Essentials of Hand Surgery
1st Edition

22
Compartment Syndrome
General Information
An acute compartment syndrome occurs when the interstitial tissue pressure rises above the tissue perfusion pressure and causes a cycle of increasing edema and cellular necrosis. Acute compartment syndromes are subdivided into three groups that are related to the time of compartment pressurization: incipient, acute, and established. The end result of an untreated compartment syndrome can be hand and forearm contracture (Volkmann’s ischemic contracture) or tissue loss. Compartment syndromes have a number of causes and can occur in both the hand and forearm.
Diagnostic Criteria
Maintaining a high index of suspicion for the development of the condition is critical to making the diagnosis. The diagnosis of compartment syndrome can be difficult, especially in cases where the interstitial tissue pressure is rising but does not yet meet the criteria for an established compartment syndrome. It may also be difficult in some clinical settings (e.g., after snakebite envenomation) where the symptoms of envenomation are similar to the symptoms of compartment syndrome.
These injuries are usually a result of a soft-tissue crushing injury (i.e., a roller injury). Cases of compartment syndrome have been reported following open and closed fractures, the application of circumferential casts, arterial laceration and repair (reperfusion), snakebite, external pressurization (drug addict lying on the arm for a prolonged period of time), medical anticoagulation, arterial puncture, hemophilic bleeding, and intraoperative limb positioning.
One of the earliest signs of compartment syndrome is pain out of proportion to the injury. Subsequently, patients describe loss of sensation and motor function. Sometimes, obtunded patients present for evaluation of limb swelling. In these cases an understanding of the conditions likely to be associated with compartment syndrome is valuable. On physical examination, the patient will have a tense swollen hand or forearm. Often the concave appearance of the palm
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reverses and becomes convex. The earliest sign is “pain on passive stretch.” Stretching muscles that pass through the compartment is painful for the patient. (For example, stretching the fingers into flexion is painful for patients with a volar forearm compartment syndrome. To test the intrinsic muscles of the hand for pain on passive stretch, place the metaphalangeal joint in extension and passively flex the interphalangeal joint.) Later, patients have abnormality on objective neurologic testing (loss of two-point discrimination and paralysis). Finally, patients lose skin coloration (pallor) and become pulseless. Patients can have a compartment syndrome with palpable pulses.
Assessment of Interstitial Tissue Pressure
The diagnosis is often made on the basis of the history and physical examination. Often, however, interstitial tissue pressure measurements are useful in confirming the diagnosis and effective treatment. Interstitial tissue pressures that are within 30 mm Hg of the mean arterial pressure or 20 mm Hg of the diastolic blood pressure are very suggestive of a compartment syndrome.
Interstitial tissue pressure measurements (ITPM) are reliable, objective observations that can be repeated during a period of observation. Do the following to measure the ITPM:
  • Assemble an “arterial line set up” and monitor.
  • Prepare the skin for puncture using Betadine solution.
  • Flush and zero the system.
  • Insert the 18-gauge catheter into the compartment (Fig. 1).
  • Read the pressure from the monitor.
  • Squeeze the compartment gently and observe the monitor for an increase in interstitial tissue pressure.
  • Remove the catheter and apply a Bandaid dressing.
FIG. 1. Interstitial tissue pressure measurement set up.
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To measure forearm compartments:
  • Volar forearm
  • Dorsal forearm
  • Mobile wad
To measure hand compartments:
  • Thenar muscles
  • Hypothenar muscles
  • Interossei muscles
    • Between index and long metacarpals
    • Between long ring and little metacarpals
  • Carpal canal pressure
The patient probably has an acute compartment syndrome if the ITPM is within 20 mm Hg of the diastolic blood pressure. If necessary, the ITPM should be measured every 2 to 3 hours to determine whether significant changes are occurring. Patients who are obtunded are excellent candidates for use of ITPM. Currently, no other imaging methods are widely used to make the diagnosis of compartment syndrome.
Treatment
The treatment for acute and established compartment syndrome is an emergency fasciotomy. Compartment syndrome is a major problem requiring urgent treatment. A fasciotomy is done in the operating room to decompress the forearm and hand. Specific incisions allow access to all of the compartments of the hand (Fig. 2). At the time of operation, the fascia is divided and the compartment
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muscle is inspected for evidence of necrosis. Devitalized tissue is resected and the wounds are left open. Serial débridements are done every 48 hours until the wound is stable. Closure is done using a delayed primary method of skin closure or split thickness skin grafting.
FIG. 2. Cross section showing the ten compartments of the hand.
If the patient is medically anticoagulated or has a significant coagulation disorder, the coagulation properties should be corrected before undertaking fasciotomy whenever possible.
Early range of motion exercises should be begun as soon as possible to limit the formation of postoperative stiffness.
Key Points
  • A compartment syndrome can occur wherever muscles are enclosed in fascial envelopes.
  • A high index of suspicion should be maintained for this condition when patients present with severe swelling.
  • This diagnosis should be made using clinical examination.
  • Measurement of the interstitial tissue pressure can obtain objective information.
  • Patients with ongoing swelling and those who cannot communicate need serial ITPM to determine the need for fasciotomy.
  • The outcome from early treatment is superior to the outcome from delayed treatment.
Selected References
Whitesides TE, Haney TC, Harada H, Holmes HC, Morimoto K. A simple method for tissue pressure determination. Arch Surg 1975;110:1311–1313.1
Footnote
1This article provides step-by-step instruction for the measurement of ITP.