Acute compartment syndrome of the hand

Practical Review on the Contemporary Diagnosis and Management of Compartment Syndrome

Acute compartment syndrome (ACS) is a limb-threatening pathology that necessitates early detection and management. The diagnosis of ACS is often made by physical examination alone; however, supplemental methods such as compartment pressure measurement, infrared spectroscopy, and ultrasound can provide additional information that support decision-making. This practical review aims to incorporate and summarize recent studies to provide evidence-based approaches to compartment syndrome for both resource-rich and -poor settings among several patient populations.

Surgical Demographics of Acute Hand Compartment Syndrome

BACKGROUND

We aimed to describe the demographic, injury-related, and treatment-related characteristics of patients who undergo fasciotomies for acute hand compartment syndrome.

METHODS

A cohort of 53 adult patients with acute hand compartment syndrome treated with fasciotomy at 2 tertiary care referral centers over a 10-year time period from January 1, 2006, to June 30, 2015, were retrospectively identified. We reviewed the electronic medical record for patient-related variables (eg, age, sex, smoking status, diabetes mellitus), injury-related variables (eg, mechanism of injury, presence of fractures), and treatment-related variables (eg, compartments released, number of operations, use of split-thickness skin grafts, and time from injury to surgery).

RESULTS

The mean age of our cohort was 45 years, and 33 patients (62%) were men. The mechanism of injury varied widely, but the most common causative mechanisms were crush injury (25%), prolonged decubitus (17%), and infection (11%). Associated hand fractures were present in 15 (28%) patients. The surgically released compartments varied; the dorsal interosseous compartments (83%), thenar compartment (75%), and hypothenar compartment (74%) were most frequently released, while the adductor pollicis compartment (43%) and Guyon canal (28%) were least frequently released.

CONCLUSIONS

The demographics of acute hand compartment syndrome have evolved in the last 25 years compared with the prior literature, partly as a result of the opioid epidemic leading to a rise in "found down" compartment syndrome. Treating providers should recognize crush injury, prolonged decubitus, and infection as the most common causes of acute hand compartment syndrome.

Acute compartment syndrome caused by hematoma with minor trauma in hemodialysis patients: Two case reports

INTRODUCTION

Acute compartment syndrome is a condition that requires an immediate diagnosis and surgical management. Compartment syndrome related to hematoma caused by minor trauma in hemodialysis patients is rarely reported.

CASE PRESENTATION

We present two cases of hemodialysis patients diagnosed with compartment syndrome of the forearm due to hematoma caused by the disruption of blood vessels after a minor trauma. The removal of the hematoma and fasciotomy with adequate skin care significantly improved soft tissue heeling with no functional impairment.

DISCUSSION

A long-term history of hemodialysis may increase the vascular vulnerability and have the potential risk of disruption by minor trauma. When the blood vessel is disrupted, a hematoma is formed and necessitating emergent surgical intervention.

CONCLUSION

Surgeons should be aware of the potential risk of damage to blood vessels with minor trauma that results in the formation of a hematoma and compartment syndrome in hemodialysis patients.

Finger compartment syndrome due to a high-pressure washer injury: A case report

BACKGROUND

Although the finger compartment syndrome is not common, it compresses the neurovascular bundles in a limited space and blocks blood flow to the fingers, causing necrosis of the fingertips. Finger fasciotomy through unilateral or bilateral midline release of the finger can achieve decompression of the finger compartment. Herein, we report a case of the compartment syndrome in a finger injury caused by a high-pressure water flow which is commonly used in car washing stations.

CASE SUMMARY

A 60-year-old man injured his right middle finger while using a high-pressure washer at a car washing station. The patient complained of severe pain in his middle finger and a 0.2 cm punctured open wound on the volar side of the distal phalangeal joint of the middle finger. The fingertip was pale, numb, and characterized by severe swelling and a limited range of motion. Finger radiography showed that there was no fracture in the finger. Digital decompression was performed through finger fasciotomy by bilateral midline incision. On the second day after surgery, the color of the fingertip returned to pink, swelling was resolved, and the range of motion returned to normal. The sensation of the fingertip was completely restored, and the capillary refill test and pinprick test were positive.

CONCLUSION

The fingertip compartment syndrome can be caused by a high-pressure water flow damage to the fingers when using high-pressure washers at a car washing station. To avoid finger necrosis, rapid diagnosis of the finger compartment syndrome and appropriate digital decompression are essential to better outcome.

Clinical Case of Acute Non-Traumatic Hand Compartment Syndrome and Systematic Review for the Upper Extremity

Background: While trauma to the upper extremity is known to cause acute compartment syndrome (ACS), nontraumatic causes of ACS of the upper extremity are rare. Nontraumatic ACS of the upper extremity can lead to adverse outcomes if not recognized early. There are limited reports of spontaneous ACS published in the literature. The aim of this comprehensive systematic review is to increase awareness among plastic surgeons and hand surgeons of this acute event and provide an algorithmic approach to management in the acute setting through an illustrative case example. Methods: A comprehensive systematic review of published literature was conducted in the Medline/PubMed database with the search terms, "compartment syndrome," "extremity," "spontaneous," "nontraumatic," and "atraumatic" without timeframe limitations. Articles were identified and included in this review based on ACS localization in the upper extremity and etiology of nontraumatic, spontaneous origin. Results: Sixteen publications and 19 total cases of nontraumatic ACS of the upper extremity from 1993 to 2016 met our search criteria. A bleeding disorder was the etiology in three cases, systemic anticoagulation in three cases, infection in six cases, and unknown in three cases. The remaining four cases included systemic sclerosis, Ehlers-Danlos syndrome, rhabdomyolysis, and McArdle disease. Conclusions: Nontraumatic causes of ACS of the upper extremity include infection, anticoagulation therapy, and bleeding disorders. Even though trauma is the most common cause of ACS, clinicians should be aware of these other potential causes of ACS in the nontraumatic setting. Appropriate medical and surgical intervention should be done to avoid potential adverse outcomes.

Compartment Syndrome of the Hand Induced by Peripherally Extravasated Phenylephrine

Background: Compartment syndrome of the hand is a rare and devastating complication of peripheral intravenous extravasation. With changes in critical care research, vasoactive medications are now more frequently administered through peripheral lines in the acute setting. Methods: We present the case of a patient diagnosed with compartment syndrome of the hand secondary to phenylephrine extravasation in the setting of hypovolemic shock. Results: The use of fasciotomy compartment release and intraoperative phentolamine resulted in significant improvement in tissue perfusion postoperatively. Conclusion: With incraesed incidence of peripherally administered vasoactive medications, the hand surgeon should be aware of potential complications and treatment of compartment syndrome with urgent fasciotomy and phentolamine administration.

Compartment Syndrome of the Hand after Laparoscopic Gynecologic Surgery

Acute compartment syndrome of the hand is a potentially devastating and infrequent condition observed after trauma, arterial injury, or prolonged compression of the upper limb. We present the case of a patient diagnosed with compartment syndrome of the hand after laparoscopic surgery for epithelial ovarian cancer. The patient is a 42-year-old woman with incidental finding of high-grade ovarian serous carcinoma after an emergency surgery. On imaging evaluation, the patient was found to have evidence of residual retroperitoneal adenopathy and was taken to the operating room for a staging procedure by laparoscopy. In the immediate postoperative period, she developed compartment syndrome of the right hand that required multiple fasciotomies and multidisciplinary management by plastic surgery, orthopedics, and rehabilitation medicine. The patient was discharged from the hospital 7 days after laparoscopic surgery to undergo rehabilitation. Three months after surgery, she is continuing to recover, with near complete recovery of hand function. The patient has completed a total of 3 cycles of chemotherapy with carboplatin/paclitaxel. Compartment syndrome of the hand is an uncommon event, but it can generate major functional deficits and even death if it is not diagnosed and treated in a timely manner. Strict criteria for patient positioning in laparoscopy surgery may avoid or reduce this complication. To date, this is the first case reporting such complications associated with laparoscopic gynecologic surgery.

Hand Compartment Syndrome

Acute hand compartment syndrome is a potentially devastating condition a hand surgeon may be called on to evaluate and treat. This pathophysiologic cascade of events that begins with an inciting event progresses to increased intracompartmental pressure, tissue necrosis, and resultant morbidity and potentially mortality. Many patients present with an altered sensorium, making the diagnosis challenging, requiring the clinician to rely on clinical findings and intracompartmental pressure measurements. The timing to definitive treatment with complete decompressive fasciotomies is critical to optimize patient outcomes. The goals of treatment are to prevent contracture, functional disability, and the loss of limb or life.

Compartment syndrome of the hand: A case report and review of literature

Elevation of pressure within tightly bound myofascial compartments has detrimental consequences if not treated promptly, leading to a loss of circulation, ischemia, myonecrosis, nerve damage, and limb loss. They are commonly seen in the distal upper and lower extremities; however, compartment syndrome of the hand is rarely encountered and prompt recognition can prevent permanent damage and tissue loss. This case study presents a complicated case of compartment syndrome of the hand and discusses the interrelationship between compartment syndrome and rhabdomyolysis. An emphasis is placed on pathophysiology of this relationship to allow a better understanding of the imaging features as well as early clinical recognition of compartment syndrome. Magnetic resonance imaging findings are specifically discussed as it remains the best imaging tool to evaluate the extent of the damage and surgical planning.

Extensile Fasciotomy for Compartment Syndrome of the Forearm and Hand

PURPOSE

The purpose of this video is to demonstrate the technique of an extensile fasciotomy of the forearm and hand.

METHODS

A patient presented to our hospital with a rapidly progressing infection of the right upper extremity and clinical signs and symptoms of compartment syndrome. The patient was immediately taken to the operating room for decompressive fasciotomy, debridement, drainage, and irrigation of what cultures subsequently revealed to be a virulent streptococcal infection. Important anatomical structures are identified in the video as the compartments of the forearm and hand are decompressed through volar and dorsal incisions. In the conclusion of the video, the skin is loosely approximated over the elbow and wrist flexion creases, and a bulky gauze dressing is applied including a plaster splint.

RESULTS

The video is 6 minutes, 20-second duration in time, and 558,180,000 bytes in size.

CONCLUSIONS

This video successfully demonstrates the anatomical approach and technique of an extensile forearm and hand fasciotomy for compartment syndrome related to a rapidly progressing infection.

Crush Injuries of the Hand

Crush injuries of the hand are a rare but devastating phenomenon, with historically poor outcomes. A compressive force, usually caused by a high-energy mechanism such as a motor vehicle or industrial accident, crushes and transiently increases the pressures within the hand. This force acts on the incompressible blood in the vasculature and leads to a dramatic rise in tissue pressures and damage to multiple tissue types, including bones, blood vessels, nerves, and soft tissues. A wide zone of injury results from a delayed inflammatory reaction involving the zone bordering the crushed cells, which may initially belie the severity of the injury. As such, these injuries go on to produce tremendous inflammation and swelling, potentially followed by compartment syndrome or other vascular damage, infection, neurological injury, and tissue necrosis. Crush injuries with minimal skin disruptions can be particularly challenging to accurately diagnose and manage. This paper provides a review of the initial evaluation of hand crush injuries as well as short- and long-term management strategies.

Compartment Syndrome of the Hand: A Rare Sequela of Transradial Cardiac Catheterization

A 64-year-old man who underwent percutaneous coronary intervention via right radial artery access reported right-hand pain and swelling 2 hours after the procedure. He had developed compartment syndrome of the hand, specifically with muscular compromise of the thenar compartment but with no involvement of the forearm. He underwent emergency right-hand compartment release and carpal tunnel release, followed by an uneventful postoperative course. In addition to our patient's case, we discuss compartment syndrome of the hand and related issues.

Compartment Syndrome of the Hand

Hand compartment syndrome has many etiologies; untreated, it has dire functional consequences. Intracompartmental pressure exceeding capillary filling pressure causes decreased tissue perfusion resulting in progressive ischemic death of compartment contents. Clinical findings can evolve. Serial physical examinations are recommended and, if equivocal, interstitial pressure monitoring is indicated. Definitive management is emergent fasciotomies with incisions designed to decompress the involved hand compartments, which could include the thenar, hypothenar, and interosseous compartments, and the carpal tunnel. Careful wound care, edema management, splinting, and hand therapy are critical. Therapy should start early postoperatively, possibly before wound closure.