
      • late finding
      • full recovery is rare in this case
    • palpable swelling
      • tense hand in intrinsic minus position
        • most consistent clinical finding
    • peripheral pulses absent
      • late finding
      • amputation usually inevitable in this case
Evaluation
  • Radiographs
    • obtain to rule-out fracture
  • Compartment pressure measurements post
    • indications
      • polytrauma patients
      • patient not alert/unreliable
      • inconclusive physical exam findings
    • relative contraindication
      • unequivocally positive clinical findings should prompt emergent operative intervention without need for compartment measurements
    • threshold for decompression
      • controversial, but generally considered to be
        • absolute value of 30-45 mm Hg
        • within 30 mm Hg of diastolic blood pressure (delta p)
          • intraoperatively, diastolic blood pressure may be decreased from anesthesia
            • if delta p is less than 30 mmHg intraoperatively, check preoperative diastolic pressure and follow postoperatively as intraoperative pressures may be low and misleading 
Treatment
  • Nonoperative
    • indications
      • exam not consistent with compartment syndrome
      • delta p > 30
  • Operative
    • emergent forearm fasciotomies 
      • indications
        • clinical presentation consistent with compartment syndrome
        • compartment measurements with absolute value of 30-45 mm Hg
        • compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
          • intraoperatively, diastolic blood pressure may be decreased from anesthesia
            • must compare intra-operative measurement to pre-operative diastolic pressure
    • emergent hand fasciotomies
      • indications
        • clinical presentation consistent with compartment syndrome
        • compartment measurements with absolute value of 30-45 mm Hg
        • compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
          • intraoperatively, diastolic blood pressure may be decreased from anesthesia
            • must compare intra-operative measurement to pre-operative diastolic pressure
Surgical Techniques
  • Forearm
    • emergent fasciotomies of all involved compartments
      • approach
        • volar incision     
          • decompresses volar compartment, dorsal compartment, carpal tunnel
            • incision starts just radial to FCU at wrist and extends proximally to medial epicondyle
            • may extend distally to release carpal tunnel
        • dorsal incision
          • decompresses mobile wad
            • dorsal longitudinal incision 2cm distal to lateral epicondyle toward midline of wrist
      • technique
        • volar incision
          • open lacertus fibrosus and fascia over FCU
          • retract FCU ulnarly, retract FDS radially
          • open fascia over deep muscles of forearm
        • dorsal incision
          • dissect interval between EDC and ECRB
          • decompress mobile wad and dorsal compartment
      • post-operative
        • leave wounds open 
          • wound VAC
          • sterile wet-to-dry dressings
        • repeat irrigation and debridement 48-72 hours later
          • debride all dead muscle
          • possible delayed primary wound closure
          • VAC dressing when closure cannot be obtained
            • follow with split-thickness skin grafting at a later time 
  • Hand
    • emergent fasciotomies of all involved compartments
      • approach  
        • two longitudinal incisions over 2nd and 4th metacarpals  
          • decompresses volar/dorsal interossei and adductor compartment
        • longitudinal incision radial side of 1st metacarpal 
          • decompresses thenar compartment
        • longitudinal incision over ulnar side of 5th metacarpal
          • decompresses hypothenar compartment
      • technique
        • first volar interosseous and adductor pollicis muscles are decompressed through blunt dissection along ulnar side of 2nd metacarpal
      • post-operative
        • wounds left open until primary closure is possible
          • if primary closure not possible, split-thickness skin grafting is used
Complications
  • Volkman's ischemic contracture
    • irreversible muscle contractures in the forearm, wrist and hand that result from muscle necrosis
    • contracture positioning
      • elbow flexion
      • forearm pronation
      • wrist flexion
      • thumb adduction
      • MCP joints in extension
      • IP joints in flexion
    • classification
      • Tsuge Classification (see table below)
Stages & Treatment of Volkman's Ischemic Contracture of Hand
Stage
Affected muscle
Treatment
Mild Finger flexors
Dynamic splinting, tendon lengthening
Moderate Wrist and finger flexors
Excision of necrotic tissue, median and ulnar neurolysis, BR to FPL and ECRL to FDP tendon transfers, distal slide of viable flexors
Severe Wrist/finger flexors and extensors Same as above (moderate) with possible free muscle transfer

 

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