Anatomic bases of the forearm compartment syndrome

Chronic exertional compartment syndrome of the forearm

Chronic exertional compartment syndrome (CECS) is an overuse injury characterized by increased intracompartmental pressure during exercise. CECS has been described in the foot, thigh, and trunk, but 95% of cases occur in the lower leg. Interestingly, CECS may also affect the upper extremities and has been best described in the forearms. Unfortunately, due to the rarity of this condition, there is no consensus regarding its diagnosis and treatment. This review seeks to discuss the prevalence, etiology, diagnosis, and treatment of CECS of the forearms, which has been described in the literature.

A cadaver study into the number of fasciotomies required to decompress the anterior compartment in forearm compartment syndrome

PURPOSE

There is no typical approach for decompression of forearm compartment syndrome, due to contradictory considerations regarding the characteristics of forearm anterior compartment deep fascia. The main purpose of this study was to determine how many fasciae should be opened to fully decompress the forearm anterior compartment. Further, the compliance of the deep anterior compartment was also investigated, to strengthen our results.

METHODS

An experimental study of a laboratory model of acute forearm compartment syndrome was performed. A deep forearm injection of egg white was undertaken to create an acute forearm compartment syndrome in sixteen non-embalmed human forearms from six male and two female donors. The pressure in the superficial and deep anterior compartments was recorded four times, both before and after each fasciotomy and the compliance of the deep anterior compartment was calculated for each step.

RESULTS

The first incision of the superficial lamina of the deep fascia was not sufficient to decrease the elevated compartment pressure in the superficial and deep anterior compartments. Whereas the pressures decreased to near-baseline levels, following the fasciotomy of the intermuscular septum observed posterior to the flexor carpi radialis. The last incision of the deep lamina of the deep anterior fascia had no noticeable impact. These observations supported the hypothesis of high compliance of the deep anterior compartment.

CONCLUSION

Two successive incisions were necessary to decompress the anterior compartment: the incision of the superficial lamina of the deep fascia and the incision of the intermuscular septum.

[Management of severe soft-tissue trauma in the upper extremity - shoulder, upper and lower arm]

OBJECTIVE

Salvage of the respective extremity. Standardized approach to adequate soft-tissue coverage (isolated severe soft-tissue trauma) and preconditioning for fracture healing (in complex trauma) as a basis for functional restoration. Limitation of secondary soft-tissue loss. Prevention of infection.

INDICATIONS

Isolated extended severe soft-tissue trauma (crush trauma, degloving injury) in the region of the shoulder and the upper extremity. Complex trauma with soft-tissue involvement Gustilo IIIB/C or Tscherne GIII/IV. Segmental soft-tissue/bone loss. Subtotal or partial amputations.

CONTRAINDICATIONS

Unstable polytraumatized patient with vital hazards and the priority for lifesaving measures. Irretrievable devascularization or unreconstructable neural destruction, extended severe loss of multiple muscular units.

SURGICAL TECHNIQUE

Systematic, eventually serial debridement, temporary joint transfixation, reconstruction of macrocirculation, dermatofasciotomy in compartment syndrome, preferably primary shortening in segmental soft-tissue/bone loss, temporary soft-tissue coverage, systematic conditioning of soft tissues, postprimary or secondary soft-tissue reconstruction, secondary change to preferably internal fixation techniques.

POSTOPERATIVE MANAGEMENT

Individualized earliest possible passive or assisted mobilization of nontransfixed joints, early removal of transfixation and change to internal fixation modes, eventually secondary reconstructive measures (e.g., augmentation of bone defects, flap correction, secondary nerve reconstruction, functional muscle transposition procedures, arthrolyses).

RESULTS

Patency rate after vascular reconstruction > 90%, flap survival > 95%, need for amputation is a rare entity; main determinants of prognosis: severity of soft-tissue trauma, neural damage, and potential for reconstruction.

Mini-invasive surgery for chronic exertional compartment syndrome of the forearm: a new technique

Chronic exertional compartment syndrome is now easily identified among the athletic population. It remains common in motorcyclists. The only treatment is the fasciotomy of the compartments and the gold standard procedure is still the open-invasive surgery. The authors describe a new mini-invasive surgical procedure to perform a 4-compartment fasciotomy of the forearm, and expose their results. Over a 3-year period, we reviewed 16 cases of forearm compartment fasciotomy for 8 patients with bilateral chronic exertional compartment syndrome of the forearm who had been operated on. All 8 were males, with an average age of 23 years. All were competition motorcyclists, either in cross-country or speed competitions. They were all treated with the same bilateral procedure: a mini-open fasciotomy of the 4 forearm compartments using the Knifelight, which is a sharp blade between 2 plastic blunt skids originally designed for carpal tunnel release. All patients had resumed their sport in the 6 weeks after the surgery. They were back to their previous level in 3 cases, and improved their level in 5 cases. No complications and no recurrences were reported during an average 2-year follow-up. The mini-invasive technique for fasciotomy seems to be as efficient as the open technique procedure, which is still the gold standard. But the length of surgery, recovery time, and scar sequelae are much better. Mini-invasive surgery is simple, efficient, and the results are reproducible.

Myositis ossificans mimicking compartment syndrome of the forearm

Myositis ossificans is a benign disorder of heterotopic bone formation occurring in response to soft tissue trauma. It most commonly presents in young adults and children as a painful, enlarging mass of the arm or thigh. Since there is frequently no significant history of injury, the lesion may be mistaken for a malignant bone or soft tissue tumor or infection. This article presents a case of a child in whom myositis ossificans presented with local signs and symptoms suggestive of a rapidly progressive compartment syndrome following trauma.

Management of forearm compartment syndrome

Compartment syndrome of the forearm is a serious medical problem, and it is commonly associated with high-energy injuries to the upper extremity. Timely recognition and treatment are critical to ensuring a good outcome and avoiding permanent functional loss. The diagnosis is primarily based on clinical suspicion. Surgical intervention with fasciotomy is the mainstay of treatment.

Upper extremity compartmental anatomy: clinical relevance to radiologists

Malignant tumors of the upper extremity are uncommon, and their care should be referred to specialized facilities with experience treating these lesions. The Musculoskeletal Tumor Society (MSTS) staging system is used by the surgeon to determine appropriate surgical management, assess prognosis, and communicate with other healthcare providers. Magnetic resonance imaging (MRI) is employed pre-operatively to identify a lesion's compartment of origin, determine extent of spread, and plan biopsy and resection approaches. Involvement of neurovascular structures may result in devastating loss of upper extremity function, requiring amputation. Violation of high-resistance compartmental barriers necessitates more extensive surgical resection. Biopsy may be performed by the radiologist using imaging guidance. Knowledge of compartmental anatomy allows the radiologist or surgeon to use an easily excisable biopsy approach and prevent iatrogenic spread to unaffected compartments. Case examples are presented to illustrate the importance of compartmental anatomy in the management of benign and malignant upper extremity tumors.

Evaluation of physiological standard pressures of the forearm flexor muscles during sport specific ergometry in sport climbers

BACKGROUND

Chronic exertional compartment syndromes (CECS) are well known in sports medicine. Most commonly affected is the tibialis anterior muscle compartment in runners and walkers. Only a few cases of CECS of the forearm flexor muscles have been reported.

OBJECTIVES

To determine pressure levels inside the deep flexor compartment of the forearms during a sport specific stress test.

METHOD

Ten healthy, high level climbers were enrolled in a prospective study. All underwent climbing specific ergometry, using a rotating climbing wall (step test, total climbing time 9-15 minutes). Pressure was measured using a slit catheter placed in the deep flexor compartment of the forearm. Pressure, blood lactate, and heart rate were recorded every three minutes and during recovery.

RESULTS

In all the subjects, physical exhaustion of the forearms defined the end point of the climbing ergometry. Blood lactate increased with physical stress, reaching a mean of 3.48 mmol/l. Compartment pressure was related to physical stress, exceeding 30 mm Hg in only three subjects. A critical pressure of more than 40 mm Hg was never observed. After the test, the pressure decreased to normal levels within three minutes in seven subjects. The three with higher pressure levels (>30 mm Hg) required a longer time to recover.

CONCLUSIONS

For further clinical and therapeutic consequences, an algorithm was derived. Basic pressure below 15 mm Hg and stress pressure below 30 mm Hg as well as pressures during the 15 minute recovery period below 15 mm Hg are physiological. Pressures of 15-30 mm Hg during recovery suggest high risk of CECS, and pressures above 30 mm Hg confirm CECS.

Forearm Compartment Syndrome: Anatomical Analysis of Surgical Approaches to the Deep Space

Forearm compartment syndrome is a surgical emergency that usually requires release of the superficial muscle compartments. In some clinical situations it is imperative to also explore the deep muscle compartments. There are no anatomical guides for surgical exploration of the deep compartments that would minimize collateral damage to surrounding vessels, nerves, and muscles. Surgical injury in the setting of ischemia, especially vascular injury, compounds the tissue damage that has already occurred. The authors evaluated four surgical approaches (three volar and one dorsal) to the deep forearm by performing detailed anatomical dissections on 10 embalmed and plastinated cadavers. They used a scoring system to rate the approaches for their ability to visualize the deep space without causing iatrogenic injury to superficial muscles, arteries, and nerves. In the volar forearm, an ulnar approach to the deep space is simple, causes the least iatrogenic surgical injury, and provides access to the deep volar forearm structures. The plane of dissection is between the flexor carpi ulnaris and the flexor digitorum superficialis. Dividing one or two distal segmental branches of the ulnar artery to the distal flexor digitorum superficialis exposes the pronator quadratus. Lifting the ulnar neurovascular bundle with the flexor digitorum superficialis in the middle third of the forearm exposes the flexor digitorum profundus and the flexor pollicis longus. This approach to the deep space requires no sharp dissection. In the dorsal forearm, a midline approach between the extensor digitorum communis and the extensor carpi radialis brevis is simple and safe.

Compartment Syndrome in Multiple Uninjured Extremities: A Case Report

Compartment syndrome is a common problem in trauma patients. It can occur within any space bound by a dense fascial layer, such as the extremities or abdomen. It exists when increased tissue pressure within the limited anatomic space compromises perfusion. Failure to decompress the compartment leads to a self-perpetuating ischemia-edema process and resultant irreversible tissue damage. In the extremities, it typically arises from a vascular injury in that same extremity. Herein is reported a case of the unexpected development of compartment syndrome in multiple uninjured extremities in a trauma patient with hypotension requiring systemic vasopressors.