Review Question - QID 218197

A total of 10 muscle compartments are released during a standard four-incision fasciotomy when treating a hand compartment syndrome.

Compartment syndrome of the hand is a potentially devastating upper extremity condition involving increased osseofascial compartment pressures that prevent venous outflow and lead to irreversible muscle and neurovascular damage, the treatment for which is emergent hand fasciotomies. Ten muscle compartments exist in the hand that must be released surgically in the setting of acute hand compartment syndrome. They include the thenar compartment, the hypothenar compartment, three palmar interosseous compartments, four dorsal interosseous compartments, and the adductor pollicis compartment. The ten compartments can be released effectively through four skin incisions: one dorsally over the index finger metacarpal to release the first dorsal interosseous, second dorsal interosseous, first palmar interosseous, and adductor pollicis compartments (Figure A); one over the ring finger metacarpal to release the third and fourth dorsal interossei compartments and the second and third palmar interossei compartments (Figure B); as well as one over the thenar compartment and one over the hypothenar compartment (Figure B). Failure to appropriately release these compartments in time can result in a Volkmann's ischemic contracture as a result of muscle necrosis that exhibits stereotypical wrist flexion, thumb adduction, MCP joint hyperextension, and IP joint flexion deformities (Illustration A).

Oak et al. provide a review of compartment syndrome of the hand. The authors note that many etiologies can create increased compartmental pressure, which causes capillary bed collapse, decreased tissue perfusion, and ultimately cell death. They conclude that early recognition and compartment release is crucial to avoid tissue damage and preserve hand function given that delays in diagnosis greater than six hours have been shown to result in inferior clinical outcomes.

Rubinstein et al. also emphasize that minimizing the time to surgical decompression in a patient diagnosed with compartment syndrome is critical to optimize patient outcomes. The authors state that adequate decompression of the 10 anatomic compartments of the hand is necessary at the time of fasciotomy to prevent the untoward sequelae of hand contracture and functional disability.

Figures A and B represent intra-operative clinical pictures depicting the appropriate dorsal and volar incisions, respectively, that are made during complete hand fasciotomies for acute compartment syndrome. Illustration A is a clinical picture demonstrating Volkmann's ischemic contracture.

Incorrect Answers:
Answers 1-3 and 5: As above, a total of 10 distinct muscular compartments are released during a 4-compartment fasciotomy of the hand for compartment syndrome.