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) login to view 3 more bullets 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 login to view 1 more bullet dorsal mobile wad (lateral) login to view 5 more bullets 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 login to view 3 more bullets 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 login to view 1 more bullet 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 login to view 3 more bullets Treatment Nonoperative observation indications login to view 2 more bullets Operative emergent forearm fasciotomies indications login to view 4 more bullets emergent hand fasciotomies indications login to view 4 more bullets Techniques Forearm emergent fasciotomies of all involved compartments approach login to view 7 more bullets technique login to view 7 more bullets post-operative login to view 8 more bullets Hand emergent fasciotomies of all involved compartments approach login to view 6 more bullets technique login to view 1 more bullet post-operative login to view 2 more bullets 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