European Journal of Trauma and Emergency Surgery

Focus on Compartment Syndrome

Acute Compartment Syndrome of the Upper Extremity Klaus J. Burkhart1, Lars P. Mueller1, Karl-Josef Prommersberger2, Pol M. Rommens1

Abstract Compartment syndrome of the upper extremity is rare, but happens frequently. It most often affects the forearm, compartment syndromes of the upper arm and hand are seen much more seldom. Early diagnosis and efficient fasciotomy is of highest importance to achieve good outcome and prevent development of Volkmann’s ischemic contracture. Key Words Compartment syndrome Æ Upper extremity Fasciotomy Æ Outcome

Acute Compartment Syndrome of the Upper Extremity:

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Eur J Trauma Emerg Surg 2007;33:584–8 DOI 10.1007/s00068-007-7162-x

Introduction Severe soft tissue damage with tissue disruption, oedema and hematoma lead to increased interstitial tissue pressure within an enclosed rigid space and consecutive impairment of its content due to ischemia. There are many different circumstances that can lead to a compartment syndrome of the upper extremity: fracture, soft tissue damage, external pressure, thrombosis, bleeding due to anticoagulation, high pressure injection injuries, industrial vacuum accidents, iatrogenic due to excessive infusion or extravasation, snake and spider bites. It was Matsen who defined the ‘‘unified concept theory’’ in 1975 stating that multiple etiologies eventually lead to the same vicious cycle of edema and ischemia [1]. The diagnosis is primary based on the clinical symptoms: swelling, pain, not tempered, but worsened by elevation of the limb, and passive muscle stretching causing pain as well as sensomotoric symptoms such as paresthesias or paralysis. Intracompartimental pressure 1

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measurement plays a minor role. It becomes important in unconscious patients that cannot be examined adequately. Treatment of choice is immediate fasciotomy in the acute stage. Delay in diagnosis or fasciotomy leads to severe sequelae of ischemia: muscle necrosis, nerve damage and scarring – Volkmann’s ischemic contracture.

(1) Upper arm (2) Forearm (3) Hand 1. Acute Compartment Syndrome of the Upper Arm Anatomy There are three compartments in the upper arm: (1) The deltoid compartment is surrounded by the deltoid fascia. It is split into two separate parts. (2) The anterior compartment is enfolded by the brachial fascia and the lateral and medial intermuscular septum. It contains the biceps, brachialis, and coracobrachialis muscle as well as all important neurovascular structures. (3) The posterior compartment is covered in the deep brachial fascia dorsally and by the medial and lateral intermuscular septum anteriorly, too. It contains the triceps muscle as well as the ulnar nerve that perforates the medial septum intermusculare in the distal part of the upper arm. Treatment Early fasciotomy is recommended. Medial skin incision should be chosen when vascular revision is needed, lateral when an osteosynthesis has to be performed. Incision of the lacertus fibrosus and release of the ulnar nerve

Department of Trauma Surgery, Johannes Gutenberg-University, Mainz, Germany, Department of Hand Surgery, Bad Neustadt/Saale, Germany.

Received: November 6, 2007; accepted: November 8, 2007; Published Online: November 26, 2007

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Burkhart KJ, et al. Acute Compartment Syndrome of the Upper Extremity

(3) The fourth compartment – the mobile wad – is segregated by the antebracial fascia, the radius and an intermuscular septum. It includes three muscles: brachioradialis, extensor carpi radialis brevis and extensor carpi radialis longus muscle. The superficial branch of the radial nerve lies within the mobile wad.

in the ulnar tunnel must be considered. In case of deltoid compartment syndrome, both parts of the deltoid compartment have to be split by epimysiotomies after fasciotomy. A single incision of the fascia is not sufficient. 2. Acute Compartment Syndrome of the Forearm Anatomy The forearm contains up to ten compartments that are not strictly separated from each other but aligned by interconnectations [2]. Functionally, there are four important compartments of the forearm:

Treatment At first all rigid casts or dressings have to be taken off – if present. Immediate fasciotomy is the treatment of acute compartment syndrome. The palmar incision (Figure 1) starts at the carpal level between the thenar and hypothenar (Figure 1A). It then follows the wrist wrinkle (Figure 1B) to the ulnar side (Figure 1C) and is continued sinuously over the palmar forearm to the radial and then back to the ulnar side to stop dorsally to the ulnar epicondyle (Figure 1D). Over this approach the carpal tunnel has to be released. The Guyon’s-Loge can be reached, too, if a ulnar nerve release is necessary. The thenar and hypothenar compartments have to be decompressed over separate incisions. During skin incision major attention has to be paid to cutaneous nerves and veins that must be preserved. The superficial and deep compartments have to decompressed through broad fasciotmies. Muscle bellies have to be watched closely to assess the reperfusion. In case of early surgery sufficient reperfusion occurs in the majority of the cases. If the soft tissues do not regenerate adequately, epimysiotomies of every single muscle have to be performed. In case of late surgery necrotic musculature must be excised in order to prevent infection and contracture. In the antecubital fossa the lacertus fibrosus may be splitted. If a main artery or vein injury is present, it should be attended during the same operation. If this injury is located proximal to the elbow, the incision can be broadened along the medial upper arm (Figure 1E) [4]. The sinuous incision pattern creates two flaps that can be used for soft tissue coverage – especially the median nerve – even in case of broad gaping of the wound edges. Furthermore linear contracture across the antecubital

(1) The palmar compartment is bounded by radius, ulna and the interosseus membrane on the dorsal side, the intermuscular septum radially and the antebrachial fascia ulnarly and palmarly. It can be devided into a deep and a superficial palmar compartment, which are segregated by a transverse fascia [3]. – Due to its rigid boundaries, the deep palmar compartment is most severely affected by compartment syndromes. It includes the flexor pollicis longus, flexor digitorum profundus and pronator quadratus muscles. – The superficial palmar compartment contains the flexor carpi ulnaris, palmaris longus, flexor carpi radialis, flexor digitorum superficialis and pronator teres muscles. Most of the important neurovascular structures such as the median and ulnar nerve as well as the anterior interosseus nerve and the deep branch of the radial nerve as well as the radial and ulnar vessels lie within the palmar compartment. (2) The dorsal compartment implies the extensor digitorum communis, the extensor digiti minimi, the extensor carpi ulnaris, the abductor pollicis longus, the extensor pollicis brevis, the extensor pollicis longus, the extensor indicis, the supinator, and the anconeus muscle as well as the posterior interosseus nerve. It is embedded by the interosseous membrane, ulna, radius and intermuscular septum. Figure 1. Skin incision along the palmar forearm.

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B

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D

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fossa is prevented. It is therefore preferred to a straight incision. The dorsal compartments are decompressed over a longitudinal straight dorsal incision as there are no important neurovascular structures that need to be covered afterwards. The incision starts 2 cm lateral and distal of the lateral epicondyle aiming at the median wrist. There is still some controversy to the fasciotomy of the dorsal compartments. As already mentioned the compartments of the forearm are interconnected. Therefore some authors note that palmar fasciotomy leads to sufficient release of the dorsal compartments, too [2, 5, 6]. If the dorsal compartments are not released separately, close clinical monitoring has to be performed. 3. Acute Compartment Syndrome of the Hand Anatomy The hand is separated into 12 compartments (Figure 2): four dorsal interossei and three palmar interossei compartments, the thenar and hypothenar compartment, the adductor compartment as well as the carpal tunnel and the Loge de Guyon. These compartments are – similar to the forearm – often interconnected [7]. Treatment The interossei compartments of the hand are decompressed over two dorsal incisions over the second and fourth metacarpal bone (Figure 2). The adductor pollicis compartment can be reached over this approach, Dor. interossei

II

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Dor. interosseous fascia

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I Hypothenar muscles Thenar muscles

Vol. interossei Ad. pollicis

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Figure 2. Fasciotomy of the hand compartments.

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too and must be decompressed. The thenar and hypothenar compartment have to be incised from the palmar side. Care has to be taken of the motoric branch of the median nerve. The fingers can be decompressed over lateral midaxial incisions that should be placed more dorsally in order to prevent flexion contractures. Primary closure of the wounds is not aspired to prevent new compressive forces. Vessel loops are used to achieve wound edge retraction. Alternatively negative pressure dressings may be used. A second-look operation should be performed two days later. Fasciotomy is the only adequate treatment of acute compartment syndrome. Conservatively treated compartment syndromes with good results [8, 9] must be questioned whether a true ischemia was present. It must be rather assumed that it was more likely a tense forearm than a forearm compartment syndrome, because a real compartment syndrome can never be ‘‘transient’’. Medical treatment can be appraised as an adjuvant therapy. Mannitol, vasodilatators, corticosteroids and antispasmodics might be used [10]. If emergency fasciotomy is performed in time and correctly, the patient has a favorable chance of full recovery [5, 11–15]. Therefore fasciotomy has to be performed within the first four hours of ischemia, because later on irreversible necrosis will occur [16] and after several days Volkmann’s ischemic contracture develops, that was first described by Volkmann in the late nineteenth century [17]. Clinical Studies Only few data about the incidence of upper extremity compartment syndrome can be found in the literature. Fractures – especially within the scope of high energy traumas – seem to be the most common reason for development of compartment syndromes of the forearm. This was found by McQueen et al. who also found that men under the age of 35 years are at the highest risk [18]. Studying 164 cases of all types of compartment syndromes they quoted an annual incidence of 7.3/ 100.000 for men and 0.7/100.000 for women. Of the 164 cases of upper and lower extremity compartment syndromes 113 and were caused by fractures. The most common fracture was the tibia fracture with 68 of 113 cases. Far behind the distal radius fracture was the second most common fracture with 16 cases, which was 0.25% of all distal radius fractures treated during this period. On the third position the diaphyseal fractures of the forearm with 13 cases followed, i.e. 3.1% of all diaphyseal forearm fractures led to a compartment syndrome. Grottkau et al. provide similar data in an

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analysis of etiology and epidemiology of pediatric compartment syndromes. In 85% fractures were the initiating cause followed by severe soft tissue trauma. They outlined, that boys outnumbered girls by 4:1. About 74% of all upper extremity fractures were forearm fractures, 15% supracondylar fractures and 11% carpal and metacarpal fractures. About 1.04% of all forearm fractures led to a compartment syndrome – 2.3% of the open fractures and 0.7% of the closed fractures [19]. Sometimes higher incidences are reported. Haasbeck et al. reported 20% of open midshaft forearm fractures in their retrospective cohort of 28 children [20]. None of their 15 patients with humerus fractures developed an upper arm compartment syndrome. Most of the literature concerning forearm compartment syndromes consists of case reports dealing with one or two cases. Regarding the outcome of compartment syndromes, poor data can be found in the current literature. Especially no prospective studies can be found documenting the benefit of early fasciotomy. There is one study dealing with a small number of compartment syndromes trying to find out which time of fasciotomy leads to a good or poor result. In a retrospective study they looked at 28 compartment syndromes and found no correlation between time from diagnosis to fasciotomy and functional deficits. An average time of 70 min to fasciotomy led to poor results but an average time of 315 min led to good results [21]. This study is contrast to the remaining literature. This is mostly made up of case reports. To summarize them: independent of the etiology, good results are reported for early diagnosis and fasciotomy whereas delayed treatment leads to poor results and complications [15, 20, 22–38]. Ragland et al. reviewed the records of 24 patients with compartment syndromes of the forearm at the time of birth. In only one case the diagnosis was made in time and early fasciotomy was performed. This patient was the only one with a good result. All other 23 patients had delayed diagnosis: 13 were introduced to the authors within the first year, the other ten between the age of 1 and 13 years. Long-term sequelae such as neuropathy, contraction, muscle loss and bone growth abnormality was seen in all of them. About 15 patients required 19 surgical procedures for their Volkmann’s contracture. Neurolysis, debridement, release of contractures, soft tissue resurfacing, correction of angular deformity, tendon lengthening and transfers as well as free muscle transfers were performed [39]. Wippermann et al. reported 14 patients with upper arm compartment syndromes. In 9 patients fasciotomy was performed within 6 h. The latest fasciotomy was

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performed after 30 h. They could review seven of them. They concluded that the bad results correlated with concomitant injuries and delayed treatment [40]. Schmidt examined 16 patients after fasciotomy of the forearm. Poor results were ascribed to concomitant injuries, too. 11 of the 25 patients were polytraumatized [41]. In another retrospective investigation of 17 patients with compartment syndrome of the hand 13 patients achieved good results. In all four patients with poor results diagnosis was delayed due to decreased consciousness of these patients [42]. A publication of Balogh et al. demonstrates the sequelae of delayed diagnosis and treatment of compartment syndromes. The study reports 19 patients with compartment syndromes of the upper (n = 9) and lower extremity (n = 10). Fourteen of them were introduced to them delayed. This resulted in the need for necrosectomies in 13 cases followed by eight amputations. Early fasciotomy resulted in good outcome [43].

Conclusions Compartment syndrome of the upper extremity is rare, but happens frequently. It most often affects the forearm, compartment syndromes of the upper arm and hand are seen much more seldom. Early diagnosis and efficient fasciotomy is of highest importance to achieve good outcomes. Surgeons always need to be aware of the eventuality of a compartment syndrome due to the broad variety of possible etiologies. Deep knowledge of the anatomy is important to provide sufficient surgery. Good clinical results can be expected with correct fasciotomy at an early stage. Delayed surgery recovers a high risk of late sequelae due to ischemia – Volkmann’s contracture. Different surgical procedures in manifest ischemic contractures may provide improved function and relief of symptoms but are always inferior compared to early treatment of acute compartment syndrome. As the consequences of ischemic contracture are out of all proportion to the complications of fasciotomy, the decision on fasciotomy must be made generously.

References 1. 2.

3.

Matsen FA 3rd. Compartmental syndrome. A unified concept. Clin Orthop Relat Res 1975;113:8–14. Gelberman RH, Zakaib GS, Mubarak SJ, et al. Decompression of forearm compartment syndromes. Clin Orthop Relat Res 1978;134:225–9. Allen MJ, Steingold F, Kotecha M, et al. The importance of the deep volar compartment in crush injuries of the forearm. Injury 1985;16:273–5.

587

Burkhart KJ, et al. Acute Compartment Syndrome of the Upper Extremity

4.

5.

6. 7. 8.

9.

10. 11.

12.

13. 14.

15.

16.

17. 18. 19. 20. 21.

22.

23.

24.

25.

26.

Gulgonen A. Compartment Syndrome. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW (eds). Green’s Operative Hand Surgery. 5th edn, Elsevier, Philadelphia 2005, pp 1985–2006. Gelberman RH, Garfin SR, Hergenroeder PT, et al. Compartment syndromes of the forearm: diangnosis and treatment. Clin Ortop Relat Res 1981;161:252–61. Frober R, Linss W. Anatomic bases of the forearm compartment syndrome. Surg Radiol Anat 1994;16:341–7. DiFelice A Jr, Seiler JG 3rd, Whitesides TE Jr. The compartments of the hand: an anatomic study. J Hand Surg Am 1998;23:682–6. Cohen J, Bush S. Case report: compartment syndrome after a suspected black widow spider bite. Ann Emerg Med 2005; 45:414–6. O’Neil D, Sheppard JE. Transient compartment syndrome of the forearm resulting from venous congestion from a tourniquet. J Hand Surg Am 1989;14:894–6. Malek R. Volkmann’s Contracture. In: Tubiana R (eds). The Hand. W.B. Saunders, Philadelphia 1999, pp 62–72. Quigley JT, Popich GA, Lanz UB. Compartment syndrome of the forearm and hand: a case report. Clin Orthop Relat Res 1981; 161:247–51. Baeten Y, De Smet L, Fabry G. Acute anterior forearm compartment syndrome following wrist arthrodesis. Acta Orthop Belg 1999;65:239–41. Cosker T, Gupta S, Tayton K. Compartment syndrome caused by suction. Injury 2004;35:1194–5. Vaienti L, Vourtsis S, Urzola V. Compartment syndrome of the forearm following an elecrtomyographic assessment. J Hand Surg Br 2005;30:656–7. Reurings JC, Verhofstad MHJ. The Volkmann ischemic contracture of the forearm is preventable. Eur J Trauma Emerg Surg 2007;33:539–44. Harman JW. The significance of local vascular phenomena in the production of ischemic necrosis in skeletal muscle. Am J Path 1948;24:625–41. von Volkmann R. Die ischaemischen Muskellahmungen und Kontrakturen. Zentralbl Chir 1881;8:801–3. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br 2000;82:200–3. Grottkau BE, Epps HR, Di Scala C. Compartment syndromes in children and adolescentes. J Pediatr Surg 2005;40:678–82. Haasbeek JF, Cole WG. Open fractures of the arm in children. J Bone Joint Surg Br 1995;77:576–81. Cascio BM, Pateder DB, Wilckens JH, et al. Compartment syndrome: time from diagnosis to fasciotomy. J Surg Orthop Adv 2005;14:117–23. Halpern AA, Mochizuki R, Long CE 3rd. Compartment syndrome of the forearm following radial-artery puncture in a patient treated with anticoagulants. J Bone Joint Surg Am 1978;60:1136–37. Greene TL, Louis DS. Compartment syndrome of the arm – a complication of the pneumatic tourniquet. A case report. J Bone Joint Surg Am 1983;65:270–3. Gainor BJ. Closed avulsion of the flexor digitorum superficialis origin causing compartment syndrome. J Bone Joint Surg Am 1984;66:467. Shall J, Cohn BT, Froimson AI. Acute compartment syndrome of the forearm in association with fracture of the distal end of the radius. J Bone Joint Surg Am 1986;68:1451–4. Brumback RJ. Compartment syndrome complicating avulsion of the origin of the triceps muscle. A case report. J Bone Joint Surg Am 1987;69:1445–7.

588

27.

28. 29.

30.

31.

32.

33.

34.

35.

36.

37.

38. 39.

40.

41. 42. 43.

Goldie BS, Jones NF, Jupiter JB. Recurrent compartment syndrome and Volkmann contracture associated with chronic osteomyelitis of the ulna. J Bone Joint Surg Am 1990;72:131–3. Segal LS, Adair DM. Compartment syndrome of the triceps as a complication of thrombolytic therapy. Orthopedics 1990;13:90–2. Burnside J, Costello JM, Angelastro NJ, et al. Forearm compartment syndrome following thrombolytic therapy for acute myocardial infarction. Clin Cardiol 1994;17:345–7. Thomas WO, Harris CN, DÁmore TF, et al. Bilateral forearm and hand compartment syndrome following thrombolysis for acute myocardial infarction. J Emerg Med 1994;12:467–72. Seiler JG 3rd, Valadie JL 3rd, Drvaric DM, et al. Perioperative compartment syndrome. A report of four cases. J Bone Joint Surg Am 1996;78:600–2. Hettiaratchy S, Kang N, Hemsley C, Powell B. Spontaneus compartment syndrome after thrombolytic therapy. J R Soc Med 1999;92:471–2. Elsner K, Giebel G. Compartment syndrome of the triceps brachii muscle after intramedullary nailing. Unfallchirurg 2001;104:363–4. Jost U, Mayer G, Rossmanith T. Complete brachial plexus paralysis caused by compartment syndrome in heroin intoxication. Unfallchirurg 2002;105:392–4. Newman MI, Kent KC, Clair DG, et al. Management strategy for compartment syndrome of the upper extremity arising during anticoagulation or thrombolytic therapy: an increasing surgical dilemma. Ann Plast Surg 2003;51:308–13. Bluman EM, Tashjian RZ, Graves PF, et al. Subathmospheric pressure induced compartment syndrome of the entire upper extremity. J Bone Joint Surg Am 2004;86:2041–4. Ilyas AM, Wisbeck JM, Shaffer GW, et al. Upper extremity compartment syndrome secondary to acquired factor VIII inhibitor. A case report. J Bone Joint Surg Am 2005;87:1606–8. Namboothiri S. Compartment syndrome and systemic hypertension. J Bone Joint Surg Br 2005;87:1420–2. Ragland R 3rd, Moukoko D, Ezaki M, et al. Forearm compartment syndrome in the newborn: report of 24 cases. J Hand Surg Am 2005;30:997–1003. Wippermann B, Schmidt U, Nerlich M. Results of treatment of compartment syndrome of the upper arm. Unfallchirurg 1991;94:231–5. Schmidt U, Tempka A, Nerlich M. Compartment syndrome of the forearm. Unfallchirurg 1991;94:236–9. Oulette EA, Kelly R. Compartment syndromes of the hand. J Bone Joint Surg Am 1996;78:1515–22. Balogh B, Piza-Katzer H. Compartment syndrome. Frequently missed, with severe sequelae. Langenbecks Arch Chir 1995;380:308–14.

Address for Correspondence Dr. Klaus Josef Burkhart Department of Trauma Surgery Johannes Gutenberg-University Mainz Langenbeckstrasse 1 55131 Mainz Germany Phone (+49/6131) 17-2845, Fax -6687 e-mail: [email protected]

Eur J Trauma Emerg Surg 2007 Æ No. 6 Ó URBAN & VOGEL

Acute Compartment Syndrome of the Upper Extremity.

Compartment syndrome of the upper extremity is rare, but happens frequently. It most often affects the forearm, compartment syndromes of the upper arm...
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