Management of Forearm Compartment Syndrome
Section snippets
Pathophysiology
The most popular theory regarding the pathophysiology of compartment syndrome, including that of the forearm, is the arteriovenous pressure gradient differential theory [23], [24], [25]. This theory postulates that as the compartment pressure rises, intraluminal venous pressure also rises leading to a reduction in the arteriovenous pressure gradient. Because of the lack of musculature in the venule wall media, only a relatively small rise in pressure is required to collapse the venule walls.
Anatomy
There are four compartments of the forearm: dorsal, superficial volar, deep volar, and the mobile wad. The anatomy of the forearm is such that the deeper forearm musculature is, in general, more prone to ischemic and compressive injury because of fascial boundaries that serve to prevent expansion of these muscles. The radius and the ulna are bridged by the very stiff interosseous membrane. Immediately volar to this membrane are the flexor pollicis longus and flexor digitorum profundus muscles.
Diagnosis
In general, the diagnosis of forearm compartment syndrome is a clinical one based on a keen index of suspicion, but is often supplemented by objective diagnostic testing. Traditionally, it has been taught that compartment syndrome will manifest itself with the five “P's”: pain, pallor, pulselessness, pain with passive stretch of muscles, and paresthesias. However, one should note that pulselessness is typically a late or even end-stage finding and does not always accompany compartment syndrome;
Nonoperative treatment
The phrase “nonoperative treatment of compartment syndrome” is a bit of a misnomer because if a patient truly has a forearm compartment syndrome, surgical treatment is a must. There are case reports in the literature that are listed as compartment syndromes, and were successfully treated with observation [10], [16]; however, by their own admission, they were “transient,” from which one can infer that true ischemia had not occurred. Our own anecdotal experience contains patients who have had
Surgical techniques
Once the diagnosis of forearm compartment syndrome is made based on clinical exam and objective data, it is of the utmost importance to intervene quickly. Whereas some groups have written about observation of compartment syndrome without surgical decompression it should be noted that these are isolated case reports and there is some question as to whether the diagnosis of forearm compartment syndrome truly applied in these patients' cases [10], [16]. If a patient is given the diagnosis of
Outcomes
Although compartment syndrome of the forearm has the potential for devastating consequences, if intervention is provided on a prompt basis, quite often these patients will recover fully with minimal residual dysfunction of the forearm or hand [9], [11], [17], [21], [32]. At this time, there are no prospective studies that demonstrate the amount of recovery that can be expected following decompression. There was, however, a recent study attempting to correlate outcome with time elapsed from
Volkmann's ischemic contracture
The most widely used classification of ischemic contracture of the forearm was provided by Tsuge (Table 1) [1]. This is a three-part classification scheme in which class 1 is mild ischemic contracture affecting mainly the flexor digitorum profundus (FDP). Class 2 affects the FDP as well as the flexor pollicis longus, pronator teres, and to some degree the flexor digitorum superficialis and flexor carpi ulnaris. The most severe class of injury within Tsuge's classification is class 3, which
Chronic compartment syndrome
When discussing forearm compartment syndrome, one must mention the entity that has been deemed chronic compartment syndrome. Although this problem does not share the same pathophysiology as does that of acute compartment syndrome, some of the same principles of diagnosis and treatment apply. It is generally agreed that chronic compartment syndrome is an effect of exertion of the forearm musculature and is commonly seen in persons who perform high-impact exercise or work activities [3], [41],
Summary
Forearm compartment syndrome is a potentially calamitous problem that can befall persons with either injuries or external compression of the forearm. The absolute necessities for a good outcome are early suspicion of forearm compartment syndrome and expeditious surgical intervention. One must be acutely aware of the prospect of compartment syndrome in the settings of forearm diaphysis and distal radius fractures. If forearm fasciotomies are provided to the patient in a rapid fashion, one can
References (42)
- et al.
Management of established Volkmann's contracture of the forearm in children
Hand Clin
(2006) - et al.
Compartment syndrome in children and adolescents
J Pediatr Surg
(2005) - et al.
Isolated ischemic contracture of the mobile wad: a report of two cases
J Hand Surg [Br]
(2004) - et al.
Case report: compartment syndrome after a suspected black widow spider bite
Ann Emerg Med
(2005) - et al.
Compartment syndrome caused by suction
Injury
(2004) - et al.
A case of forearm compartment syndrome following a ring avulsion injury
Injury
(2002) - et al.
Compartment syndrome of the hand following intra-arterial injection of heroin
J Hand Surg [Br]
(1999) - et al.
Transient compartment syndrome of the forearm resulting from venous congestion from a tourniquet
J Hand Surg [Am]
(1989) - et al.
Compartment syndrome of the pronator quadratus: a case report
J Hand Surg [Am]
(1997) - et al.
Compartment syndrome of the forearm following an electromyographic assessment
J Hand Surg [Br]
(2005)
Current concepts in the pathophysiology, evaluation, and diagnosis of compartment syndrome
Hand Clin
Acute compartment syndromes
Surg Clin North Am
Compartment syndromes in obtunded patients
Hand Clin
Forearm compartment syndrome in the newborn: report of 24 cases
J Hand Surg [Am]
Volkmann's ischaemic contracture of the forearm
Injury
Volkmann's ischemic contracture
Clin Plast Surg
Treatment of established Volkmann's contracture
J Bone Joint Surg Am
Results of compartment decompression in chronic forearm compartment syndrome: six case presentations
Br J Sports Med
Diagnosing acute compartment syndrome
J Bone Joint Surg Br
Acute compartment syndrome. Who is at risk?
J Bone Joint Surg Br
Compartment syndrome following intravenous regional anesthesia
Can J Anaesth
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Complications of transradial cardiac catheterization and management
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