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Acute Hand Compartment Syndromes After Closed Crush: a Reappraisal

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Acute Hand Compartment Syndromes After Closed Crush: a Reappraisal Acute Hand Compartment Syndromes after Closed Crush: A Reappraisal Francisco del Piñal, M.D., Dr. Med., Francisco Herrero, M.D., Emilia Jado, M.D., Francisco J. García-Bernal, M.D., Dr. Med., and Luis Cerezal, M.D. Santander, Spain Severe crush to the hand is associated with a poor intrinsic muscles, known as Finochietto’s prognosis. The authors investigated the hypothesis that contracture.6,7 compartment syndrome complicates such injuries. From 6,8 1996 to 2000, the authors retrospectively identified 11 Zancolli identified three types of ischemic patients who, after sustaining a closed crush injury, de- contracture involving the hand: generalized, veloped acute hand compartment syndrome. Diagnosis which affects all compartments of the hand; was made on clinical grounds in two patients (the intra- localized, which affects only a group of com- compartmental pressure was not measured) and after clin- partments, mostly referring to the radial- ical examination plus measurement of intracompartmen- tal pressure in nine patients. In all cases, the muscle burst thenar; and atypical, which affects single or out once the fascia was released from the affected com- unevenly distributed compartments. The syn- partment. Clinical clues to elicit the diagnoses were mas- drome is characterized by flexion at the meta- sive hand swelling and tenseness to palpation. Classic carpophalangeal joint, extension of the proxi- symptoms, such as excruciating pain, were absent or their mal and distal interphalangeal joints of the intensity was attributed to the trauma event (in six pa- tients). Classic signs such as intrinsic muscle minus posi- fingers, and retropulsion or adduction-palmar 6–10 tion and pain on stretching were absent in six and three abduction of the thumb (in the palm). patients, respectively. In addition, the latter stretch test In this study, we investigated the hypothesis could not be properly judged in five more patients be- that acute compartment syndrome surrepti- cause of interference by the associated injuries. None of tiously aggravates crush injuries to the hand. the patients developed contracture or sequela that could be attributed to compartment syndrome. On the basis of Furthermore, we emphasize the need for the this experience, it was concluded that crush injury does surgeon to actively look for compartment syn- not in itself carry a poor functional prognosis, provided drome and to measure the intracompartmen- that attention is paid to the often-concomitant compart- tal pressure, because the clinical signs may be ment syndrome. Elevated subfascial pressure may be scant and nonpathognomonic. present despite the absence of classic signs and symptoms. (Plast. Reconstr. Surg. 110: 1232, 2002.) PATIENTS AND METHODS Over a 5-year period (January of 1996 to Severe crush to the hand has traditionally December of 2000), the authors retrospectively been associated with a poor functional out- identified 11 patients who required urgent sur- come.1–4 It should be noted, however, that fail- gical decompression of the intrinsic muscles ure to release swelling muscles confined in (all or some) of the hand after sustaining a closed osteofascial compartments invariably closed crush. All patients in the study group causes muscle death and, subsequently, con- were male, 20 to 57 years of age, involved in tracture.5 Irreversible damage to the muscle heavy labor, and covered under workers’ com- enclosed in the osteofascial compartments of pensation. Not included in this study were the hand causes ischemic retraction of the those patients with open crush injuries whose From Instituto de Cirugía Plástica y de la Mano, Hospital Mutua Montañesa, and Clínica Mompía. Received for publication October 26, 2001; revised January 28, 2002. Presented at the 10th Kleinert Society Clinical Reunion, Louisville, Kentucky, September 30 to October 3, 2001. DOI: 10.1097/01.PRS.0000025183.78057.9B 1232 ily in every case to protectforearm the compartment median (patient nerve, 11). quired treatment for antained associated a acute volar crushDiscussion to section). the Adertaken hand final after and opening patient, forearm, therelease who carpal of re- sus- tunnel the volar (see was antebrachial higher fascia than wasthe un- 30 tissue mmHg. pressure In insias three the in patients, carpal the compartment if median preoperatively the nerve patient distribution referred paresthe- and/or the upper normal limit. manufacturer, and 30surements mmHg were performed was as selectedgical suggested by as Co., the Kalamazoo,monitor designed Mich.) for this was purposewas (Striker used. Sur- a Mea- crush.swollen, particularly if A the mechanism hand-heldmental of pressure injury in digital any patient transducer was whose hand maintained was palpation. in In measuring addition,thesias intracompart- a in some low-threshold or policy allintrinsic fingers, minus and stance, tenseness hypoesthesias on taneously or or elicited pares- duringmarked the intrinsic swelling, test, disproportionatement pain syndrome spon- wasferred suspected to on in the Tableand I. basis The of grading diagnosis offirst of compart- surgeons the were involvedrelated. signs In in every and the case, assessment mately one symptoms (or 600 both) re- hand of injuriescenters the two per that, year, between most work- them, receivepartments approxi- remained intact. exclusion provided thatence the of ragged underlying skinsame com- flaps or neighboring was compartments. notthe The a pres- injury reason and for requiredcompartments were further spontaneously release released of by the Vol. 110, No. 5 books. technique canforms. be Detailed founderalized information in form) or on the as requiredsions the classic in more if surgical text- localized allthenar, compartments one were hypothenar, affectedpartments and (gen- was two undertaken dorsalgery at inci- by 12 hours). meansin Release of all of the except one affectedout for com- delay case ( 11,pressure who in underwent nine, sur- surgeryical was performed plus with- mental pressure recording was not measured),ical intracompartmental or grounds on in clin- two patients (the intracompart- Closure of the carpal canal was done primar- Patients were recruited from two casualty Once the diagnosis was made, either on clin- 15,16 The carpal tunnel was released only Ͻ 6 hours after the traumatic event / ACUTE HAND COMPARTMENT SYNDROMES 12 – 14 11 TABLE I Assessment and Grading of Signs and Symptoms of Compartment Syndrome Intrinsic Patient/Age/ Compartment Minus Paresthesias/ Pain on Compartment Dominance Affected* Pain† Swelling† Position Hypoesthesia Stretch Test† Tenseness† Associated Injuries‡ ICP/Compartment§ 1/26/ND L ϩϩϩ ϩϩϩϩ No No ࿣ ϩϩϩϩ 1st MPJ dislocation 50/thenar 2/57/D L ϩϩϩϩ ϩϩϩϩ No Thumb ࿣ ϩϩϩϩ 1st MPJ Fx/thumb ischemic Not done 3/46/ND G ϩϩ ϩϩϩϩ Yes No ࿣ ϩϩϩϩ Comminuted Fx MPJ 2–5 73/hypothenar 4/45/ND A ϩϩ ϩϩϩ No No ϩϩϩ ϩϩϩ None 98/2nd web space 5/24/D GϩACTϩDTF ϩϩϩ ϩϩϩ Yes Median ϩϩϩ ϩϩϩϩ Acute scapho-lunate dissociation 60/carpal tunnel 6/30/ND GϩACTϩDTF ϩϩ ϩϩϩ Yes Median ϩϩ ϩϩϩ Intraarticular distal radius Fx 58/thenar 7/31/ND GϩACT ϩϩ ϩϩϩϩ Yes Median ϩϩϩϩ ϩϩϩ None Not done 8/24/D GϩACTϩDTF ϩϩϩ ϩϩϩϩ Yes Median ࿣ ϩϩϩϩ Fx dislocation CMC joint 1–5 95/thenar 9/32/D LϩACT ϩϩϩϩ ϩϩϩϩ No Third finger ϩϩ ϩϩϩϩ None 80/thenar 10/20/D GϩACT ϩϩϩ ϩϩϩϩ No Median ϩ ulnar ࿣ ϩϩϩ 1 MT Fx/3–5 Fx- dislocated CMC 66/1st web space 11/52/D AϩACTϩVF ϩϩ ϩϩ No Median ϩ ulnar ϩ ϩϩϩ Intraarticular distal radius Fx 42/thenar¶ * L, localized hand compartment; G, generalized hand compartment; A, atypical hand compartment; ACT, acute carpal tunnel; DTF, distal third of the forearm; VF, full volar forearm. † 0, normal to 4ϩ, maximum. ‡ MPJ, metacarpophalangeal joint; Fx, fracture; CMC, carpal metacarpal; MT, metatarsal. § ICP/Comp, intracompartmental pressure in mmHg and recorded values in the most affected compartment. 1233 ࿣ Difficult to assess because of the associated injuries. ¶ In this patient the maximal pressure was at the volar forearm (48 mmHg). 1234 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2002 and efforts were made to attempt primary skin the current injury. The width of the first web closure, or to mobilize local tissues, when nec- was comparable with that of the normal side in essary to protect underlying synthesis material. all patients. No sensory loss was reported at the The rest of the wounds were left open to close latest follow-up, and two-point discrimination secondarily (at approximately 1 week) or to was comparable with that of the normal side. receive a skin graft as required. Patient 5, however, had hypesthesia in the me- Associated injuries were common (Table I) dian territory, which slowly improved to nor- and, as stated above, some patients presented mal over a 3-month period. In this patient, bruised and ragged flaps that at times required during carpal tunnel release the median nerve secondary skin grafts. Losses of muscle mass was found to be hemorrhagic (possibly because secondary to the crush event were seen fre- of the traumatic event), and epineurotomy and quently and were debrided. hematoma debridement were performed. At the latest follow-up, the patients were eval- All but two patients returned to their prein- uated for intrinsic muscle tightness, including jury heavy-labor jobs. Patient 3, a miner, re- the Finochietto-Bunnell test,6,9 and were asked jected a tenolysis of the extensor tendons and to actively place their fingers in intrinsic plus retired. Patient 6, a mason, complained of wrist and minus (hook) to assess the contraction pain secondary to concomitant intraarticular and gliding of the interosseus. The width and distal radius fracture; this patient is currently suppleness of the first web was compared with unemployed and pursuing litigation. that of the normal side. The patients were questioned in relation to pain, paresthesias, or DISCUSSION diminished sensation in the median or ulnar Multiple etiologic causes have been impli- nerve distribution. Range of motion and grip cated in Finochietto’s ischemic retraction: strength were also studied but were found to crush,6,9 tight hand casts,9 proximal arterial in- be related to the associated injuries and so juries,9 burns,17 massive extravasation from ar- were disregarded.
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