Review Question - QID 218153

This patient sustained a crush injury with worsening symptoms of forearm compartment syndrome (acute carpal tunnel syndrome and exquisite pain with passive extension of digits). He should undergo emergent forearm fasciotomies and carpal tunnel release (Answer 5).

Compartment syndrome (CS) occurs when there is increased pressure within a fibro-osseous space resulting in decreased tissue perfusion. CS most often occurs secondary to crush injuries, however, it can occur in the setting of open fractures as well. When the compartment pressure nears (~30mm Hg) or exceeds the patient’s diastolic blood pressure, irreversible ischemic changes may ensue if left untreated. Muscle damage can begin as early as 3-4 hours of warm ischemia, and therefore 'time is tissue.' Early recognition and treatment ensure optimal outcomes as delays in presentation or treatment may result in a Volkmann ischemic contracture with a notable loss of hand function. Fasciotomies are the mainstay of treatment with delayed closure. Further, any involved nerves should undergo neurolysis and release from local anatomic constraints (i.e.carpal tunnel release).

Prasarn and Ouellette provided a comprehensive review of compartment syndrome of the upper extremity. They discuss that among the upper extremity cases, forearm compartment syndrome is the most common, specifically within the volar fascial compartment of the forearm. However, it may occur in the 2 fascial compartments of the upper arm (anterior and posterior), the 3 fascial compartments of the forearm (volar, dorsal, and mobile wad), and/or the 10 fascial compartments of the hand (thenar, adductor pollicis, hypothenar, 4 dorsal interosseous, and 3 volar interosseous). The authors stress the knowledge of anatomy for surgical planning purposes and performing early fascial releases to minimize negative sequelae.

Goodman and colleagues provided a review on the diagnosis and management of hand compartment syndrome. They discuss that of the classic physical manifestations (pain, pallor, paresthesias, pulselessness, and paralysis), only pain out of proportion to clinical examination or with passive stretch is thought to present early enough to recognize/treat before deep tissue necrosis occurs. They further discuss complications unique to hand compartment syndrome and the treatment approaches to minimize sequelae. The authors conclude that hand salvage should always be sought over acute amputation given the paramount role of the hand for everyday life.

Figures A and B demonstrate this patient’s clinic photos with increased forearm swelling, resting finger flexion posturing, and delayed capillary refill. Illustration A further demonstrates this patient’s delayed capillary refill secondary to swelling around his wrist. He underwent forearm fasciotomies and carpal tunnel release without permanent sequelae other than a skin graft applied to assist during delayed closure.

Incorrect Answers:
Answer 1: This patient demonstrates worsening signs/symptoms of compartment syndrome and delays in treatment may result in worse outcomes.
Answer 2: Compartment syndrome is a clinical diagnosis. While measuring compartment pressures can assist in establishing the diagnosis, obtaining a CT angiography is not necessary and will likely delay treatment.
Answer 3: Performing any peripheral nerve block is contraindicated when there is a concern for compartment syndrome, as blocks can mask the worsening symptoms and result in delayed treatment.
Answer 4: While this patient is endorsing symptoms consistent with carpal tunnel syndrome, they require additional fasciotomies in addition to carpal tunnel release.