summary Hand & Forearm Compartment Syndrome are devastating upper extremity conditions where the osseofascial compartment pressure rises to a level that decreases perfusion to the hand or forearm and may lead to irreversible muscle and neurovascular damage. Diagnosis is made with the presence of severe and progressive hand or forearm pain that worsens with passive finger or wrist motion, respectively. Firmness and decreased compressibility of the compartments is often present. Needle compartment pressures are diagnostic in cases of inconclusive physical exam findings and in sedated patients. Treatment is emergent fasciotomies. Epidemiology Anatomic location 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 Etiology 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 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 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 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 observation indications exam not consistent with compartment syndrome delta p > 30 Operative emergent forearm fasciotomies indications clinical presentation consistent with compartment syndrome 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 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 Techniques Forearm emergent fasciotomies of all involved compartments approach volar incision decompresses volar compartment and 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 and dorsal compartment 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) Tsuge classification (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 neurolysisBR 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 Prognosis May lead to loss of function Volkmann ischemic contracture neurologic deficit infection amputation