EVIDENCE-BASED MEDICINE
Acute Compartment Syndrome of the Hand Jason L. Codding, MD, Michael M. Vosbikian, MD, Asif M. Ilyas, MD THE PATIENT A 35-year-old male laborer presented to the emergency department with pain and swelling in his hand after a crush injury. Radiographs did not demonstrate any fractures. His blood pressure at the time of examination was 145/70 mm Hg. He described the pain as extreme. He denied any numbness. On physical exam, the diffuse swelling of his hand was found to be tense. Vascular exam noted capillary refill that was approximately 2 seconds. Passive adduction and abduction of the fingers at the extended metacarpophalangeal joints resulted in pain. Intracompartmental pressures of 30 mm Hg were measured. THE QUESTION What symptoms, signs, and pressure measurements are diagnostic of compartment syndrome of the hand? CURRENT OPINION Compartment syndrome is one of the most important diagnoses in orthopedic surgery. Timely diagnosis can prevent muscle necrosis, which can lead to severe permanent functional impairment and kidney damage. Compartment syndrome of the forearm is diagnosed based on pain out of proportion to the injury, pain with passive stretch of the extrinsic finger flexors, the progressive development of objective neurologic dysfunction, and potentially, Volkmann’s ischemic contracture.1,2 In contrast, compartment syndrome of the hand is usually considered when the hand is significantly swollen in a context where it is From the Department of Orthopaedic Surgery, Thomas Jefferson University Hospital; and the Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA. Received for publication January 8, 2015; accepted in revised form January 30, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jason L. Codding, MD, Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, 1025 Walnut Street, Room 516 College Building, Philadelphia, PA 19107; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.01.034
difficult to determine if there is more pain than would be expected from a certain injury (eg, a crushed hand or altered sensorium), with no neurological dysfunction expected, and therefore there are limited objective criteria to assist in diagnosis. Criteria used to support a diagnosis of compartment syndrome of the hand include the extent of swelling, compartment tension by palpation, and pain intensity.3e6 These criteria are nonspecific and likely unreliable and inaccurate. Some surgeons therefore rely more on objective intracompartmental pressure measurement, but the threshold pressure for diagnosis of compartment syndrome in the hand is debated.3,4 THE EVIDENCE Compartment syndrome of the hand can result from trauma, drug overdose leading to crush syndrome, crotalid envenomation, and insect bites.3,6e11 The ability of extravasation of intravenous fluids and bleeding diatheses to cause compartment syndrome in the hand is debatable.3,7,8,12,13 Halpern et al described the most sensitive clinical sign for compartment syndrome of the hand as pain with passive motion at the metacarpophalangeal joint corresponding to the affected intrinsic musculature.4 In addition, they used an intracompartmental pressure threshold of 50 mm Hg to confirm the diagnosis, as described by Whitesides et al.14 The authors concluded that this is the threshold at which tissue necrosis begins to develop without decompressive fasciotomy in the normotensive patient. In addition, Whitesides et al noted that in a canine study by Rorabeck et al and another study by Ashton, tissue perfusion is decreased when the intracompartmental pressure is within than 10 to 30 mm Hg of the diastolic blood pressure.14e16 Ouelette and Kelly felt that a tense swollen hand with intrinsic minus position was sufficient for diagnosis and suggested a threshold pressure of 15 to 25 mm Hg with clinical symptoms or 25 mm Hg without symptomatology. A justification for these relatively low pressure thresholds was not given. The majority of their patients had an obtunded sensorium, limiting the examination.3
Ó 2015 ASSH
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Published by Elsevier, Inc. All rights reserved.
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2
ACUTE COMPARTMENT SYNDROME OF THE HAND
Shuler and Dietz noted that palpation (ie, tense compartments) had a sensitivity of 24%, a specificity of 55%, and positive and negative predictive values of 19% and 63%, respectively, in the diagnosis of compartment syndrome in the leg.17 Similarly, Ulmer also found poor reliability, noting that the sensitivity of clinical findings (pain, pain with passive stretch, paresthesias, and paresis) as a whole is only 13% to 19%, with a positive predictive value of 11% to 15% for accurately diagnosing compartment syndrome in the lower extremity.18 Guyton et al, in a cadaveric study, found that there are no true anatomic barriers between adjacent interosseous compartments. Rather, between each dorsal and volar interosseous compartment there exists a thin tissue barrier that becomes incompetent at pressures lower than 15 mm Hg.13 In another anatomic study, DiFelice et al found variability in the compartmentalization of the thenar and hypothenar myofascial spaces in 52% and 76% of specimens, respectively. In each of these specimens, two discrete subcompartments were identified.19 The clinical effect of this subcompartmentalization on the measurement of compartment pressures and the treatment of hand compartment syndrome is unknown. Current evidence shows that the Whitesides manometer demonstrates unacceptably high scatter and lacks the precision needed for useful clinical application, with a correlation coefficient of 0.9115 between actual and measured pressures. Arterial line manometers are far more reliable, with a correlation coefficient of 0.9978. The Stryker system (Mahwah, NJ) has been shown to be quite accurate and is less user-dependent with the least constant bias.20 It has been noted by Moed and Thorderson that straight needles are less accurate in pressure measurement techniques than both side-port needles and slit catheters, demonstrating a mean overestimation of compartment pressure by 19.3 and 18.3 mm Hg, respectively. These findings were echoed by the work of Boody and Wongworowat.20,21 A canine study by Matava et al demonstrated a dependence on diastolic pressure, with 20 mm Hg below the diastolic pressure critical to the development of ischemic muscle necrosis.22 An additional study in a canine model, by Heppenstall et al, described the normal cellular metabolic state of healthy tissue to exist at 30 mm Hg.23
presentation, clinical examination, and diagnosis of hand compartment syndrome is based mostly on case reports and small case series with varying etiology.3,6e12,24 There are no studies currently examining the reliability of the aforementioned factors as diagnostic tools. A consensus reference standard for the diagnosis of compartment syndrome of the hand is also lacking. Subjective and unreliable signs (substantial swelling in particular) seem to be the basis for most diagnoses. It is difficult to distinguish an acute hand injury from an evolving compartment syndrome of the hand. It is also difficult to distinguish the sequelae of complex hand trauma (including extrinsic and intrinsic contributions to stiffness and tendon adhesions) from Volkmannso ischemic contracture of the hand. In addition, there is currently no consensus regarding the absolute pressure or pressure differential between the measured intracompartmental pressure and the diastolic blood pressure (delta P) to clearly diagnose compartment syndrome in the hand. DIRECTIONS FOR FUTURE RESEARCH We need a consensus reference standard for the diagnosis of compartment syndrome of the hand. There may not be a reliable and accurate reference standard (eg,. even the ischemic contracture of Volkmann is difficult to distinguish from other reasons for hand stiffness), and we may need to use latent class analysis and accept that diagnosis is a probability rather than a certainty. Moreover, it would be of great value to determine critical pressure thresholds leading to decreased perfusion and the development of the sequelae of compartment syndrome in the hand. The goals of future work should be to assess the accuracy, reliability, and validity of interstitial tissue pressure measurement in the hand at risk for compartment syndrome. The precise anatomic placement of such pressure-measuring devices and the effect of anatomic variation need to be defined. In addition, it is also important to determine the outcomes of patients who have undergone fasciotomy compared with those who have not, to determine if diagnosis and treatment of compartment syndrome of the hand is beneficial. OUR CURRENT CONCEPTS FOR THIS PATIENT Given the substantial potential morbidity of a missed compartment syndrome, including irreversible intrinsic dysfunction and functional deficits, we have a low threshold to release the compartments of the hand in the setting of a crush injury with significant
SHORTCOMINGS OF THE EVIDENCE Hand compartment syndrome is uncommon and difficult to study. Current evidence regarding the J Hand Surg Am.
r
Vol. -, - 2015
ACUTE COMPARTMENT SYNDROME OF THE HAND
pain and swelling, especially in the patient with an altered sensorium. Due to the subjective and unreliable signs and symptoms of compartment syndrome in the hand, we rely on intracompartmental pressure measurements in cases where the diagnosis of compartment syndrome is unclear or the patient is unable to provide objective data to relate to the clinical examination. We recommend releasing the compartments of the hand when the pressures are within 30 mm Hg of the patient’s diastolic blood pressure (delta P < 30), based on our general understanding of altered tissue metabolism and muscle ischemia at that pressure.22,23
10. McKnight AJ, Koshy JC, Xue AS, Shetty M, Bullocks JM. Pediatric compartment syndrome following an insect bite: A case report. Hand. 2011;6(3):337e339. 11. Sawyer JR, Kellum EL, Creek AT, Wood GW III. Acute compartment syndrome of the hand after a wasp sting: A case report. J Pediatr Orthop B. 2010;19(1):82e85. 12. Egro FM, Jaring MRF, Khan AZ. Compartment syndrome of the hand: Beware of innocuous radius fractures. Eplasty. 2014;14: 46e51. 13. Guyton GP, Shearman CM, Saltzman CL. Compartmental divisions of the hand revisited. Rethinking the validity of cadaver infusion experiments. J Bone Joint Surg Br. 2001;83(2):241e244. 14. Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res. 1975;(113):43e51. 15. Rorabeck CH, Macnab I, Waddell JP. Anterior tibial compartment syndrome: A clinical and experimental review. Can J Surg. 1972;15: 249. 16. Ashton H. Critical closure in human limbs. Br Med Bull. 1963;19(2): 149e154. 17. Shuler FD, Dietz MJ. Physicians’ ability to manually detect isolated elevations in leg intracompartmental pressure. J Bone Joint Surg Am. 2010;92(2):361e367. 18. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: Are clinical findings predictive of the disorder? J Orthop Trauma. 2002;16(8):572e577. 19. DiFelice A Jr, Seiler JG III, Whitesides TE Jr. The compartments of the hand: An anatomic study. J Hand Surg Am. 1998;23(4): 682e686. 20. Boody AR, Wongworawat MD. Accuracy in the measurement of compartment pressures: A comparison of three commonly used devices. J Bone Joint Surg Am. 2005;87(11):2415e2422. 21. Moed BR, Thorderson PK. Measurement of intracompartmental pressure: A comparison of the slit catheter, side-ported needle, and simple needle. J Bone Joint Surg Am. 1993;75(2):231e235. 22. Matava MJ, Whitesides TE Jr, Seiler JG III, Hewan-Lowe K, Hutton WC. Determination of the compartment pressure threshold of muscle ischemia in a canine model. J Trauma. 1994;37(1):50e58. 23. Heppenstall RB, Sapega AA, Scott R, et al. The compartment syndrome: An experimental and clinical study of muscular energy metabolism using phosphorus nuclear magnetic resonance spectroscopy. Clin Orthop Relat Res. 1988;(226):138e155. 24. Werman H, Rancour S, Nelson R. Two cases of thenar compartment syndrome from blunt trauma. J Emerg Med. 2013;44(1):85e88.
REFERENCES 1. Tsuge K. Treatment of established Volkmann’s contracture. J Bone Joint Surg Am. 1975;57(7):925e929. 2. Volkmann RV. THE CLASSIC: Ischaemic muscle paralyses and contractures. Clin Orthop Relat Res. 2007;456:20e21. 3. Ouellette EA, Kelly R. Compartment syndromes of the hand. J Bone Joint Surg Am. 2009;78(10):1515e1523. 4. Halpern AA, Greene R, Nichols T, Burton DS. Compartment syndrome of the interosseous muscles: Early recognition and treatment. Clin Orthop Relat Res. 1979;(140):23e25. 5. Leversedge FJ, Moore TJ, Peterson BC, Seiler JG. Compartment syndrome of the upper extremity. J Hand Surg Am. 2011;36(3): 544e559. 6. Seiler JG III, Olvey SP. Compartment syndromes of the hand and forearm. J Am Soc Surg Hand. 2003;3(4):184e198. 7. Belzunegui T, Louis CJ, Torrededia L, Oteiza J. Extravasation of radiographic contrast material and compartment syndrome in the hand: A case report. Scand J Trauma Resusc Emerg Med. 2011;19:9. 8. Ilyas AM, Wisbeck JM, Shaffer GW, Thoder JJ. Upper extremity compartment syndrome secondary to acquired factor VIII inhibitor: A case report. J Bone Joint Surg Am. 2005;87(7):1606e1608. 9. Sharma R, Rao RB, Chu J. Compartment syndrome of the hand from prolonged immobilization secondary to drug overdose. J Emerg Med. 2013;44(4):845e846.
J Hand Surg Am.
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Acute Compartment Syndrome of the Hand Jason L. Codding, MD, Michael M. Vosbikian, MD, Asif M. Ilyas, MD THE PATIENT A 35-year-old male laborer presented to the emergency department with pain and swelling in his hand after a crush injury. Radiographs did not demonstrate any fractures. His blood pressure at the time of examination was 145/70 mm Hg. He described the pain as extreme. He denied any numbness. On physical exam, the diffuse swelling of his hand was found to be tense. Vascular exam noted capillary refill that was approximately 2 seconds. Passive adduction and abduction of the fingers at the extended metacarpophalangeal joints resulted in pain. Intracompartmental pressures of 30 mm Hg were measured. THE QUESTION What symptoms, signs, and pressure measurements are diagnostic of compartment syndrome of the hand? CURRENT OPINION Compartment syndrome is one of the most important diagnoses in orthopedic surgery. Timely diagnosis can prevent muscle necrosis, which can lead to severe permanent functional impairment and kidney damage. Compartment syndrome of the forearm is diagnosed based on pain out of proportion to the injury, pain with passive stretch of the extrinsic finger flexors, the progressive development of objective neurologic dysfunction, and potentially, Volkmann’s ischemic contracture.1,2 In contrast, compartment syndrome of the hand is usually considered when the hand is significantly swollen in a context where it is From the Department of Orthopaedic Surgery, Thomas Jefferson University Hospital; and the Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA. Received for publication January 8, 2015; accepted in revised form January 30, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jason L. Codding, MD, Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, 1025 Walnut Street, Room 516 College Building, Philadelphia, PA 19107; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.01.034
difficult to determine if there is more pain than would be expected from a certain injury (eg, a crushed hand or altered sensorium), with no neurological dysfunction expected, and therefore there are limited objective criteria to assist in diagnosis. Criteria used to support a diagnosis of compartment syndrome of the hand include the extent of swelling, compartment tension by palpation, and pain intensity.3e6 These criteria are nonspecific and likely unreliable and inaccurate. Some surgeons therefore rely more on objective intracompartmental pressure measurement, but the threshold pressure for diagnosis of compartment syndrome in the hand is debated.3,4 THE EVIDENCE Compartment syndrome of the hand can result from trauma, drug overdose leading to crush syndrome, crotalid envenomation, and insect bites.3,6e11 The ability of extravasation of intravenous fluids and bleeding diatheses to cause compartment syndrome in the hand is debatable.3,7,8,12,13 Halpern et al described the most sensitive clinical sign for compartment syndrome of the hand as pain with passive motion at the metacarpophalangeal joint corresponding to the affected intrinsic musculature.4 In addition, they used an intracompartmental pressure threshold of 50 mm Hg to confirm the diagnosis, as described by Whitesides et al.14 The authors concluded that this is the threshold at which tissue necrosis begins to develop without decompressive fasciotomy in the normotensive patient. In addition, Whitesides et al noted that in a canine study by Rorabeck et al and another study by Ashton, tissue perfusion is decreased when the intracompartmental pressure is within than 10 to 30 mm Hg of the diastolic blood pressure.14e16 Ouelette and Kelly felt that a tense swollen hand with intrinsic minus position was sufficient for diagnosis and suggested a threshold pressure of 15 to 25 mm Hg with clinical symptoms or 25 mm Hg without symptomatology. A justification for these relatively low pressure thresholds was not given. The majority of their patients had an obtunded sensorium, limiting the examination.3
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
ACUTE COMPARTMENT SYNDROME OF THE HAND
Shuler and Dietz noted that palpation (ie, tense compartments) had a sensitivity of 24%, a specificity of 55%, and positive and negative predictive values of 19% and 63%, respectively, in the diagnosis of compartment syndrome in the leg.17 Similarly, Ulmer also found poor reliability, noting that the sensitivity of clinical findings (pain, pain with passive stretch, paresthesias, and paresis) as a whole is only 13% to 19%, with a positive predictive value of 11% to 15% for accurately diagnosing compartment syndrome in the lower extremity.18 Guyton et al, in a cadaveric study, found that there are no true anatomic barriers between adjacent interosseous compartments. Rather, between each dorsal and volar interosseous compartment there exists a thin tissue barrier that becomes incompetent at pressures lower than 15 mm Hg.13 In another anatomic study, DiFelice et al found variability in the compartmentalization of the thenar and hypothenar myofascial spaces in 52% and 76% of specimens, respectively. In each of these specimens, two discrete subcompartments were identified.19 The clinical effect of this subcompartmentalization on the measurement of compartment pressures and the treatment of hand compartment syndrome is unknown. Current evidence shows that the Whitesides manometer demonstrates unacceptably high scatter and lacks the precision needed for useful clinical application, with a correlation coefficient of 0.9115 between actual and measured pressures. Arterial line manometers are far more reliable, with a correlation coefficient of 0.9978. The Stryker system (Mahwah, NJ) has been shown to be quite accurate and is less user-dependent with the least constant bias.20 It has been noted by Moed and Thorderson that straight needles are less accurate in pressure measurement techniques than both side-port needles and slit catheters, demonstrating a mean overestimation of compartment pressure by 19.3 and 18.3 mm Hg, respectively. These findings were echoed by the work of Boody and Wongworowat.20,21 A canine study by Matava et al demonstrated a dependence on diastolic pressure, with 20 mm Hg below the diastolic pressure critical to the development of ischemic muscle necrosis.22 An additional study in a canine model, by Heppenstall et al, described the normal cellular metabolic state of healthy tissue to exist at 30 mm Hg.23
presentation, clinical examination, and diagnosis of hand compartment syndrome is based mostly on case reports and small case series with varying etiology.3,6e12,24 There are no studies currently examining the reliability of the aforementioned factors as diagnostic tools. A consensus reference standard for the diagnosis of compartment syndrome of the hand is also lacking. Subjective and unreliable signs (substantial swelling in particular) seem to be the basis for most diagnoses. It is difficult to distinguish an acute hand injury from an evolving compartment syndrome of the hand. It is also difficult to distinguish the sequelae of complex hand trauma (including extrinsic and intrinsic contributions to stiffness and tendon adhesions) from Volkmannso ischemic contracture of the hand. In addition, there is currently no consensus regarding the absolute pressure or pressure differential between the measured intracompartmental pressure and the diastolic blood pressure (delta P) to clearly diagnose compartment syndrome in the hand. DIRECTIONS FOR FUTURE RESEARCH We need a consensus reference standard for the diagnosis of compartment syndrome of the hand. There may not be a reliable and accurate reference standard (eg,. even the ischemic contracture of Volkmann is difficult to distinguish from other reasons for hand stiffness), and we may need to use latent class analysis and accept that diagnosis is a probability rather than a certainty. Moreover, it would be of great value to determine critical pressure thresholds leading to decreased perfusion and the development of the sequelae of compartment syndrome in the hand. The goals of future work should be to assess the accuracy, reliability, and validity of interstitial tissue pressure measurement in the hand at risk for compartment syndrome. The precise anatomic placement of such pressure-measuring devices and the effect of anatomic variation need to be defined. In addition, it is also important to determine the outcomes of patients who have undergone fasciotomy compared with those who have not, to determine if diagnosis and treatment of compartment syndrome of the hand is beneficial. OUR CURRENT CONCEPTS FOR THIS PATIENT Given the substantial potential morbidity of a missed compartment syndrome, including irreversible intrinsic dysfunction and functional deficits, we have a low threshold to release the compartments of the hand in the setting of a crush injury with significant
SHORTCOMINGS OF THE EVIDENCE Hand compartment syndrome is uncommon and difficult to study. Current evidence regarding the J Hand Surg Am.
r
Vol. -, - 2015
ACUTE COMPARTMENT SYNDROME OF THE HAND
pain and swelling, especially in the patient with an altered sensorium. Due to the subjective and unreliable signs and symptoms of compartment syndrome in the hand, we rely on intracompartmental pressure measurements in cases where the diagnosis of compartment syndrome is unclear or the patient is unable to provide objective data to relate to the clinical examination. We recommend releasing the compartments of the hand when the pressures are within 30 mm Hg of the patient’s diastolic blood pressure (delta P < 30), based on our general understanding of altered tissue metabolism and muscle ischemia at that pressure.22,23
10. McKnight AJ, Koshy JC, Xue AS, Shetty M, Bullocks JM. Pediatric compartment syndrome following an insect bite: A case report. Hand. 2011;6(3):337e339. 11. Sawyer JR, Kellum EL, Creek AT, Wood GW III. Acute compartment syndrome of the hand after a wasp sting: A case report. J Pediatr Orthop B. 2010;19(1):82e85. 12. Egro FM, Jaring MRF, Khan AZ. Compartment syndrome of the hand: Beware of innocuous radius fractures. Eplasty. 2014;14: 46e51. 13. Guyton GP, Shearman CM, Saltzman CL. Compartmental divisions of the hand revisited. Rethinking the validity of cadaver infusion experiments. J Bone Joint Surg Br. 2001;83(2):241e244. 14. Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res. 1975;(113):43e51. 15. Rorabeck CH, Macnab I, Waddell JP. Anterior tibial compartment syndrome: A clinical and experimental review. Can J Surg. 1972;15: 249. 16. Ashton H. Critical closure in human limbs. Br Med Bull. 1963;19(2): 149e154. 17. Shuler FD, Dietz MJ. Physicians’ ability to manually detect isolated elevations in leg intracompartmental pressure. J Bone Joint Surg Am. 2010;92(2):361e367. 18. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: Are clinical findings predictive of the disorder? J Orthop Trauma. 2002;16(8):572e577. 19. DiFelice A Jr, Seiler JG III, Whitesides TE Jr. The compartments of the hand: An anatomic study. J Hand Surg Am. 1998;23(4): 682e686. 20. Boody AR, Wongworawat MD. Accuracy in the measurement of compartment pressures: A comparison of three commonly used devices. J Bone Joint Surg Am. 2005;87(11):2415e2422. 21. Moed BR, Thorderson PK. Measurement of intracompartmental pressure: A comparison of the slit catheter, side-ported needle, and simple needle. J Bone Joint Surg Am. 1993;75(2):231e235. 22. Matava MJ, Whitesides TE Jr, Seiler JG III, Hewan-Lowe K, Hutton WC. Determination of the compartment pressure threshold of muscle ischemia in a canine model. J Trauma. 1994;37(1):50e58. 23. Heppenstall RB, Sapega AA, Scott R, et al. The compartment syndrome: An experimental and clinical study of muscular energy metabolism using phosphorus nuclear magnetic resonance spectroscopy. Clin Orthop Relat Res. 1988;(226):138e155. 24. Werman H, Rancour S, Nelson R. Two cases of thenar compartment syndrome from blunt trauma. J Emerg Med. 2013;44(1):85e88.
REFERENCES 1. Tsuge K. Treatment of established Volkmann’s contracture. J Bone Joint Surg Am. 1975;57(7):925e929. 2. Volkmann RV. THE CLASSIC: Ischaemic muscle paralyses and contractures. Clin Orthop Relat Res. 2007;456:20e21. 3. Ouellette EA, Kelly R. Compartment syndromes of the hand. J Bone Joint Surg Am. 2009;78(10):1515e1523. 4. Halpern AA, Greene R, Nichols T, Burton DS. Compartment syndrome of the interosseous muscles: Early recognition and treatment. Clin Orthop Relat Res. 1979;(140):23e25. 5. Leversedge FJ, Moore TJ, Peterson BC, Seiler JG. Compartment syndrome of the upper extremity. J Hand Surg Am. 2011;36(3): 544e559. 6. Seiler JG III, Olvey SP. Compartment syndromes of the hand and forearm. J Am Soc Surg Hand. 2003;3(4):184e198. 7. Belzunegui T, Louis CJ, Torrededia L, Oteiza J. Extravasation of radiographic contrast material and compartment syndrome in the hand: A case report. Scand J Trauma Resusc Emerg Med. 2011;19:9. 8. Ilyas AM, Wisbeck JM, Shaffer GW, Thoder JJ. Upper extremity compartment syndrome secondary to acquired factor VIII inhibitor: A case report. J Bone Joint Surg Am. 2005;87(7):1606e1608. 9. Sharma R, Rao RB, Chu J. Compartment syndrome of the hand from prolonged immobilization secondary to drug overdose. J Emerg Med. 2013;44(4):845e846.
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