| 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
- 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
- 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
- indications
- polytrauma patients
- patient not alert/unreliable
- inconclusive physical exam findings
- relative contraindication
- unequivocally positive clinical findings should prompt emergent operative interventionwithout 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
|
