Acute Compartment Syndrome of the Upper Extremity

Review Article Acute Compartment Syndrome of the Upper Extremity

Abstract Mark L. Prasarn, MD Acute compartment syndrome occurs when pressure within a ﬁbro- Elizabeth A. Ouellette, MD osseous space increases to a level that results in a decreased perfusion gradient across tissue capillary beds. Compartment syndromes of the hand, forearm, and upper arm can result in tissue necrosis, which can lead to devastating loss of function. The etiology of acute compartment syndrome in the upper extremity is diverse, and a high index of suspicion must be maintained. Pain out of proportion to injury is the most reliable early symptom of impending compartment syndrome. Diagnosis is particularly difficult in obtunded patients and in young children. Early recognition and expeditious surgical treatment are essential to obtain a good clinical outcome and prevent permanent disability.

ompartment syndrome was first most frequent causes of compart- Cdescribed in 1881 by Richard ment syndrome in the upper extrem- von Volkmann.1 The etiology, patho- ity.1,2 Compartment syndrome is a physiology, and management of clinical diagnosis, and it can be diffi- compartment syndrome and the as- cult to make in certain patient popu- sociated complications have been ex- lations, such as persons who are ob- tensively described. Acute compart- tunded and children.2-5 Emergent ment syndrome (ACS) occurs with surgical treatment is required; the elevation of interstitial pressure in a most important determinant of out- closed fascial compartment, resulting come is early recognition and expedi- in microvascular compromise. This tious surgical intervention.3,5-9 Re- From the Department of causes the perfusion gradient to fall constructive procedures can be Orthopaedics, University of below a critical value, leading to is- performed to improve the function Rochester, Rochester, NY chemia of the tissues within this con- of the affected upper extremity in the (Dr. Prasarn), and Physicians for patient with Volkmann contracture; The Hand, Miami, FL (Dr. Ouellette). fined space. In the upper extremity, the dorsal and volar compartments however, return of normal function Dr. Ouellette or an immediate family should not be expected.10-16 member serves as a paid consultant of the forearm are the most com- to or is an employee of Stryker. monly affected. Upper extremity Neither Dr. Prasarn nor any ACS can lead to devastating loss of immediate family member has Anatomy received anything of value from or function, including Volkmann ische- owns stock in a commercial mic contracture, neurologic deficit, The upper extremity contains 15 company or institution related infection, amputation, and death. compartments. The upper arm con- directly or indirectly to the subject of A wide range of causes of ACS in this article. sists of a flexor (ie, volar) compart- the upper extremity has been re- ment and an extensor (ie, dorsal) J Am Acad Orthop Surg 2011;19: ported, and a high index of suspicion 49-58 compartment. The forearm is divided must be maintained. Distal radius into three compartments: volar, dor- Copyright 2011 by the American fracture in adults and supracondylar sal, and lateral (ie, mobile wad) (Fig- Academy of Orthopaedic Surgeons. humerus fracture in children are the ure 1). The hand has 10 compart-

January 2011, Vol 19, No 1 49 Acute Compartment Syndrome of the Upper Extremity

Figure 1 this membrane lie the flexor digitorum profundus, flexor pollicis longus, and pronator quadratus muscles. Some consider the pronator quadratus to lie within an additional compartment of the distal volar forearm, separate from the flexor tendons at this level.20 These deep volar muscles are the most commonly damaged muscles in forearm compartment syndrome. The remaining, more superficial flexor muscles are less prone to ischemia than their deeper counterparts. The finger and wrist extensors lie on the posterior aspect of the forearm. Isolated exercise-induced compartment syndromes of the extensor carpi ulnaris muscle have been noted in case re- ports.21,22 The mobile wad, which consists of the brachioradialis, flexor carpi radialis longus, and flexor carpi radialis brevis tendons, is rarely Cross section at the junction of the proximal and middle thirds of the forearm involved.12 The antebrachial fascia, demonstrating the compartments and the important neurovascular structures. The volar compartment contains the flexor muscles of the wrist and digits, which is a continuation of the bra- including the flexor digitorum superficialis (FDS), flexor carpi radialis (FCR), chial fascia, envelops the compart- flexor pollicis longus (FPL), flexor digitorum profundus (FDP), and flexor carpi ments and muscles in the forearm. ulnaris (FCU), as well as the ulnar nerve (UN), ulnar artery (UA), median nerve (MN), median artery (MA), radial artery (RA), superficial branch of the The compartments of the hand are radial nerve (RN), anterior interosseous artery (AIA), and anterior divided by the carpal bones, metacar- interosseous nerve (AIN). The dorsal and volar compartments are separated pals, and individual investing fascial by the interosseous membrane. The dorsal compartment contains the finger layers. Pressures within the carpal tun- and thumb extensors and the long thumb abductor as well as the posterior interosseous artery (PIA), posterior interosseous nerve (PIN), extensor carpi nel may become elevated in cases of ulnaris (ECU), extensor pollicis longus (EPL), and extensor digitorum hand or volar forearm compartment communis (EDC). The mobile wad, which is often considered to be a third syndrome. Release of the transverse compartment, is composed of the extensor carpi radialis brevis and longus carpal ligament is often necessary in muscles (ECR) and the brachioradialis (BR). (Reproduced with permission from Ouellette EA: Compartment syndromes in obtunded patients. Hand Clin addition to release of the other in- 1998;14[3]:431-450.) volved compartments. The digital fascial compartments are bound by the Cleland ligament and the Grayson lig- ments: hypothenar, thenar, and tal fasciotomy is necessary in some ament, and elevated pressure may oc- adductor pollicis as well as four dor- cases19 (Figure 3). cur in individual digits (Figure 3). sal interosseous and three volar in- In the upper arm, the medial and Compartment syndrome of the hand terosseous17 (Figure 2). The volar the lateral intermuscular septa sepa- typically necessitates carpal tunnel re- forearm is the most commonly af- rate the flexor compartment from lease and dorsal interosseous compart- fected compartment in the upper ex- the extensor compartment. The bra- ment releases; however, any compart- tremity. Compartment syndrome in chial fascia is a dense fibrous sheath ment may be involved and may require this area typically occurs following that surrounds the muscles in each of release. The decision regarding the fracture of the distal radius, supra- the two compartments. In the fore- number and location of incisions condylar humerus, or diaphysis of arm, the stiff interosseous membrane should be based on the clinical findings the radius or ulna.2,17,18 Any compart- bridges the distance between the ra- and on intraoperative pressure mea- ment can be affected, however. Digi- dius and the ulna. Just anterior to surements.3

50 Journal of the American Academy of Orthopaedic Surgeons Mark L. Prasarn, MD, and Elizabeth A. Ouellette, MD

Etiology Figure 2

ACS of the upper extremity is caused by a myriad of factors, including fracture, bleeding disorders, constrictive dressing and casting, arterial injury, extravasation of intravenous or intraosseous infusion, and regional anesthesia3-5,23-35 (Table 1). Anything that causes increased volume within the confined fascial space (eg, bleeding, edema, purulent material, extra- neous fluids) or restricts the compartment from expanding (eg, burn, casting, dressing, tourniquet) can cause ACS. It is difficult to estimate the true incidence of compartment syndrome of the upper extremity, but most Cross section at the level of the metacarpal shafts demonstrating the 10 cases occur in the setting of fracture. compartments of the hand: hypothenar, thenar, and adductor pollicis as well McQueen et al17 analyzed 164 pa- as four dorsal interosseous and three volar interosseous. (Reproduced with permission from Ouellette EA: Compartment syndromes in obtunded tients with traumatic ACS. In 69% patients. Hand Clin 1998;14[3]:431-450.) of cases, compartment syndrome was associated with fracture. The most frequent fracture types observed fractures of the distal end of the ra- to decreased arteriolar pressure and were of the tibial diaphysis (36%), dius is substantially higher with con- possibly closure of end arterioles, the distal radius (9.8%), and the di- comitant ipsilateral elbow injury leading to a further decrease in tissue aphysis of the forearm bones (7.9%). than with distal radial fracture perfusion4 (Figure 4). Only 2.5% occurred following hand alone.36 fracture, and the incidence was 0.6% Ischemia occurs when a critical each for elbow fracture-dislocation threshold is reached in the local arte- and humeral fracture. Soft-tissue in- Pathophysiology riovenous gradient and when circula- jury without fracture was the second tion is compromised to the point that most common cause of injury Compartment syndrome is caused by blood flow is insufficient to meet the (23.2%). Incidence in the forearm an elevation of pressure within a metabolic demands of the tissue.4 and hand was 5.5% and 0.6%, re- fibro-osseous space resulting in de- This critical variable is represented spectively. Within this subgroup, creased tissue perfusion. The initial by the absolute difference between 10.3% occurred in patients with rise in intracompartmental pressure compartment pressure and blood bleeding disorders or who were tak- causes increased extravascular ve- pressure.37 Heppenstall and col- ing anticoagulants. nous pressure. Because of lack of leagues38,39 prefer to compare intra- Grottkau et al2 reviewed a national musculature in the wall media, this compartmental pressure with mean trauma database and found the inci- relatively small rise in pressure arterial pressure, but diastolic blood dence of pediatric forearm compart- causes the venule walls to collapse. pressure is easier to obtain and cal- ment syndrome to be 1%. Ouellette The resulting decrease in hydrostatic culate. Experimental data in a canine and Kelly3 reported on 19 patients gradient causes reduced local perfu- model have shown that terminal ar- with compartment syndrome of the sion and increased interstitial pres- terial pressure is equal to diastolic hand. Most cases were iatrogenic, re- sure. This increased interstitial pres- blood pressure;40 thus, we use dia- sulting from complications related to sure in turn causes increased edema stolic blood pressure to determine intravenous or intra-arterial adminis- within the compartment, and this the critical threshold. tration of drugs. The incidence of cascade of events repeats itself per- In a canine study, muscle necrosis compartment syndrome in unstable petually.12 Vasospasm and shock lead occurred when the intracompart-

January 2011, Vol 19, No 1 51 Acute Compartment Syndrome of the Upper Extremity

Figure 3 Table 1 Causes of Compartment Syndrome of the Upper Extremity3-5,23-35 Fracture Crush injury Injection injury Ring avulsion Suction injury Penetrating trauma Constrictive dressings Casts Burns Infection Bleeding disorders Spider bite Snakebite Arterial injury Reperfusion In utero compression Extravasation of infusions Injection of illicit drugs Regional anesthesia Prolonged compression

Finger decompression. A, Illustration demonstrating a midaxial incision made on the index finger. This incision is made on the ulnar side of digits 2 through 4 and on the radial side of digits 1 and 5. The neurovascular bundles are are poor even with expedient fasciot- identified and retracted volarward, and the fascia between them is cut along omy. Pain out of proportion to in- with the flexor sheath. B and C, Clinical photographs following fasciotomies of the hand and digits. (Reproduced with permission from Ouellette EA: jury and pain with passive stretching Compartment syndromes in obtunded patients. Hand Clin of muscles in the involved compart- 1998;14[3]:431-450.) ment are the earliest indicators of compartment syndrome.23 Compart- ment syndrome also should be sus- mental pressure rose to a level 20 tude of these systemic effects is de- pected with tense, swollen compart- mm Hg below diastolic blood pres- pendent on the duration of ischemia ments. In a series of patients with sure.40 Heckman et al41 demonstrated and the size of the muscle compart- compartment syndrome of the hand, that irreversible changes to the pe- ments involved.4 Ouellette and Kelly3 demonstrated ripheral nerves and skeletal muscle that the most consistent clinical find- occur following 8 hours of complete ing was a tense, swollen hand in an ischemia. Following onset of cellular Clinical Evaluation intrinsic minus position (ie, exten- anoxia, affected cells begin anaero- sion of the metacarpophalangeal bic metabolism and may die. Devas- Historically, the five Ps (pain, pallor, joints and flexion of the intercarpal tating loss of function may occur fol- pulselessness, paralysis, paresthesia) joints) (Figure 5). lowing substantial loss of muscle and were taught as the symptoms that ACS is typically diagnosed clini- neural tissue in the upper extremity. herald compartment syndrome. cally. However, it may be necessary Muscle ischemia can lead to release Pulselessness is rare, occurring only to measure compartment pressure of myoglobin, which can cause myo- after arterial injury. Most of these (Figure 6). Animal studies demon- globinuria, metabolic acidosis, and symptoms present only after a sub- strate that compartment syndrome is hyperkalemia. Renal failure, cardiac stantial amount of time has elapsed indicated in the presence of a differ- arrhythmia, cardiac failure, and following the onset of compartment ence between diastolic blood pres- shock may then ensue. The magni- syndrome, and outcomes typically sure and the compartment measuring

52 Journal of the American Academy of Orthopaedic Surgeons Mark L. Prasarn, MD, and Elizabeth A. Ouellette, MD

Figure 4

Algorithm demonstrating the cascade of events in the pathophysiology of compartment syndrome.

Figure 5 examinations and pressure measurements. Increasing swelling and rising pressures warrant decompression even when the pressure differential is ≤20 mm Hg. Emergent fasciotomy is also performed in the setting of a concerning physical examination and extremely elevated pressures, even with a pressure differential of >20 mm Hg. Compartment pressure should be measured when suspected in a patient who is uncooperative, A and B, Photographs demonstrating a tense, swollen hand and forearm. who has an altered mental status, or The hand is held in the intrinsic minus position. (Reproduced with permission whose young age renders the clinical from Prasarn ML, Ouellette EA, Livingstone A, Giuffrida AY: Acute pediatric examination inadequate.3-6,8,23 In pe- upper extremity compartment syndrome in the absence of fracture. J Pediatr diatric patients, Bae et al6 demon- Orthop 2009;29[3]:263-268.) strated that an increased need for an- algesics was most predictive of compartment syndrome. ≤20 mm Hg40 or a difference be- pressure and the compartment of tween mean arterial pressure and the ≤20 mm Hg to be an absolute indica- compartment measuring ≤30 mm tion for emergent fasciotomy. In the Compartment Pressure Hg.41 Fasciotomy is often performed patient with swollen compartments Measurement in patients with absolute pressure and nearly normal pressures (<30 measuring >30 mm Hg.6,42 We con- mm Hg absolute pressure), we advo- We typically measure compartment sider a differential between diastolic cate waiting and performing serial pressures in patients with equivocal

January 2011, Vol 19, No 1 53 Acute Compartment Syndrome of the Upper Extremity

Figure 6 that the Whitesides manometer lacks the precision required for clinical use.

Fasciotomy

The main goals in the management of ACS of the upper extremity are expedient release of all fascial and epimysial envelopes and decompression of all affected compartments and nerves. Compartments that are clearly affected clinically are released, and those that cannot be examined adequately are measured with the Intra-Compartmental Pres- sure Monitor System or an arterial manometer. Pressure in the carpal tunnel is measured when involvement of that area is suspected. Pres- sure measurement ≥20 mm Hg with decreased sensation and/or dimin- ished strength in the thenar muscles Algorithm for evaluating and managing suspected compartment syndrome. is an indication for open carpal tunnel release. Ronel et al20 described a technique examination and in those who can- tained at other sites. that allows decompression of the su- not be examined fully. An equivocal The two most common measure- perficial muscles and the deep mus- examination is one in which com- ment techniques involve the use of a cles of the volar forearm as well as partment syndrome is suspected and slit catheter or a side port needle. release of the median nerve at possi- uncertainty exists regarding the clini- Straight needles have been shown to ble sites of compression. We use this cal examination. Measurements are provide less accurate results.43 The approach because it causes the least also often taken in the operating the- catheter may be left in situ for repeat amount of iatrogenic injury to the ater to verify which compartment or or continuous pressure measure- superficial muscles, arteries, and compartments are affected and to en- ments. In the past, we used an arte- nerves compared with other de- sure that they are fully decompressed rial line and a pressure transducer scribed approaches to the volar fore- following fasciotomy. Compartments similar to the continuous-infusion arm. A longitudinal skin incision is that clinically appear to be involved technique described by Matsen,8 but made beginning just radial to the are tested, and measurements are we did not use the infusion pump. flexor carpi ulnaris at the wrist. The taken when the compartment ap- More recently we have begun using incision is extended proximally to pears to be the most tense and swol- the Stryker Intra-Compartmental the medial epicondyle, then curved len. In the case of associated frac- Pressure Monitor System (Stryker, radially over the antecubital fossa ture, the catheter is inserted close to Kalamazoo, MI), which is more con- (Figure 7). Distally, the incision may the fracture site. Otherwise, mea- venient and requires no setup. Boody be extended to the midline to incor- surements are taken at the location and Wongworawat43 evaluated three porate open carpal tunnel release. that is most accessible to the com- commonly used modalities for com- The lacertus fibrosus and fascia over partment. Typically, a single mea- partment pressure measurement and the flexor carpi ulnaris are opened. surement is taken for each suspected found an arterial manometer to be The flexor carpi ulnaris is retracted compartment. When in doubt re- the most accurate method, followed ulnarly, and the flexor digitorum su- garding the resulting pressure value, by the Intra-Compartmental Pressure perficialis is retracted radially to al- repeat measurements should be ob- Monitor System. They concluded low visualization and opening of the

54 Journal of the American Academy of Orthopaedic Surgeons Mark L. Prasarn, MD, and Elizabeth A. Ouellette, MD fascia over the deep muscles of the Figure 7 forearm. Release of the volar compartment often results in decompression of the dorsal compartment and the mobile wad, as well. Should the pressures remain elevated in the dorsal compartment or the mobile wad, a second fasciotomy is performed. We use a dorsal longitudinal incision extend- ing from 2 cm distal to the lateral epicondyle of the humerus toward the midline of the wrist. Deep dissection is made through the interval between the extensor digitorum communis and the extensor carpi radialis brevis. This allows decompression of the musculature in the dorsal compartment and the mobile wad. Release of the volar and dorsal interosseous compartments and the adductor compartment to the thumb is begun by making two longitudinal incisions dorsally over the 2nd and 4th metacarpals (Figure 2 and Figure 8). The fascia over the dorsal interosseous muscles is incised. To de- compress the first volar interosseous and adductor pollicis muscles, blunt dissection is performed along the ulnar side of the 2nd metacarpal through the more radial incision. The second and third volar interosseous compartments are released by dissecting along the radial aspect of the 4th and 5th metacarpals through the more ulnar incision. To release the thenar and hypothenar compartments, longitudinal incisions are made at the junctions of the glabrous and nonglabrous skin over the radial side of the 1st metacarpal and the ulnar side of the 5th metacarpal. Compartment syndrome of the upper arm is rare. The anterior and the Surgical approaches to the volar compartment of the forearm. A, Illustration demonstrating the skin incision for the ulnar approach. B, The interval posterior compartments can be de- between the flexor carpi ulnaris muscle and the flexor digitorum superficialis compressed through a single medial muscle is entered. C, After the ulnar nerve and artery are identified and or lateral incision. Maginn and El- protected, the fascia over the deep compartment is opened completely. liot44 suggested that the creation of D, Incision for the Henry approach, which is performed through the interval between the flexor carpi radialis and the brachioradialis muscles. two separate midline incisions di- (Reproduced with permission from Ouellette EA: Compartment syndromes in rectly over the anterior and posterior obtunded patients. Hand Clin 1998;14[3]:431-450.) compartments causes less disruption

January 2011, Vol 19, No 1 55 Acute Compartment Syndrome of the Upper Extremity

Figure 8 nosis to treatment is reported to be 6 Wound Closure to 24 hours.3-6,8,9,23,37,47 Irreversible damage has been shown to occur af- Wounds are typically left open and ter 8 hours in a canine model.40 Full initially are covered with sterile wet- recovery with minimal residual dys- to-dry dressings. The skin should not function can be expected with be closed acutely following fasciot- prompt diagnosis and intervention of omy. We do not routinely use reten- compartment syndrome of the upper tion sutures or rubber catheters to extremity.3-6,12,13,25,48 Delay beyond 6 prevent wound edge retraction. In to 24 hours may result in Volkmann wounds with exposed tendon, bone, ischemic contracture, neurologic def- or neurovascular structures, a bovine icit, infection, amputation, or death. collagen matrix wound dressing (In- How late is too late to perform tegra artificial dermis; Integra Life- surgical decompression? In most Sciences, Plainsboro, NJ) is applied cases the exact time of onset of com- to prevent desiccation. This can be partment syndrome cannot be deter- grafted over later. The patient is re- mined; thus, it is impossible to deter- turned to the operating suite after 48 mine its duration. In such instances, to 72 hours for irrigation and dé- the clinical examination is relied on bridement. Delayed primary wound heavily. Voluntary muscle contrac- closure may be done at this time, as Illustration demonstrating two tion in the setting of compression is longitudinal incisions made over well. In the patient with muscle ne- indicative of the existence of viable the 2nd and 4th metacarpals to crosis, all nonviable muscle is release the dorsal and volar muscle, and emergent fasciotomy sharply débrided. When muscle via- interosseous compartments and should be performed. In the patient the adductor compartment of the bility is a concern, repeat débride- with no demonstrable muscle func- thumb. (Reproduced with ment is done every 48 hours. Under- tion, the best treatment may involve permission from Ouellette EA: mining the skin flaps often assists Compartment syndromes in supportive care for myoglobinuria with tension-free closure. For obtunded patients. Hand Clin and aggressive splinting to maintain 1998;14[3]:431-450.) wounds that cannot be closed, a the arm and hand in a functional po- vacuum-assisted wound closure sys- sition.37 tem (VAC Therapy System; KCI, San Ouellette and Kelly3 noted poor re- Antonio, TX) is placed, and split- sults in 4 of 19 patients with hand thickness skin grafting is performed to the perforating septal vessels, re- compartment syndrome. All four pa- at a later date. Potential advantages sulting in decreased iatrogenic ische- tients were obtunded at the time of of a vacuum-assisted closure system mia to the muscles and flaps com- onset, and two required amputation. include shorter hospital stays, re- pared with a single medial incision. A high index of suspicion for com- duced need for skin grafting, and a In our experience, compartment syn- partment syndrome must be main- lower rate of nosocomial infec- drome in the upper extremity is usu- tained in persons who are who are tion.45,46 ally associated with humeral frac- difficult to examine and who cannot ture, which requires open reduction communicate effectively. Gelberman and internal fixation. This cannot be Outcomes and et al49 reported the results of surgical done through a medial approach. It Complications decompression of compartment syn- is rare that both compartments are drome of the forearm in 10 patients. involved. Thus, we make a longitudi- Outcomes following compartment No patient developed Volkmann nal incision over the affected com- syndrome are dependent on injury contracture, but only two patients partment to first perform thorough severity, duration of ischemia, and had normal postoperative results. Six decompression. We use the same in- preinjury status and comorbidities. patients who underwent volar fas- cision for open reduction and inter- The amount of infarction varies con- ciotomy required supplemental skin nal fixation of the fractured hu- siderably, as do outcomes. Time grafting. The worst results were ob- merus. If the other compartment is from diagnosis to fasciotomy is the served in patients with severe crush also involved, a second fasciotomy is most important predictor of out- injuries and in another with arterial made over it. come. The critical delay from diag- injury.

56 Journal of the American Academy of Orthopaedic Surgeons Mark L. Prasarn, MD, and Elizabeth A. Ouellette, MD

pronator slide may be performed to Muskellähmungen und Kontracturen. Volkmann Contracture improve hand position as well as Centralblatt für Chirurgie, Leipzig 1881; 8:801-803. function of the forearm flexors. Ten- Irreversible tissue ischemia results in 2. Grottkau BE, Epps HR, Di Scala C: don transfer may be performed to muscle necrosis within the affected Compartment syndrome in children and improve specific dysfunction in per- adolescents. J Pediatr Surg 2005;40(4): compartment, which leads to con- sons with moderate contracture. 678-682. tracture. In the forearm, the typical Usually this involves use of an exten- 3. Ouellette EA, Kelly R: Compartment posture that develops includes elbow syndromes of the hand. J Bone Joint sor tendon transfer; however, flexor flexion, forearm pronation, wrist Surg Am 1996;78(10):1515-1522. tendons can be transferred in the flexion, and thumb adduction with 4. Ouellette EA: Compartment syndromes case of dorsal contracture. Free mus- the metacarpophalangeal joints in in obtunded patients. Hand Clin 1998; cle transfer, typically using the graci- 14(3):431-450. extension and the interphalangeal lis muscle, is necessary to improve 5. Prasarn ML, Ouellette EA, Livingstone joints in flexion. The median nerve is function in persons with severe con- A, Giuffrida AY: Acute pediatric upper often affected to a greater degree 12,15,16 extremity compartment syndrome in the tracture. absence of fracture. J Pediatr Orthop than the ulnar nerve because the me- 2009;29(3):263-268. dian nerve lies in the deeper zone 6. Bae DS, Kadiyala RK, Waters PM: Acute that is more severely compromised Summary compartment syndrome in children: by ischemia. Contemporary diagnosis, treatment, and outcome. J Pediatr Orthop 2001;21(5): 15 ACS of the upper extremity is a poten- Tsuge classified contracture as 680-688. mild, moderate, and severe. The mild tially devastating condition that can 7. Mabee JR, Bostwick TL: Patho- type involves mild ischemic contrac- lead to substantial loss of function. physiology and mechanisms of ture primarily of the flexor digito- Compartment syndrome has many compartment syndrome. Orthop Rev 1993;22(2):175-181. rum profundus and no neurologic causes, and a high index of suspicion deficit. In the moderate type, the must be maintained. The final common 8. Matsen FA: Compartmental Syndromes. New York, NY, Grune and Stratton, flexor digitorum profundus, flexor pathway is a vicious cycle of increased 1980. tissue pressure with resulting cellular is- pollicis longus, and pronator teres 9. McQueen MM, Christie J, Court-Brown are affected, and the flexor digito- chemia. All affected compartments in CM: Acute compartment syndrome in rum superficialis and flexor carpi ul- the upper extremity must be recog- tibial diaphyseal fractures. J Bone Joint Surg Br 1996;78(1):95-98. naris are affected to a lesser degree. nized, and thorough decompression must be performed in an expedient 10. Bunnell S, Doherty EW, Curtis RM: Intrinsic muscle paralysis and sen- Ischemic contracture, local, in the hand. sory neuropathy of the median and manner. Compartment syndrome is dif- Plast Reconstr Surg 1948;3:424-433. ficult to diagnose in some cases, partic- ulnar nerves are also present. The se- 11. Dellaero DT, Levin LS: Compartment vere type involves ischemic damage ularly in obtunded patients and young syndrome of the hand: Etiology, children. Prompt diagnosis and emer- diagnosis, and treatment. Am J Orthop to all of the flexors in the fore- (Belle Mead NJ) 1996;25(6):404-408. arm, variable involvement of the ex- gent surgical decompression are essential to obtain a good clinical outcome 12. Friedrich JB, Shin AY: Management of tensors, and severe neurologic forearm compartment syndrome. Hand injury.12,14-16 and preventing a catastrophic result. Clin 2007;23(2):245-254, vii. The main goal in the management 13. Gelberman RH, Garfin SR, of Volkmann contracture is to re- Hergenroeder PT, Mubarak SJ, Menon J: References Compartment syndromes of the forearm: store function; however, normal Diagnosis and treatment. Clin Orthop function of the upper extremity Relat Res 1981;(161):252-261. Evidence-based Medicine: Levels of should not be expected.10-16 Affected evidence are described in the table of 14. Stevanovic M, Sharpe F: Management of muscles are exposed, and fibrotic or established Volkmann’s contracture of contents. In this article, references the forearm in children. Hand Clin 2006; necrotic tissue is débrided. Thorough 2-6, 9, 10, 14-20, 28, 31, 42, 46, 22(1):99-111. neurolysis of the median and ulnar and 47 are level IV studies. Refer- 15. Tsuge K: Treatment of established nerves should be performed as well ences 11-13, 23, 37, 44, and 45 are Volkmann’s contracture. J Bone Joint as tenolysis of scarred tendons. Iso- Surg Am 1975;57(7):925-929. level V expert opinion. lated tendon lengthening is not rec- 16. Ultee J, Hovius SE: Functional results ommended because it typically re- Citation numbers printed in bold after treatment of Volkmann’s ischemic type indicate references published contracture: A long-term followup study. sults in recurrent contracture and Clin Orthop Relat Res 2005;(431):42- loss of grip strength.12,16 In persons within the past 5 years. 49. with mild contracture, the flexor/ 1. von Volkmann R: Die ischämischen 17. McQueen MM, Gaston P, Court-Brown

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CM: Acute compartment syndrome: 29. Cohen J, Bush S: Case report: spectroscopy. Clin Orthop Relat Res Who is at risk? J Bone Joint Surg Br Compartment syndrome after a 1988;(226):138-155. 2000;82(2):200-203. suspected black widow spider bite. Ann Emerg Med 2005;45(4):414-416. 40. Matava MJ, Whitesides TE Jr, Seiler JG 18. Elliott KG, Johnstone AJ: Diagnosing III, Hewan-Lowe K, Hutton WC: acute compartment syndrome. J Bone 30. Roberts RS, Csencsitz TA, Heard CW Jr: Determination of the compartment Joint Surg Br 2003;85(5):625-632. Upper extremity compartment pressure threshold of muscle ischemia in syndromes following pit viper a canine model. J Trauma 1994;37(1): 19. Schnall SB, Vu-Rose T, Holtom PD, envenomation. Clin Orthop Relat Res 50-58. Doyle B, Stevanovic M: Tissue pressures 1985;(193):184-188. 41. Heckman MM, Whitesides TE Jr, Grewe in pyogenic flexor tenosynovitis of the 31. Ragland R III, Moukoko D, Ezaki M, SR, Judd RL, Miller M, Lawrence JH III: finger: Compartment syndrome and its Carter PR, Mills J: Forearm Histologic determination of the ischemic management. J Bone Joint Surg Br 1996; compartment syndrome in the newborn: threshold of muscle in the canine 78(5):793-795. Report of 24 cases. J Hand Surg Am compartment syndrome model. J Orthop 20. Ronel DN, Mtui E, Nolan WB III: 2005;30(5):997-1003. Trauma 1993;7(3):199-210. Forearm compartment syndrome: 32. Benson LS, Sathy MJ, Port RB: Forearm 42. Yuan PS, Pring ME, Gaynor TP, Anatomical analysis of surgical compartment syndrome due to Mubarak SJ, Newton PO: Compartment approaches to the deep space. Plast automated injection of computed syndrome following intramedullary Reconstr Surg 2004;114(3):697-705. tomography contrast material. J Orthop fixation of pediatric forearm fractures. Trauma 1996;10(6):433-436. J Pediatr Orthop 2004;24(4):370-375. 21. Tompkins DG: Exercise myopathy of the extensor carpi ulnaris muscle: Report of 33. Moen TC, Sarwark JF: Compartment 43. Boody AR, Wongworawat MD: a case. J Bone Joint Surg Am 1977;59(3): syndrome following intraosseous Accuracy in the measurement of 407-408. infusion. Orthopedics 2008;31(8):815. compartment pressures: A comparison of three commonly used devices. J Bone 22. Schmidt GL, Uroskie JA: Isolated 34. Funk L, Grover D, de Silva H: Joint Surg Am 2005;87(11):2415-2422. compartment syndrome of the extensor Compartment syndrome of the hand carpi ulnaris: A case report. Am J following intra-arterial injection of 44. Maginn P, Elliot D: Upper arm Orthop (Belle Mead NJ) 2004;33(10): heroin. J Hand Surg Br 1999;24(3):366- fasciotomy: A new approach. J Hand 519-520. 367. Surg [Br] 1996;21:59-62. 23. Whitesides TE, Heckman MM: Acute 35. Ananthanarayan C, Castro C, McKee N, 45. Tarkin IS: The versatility of negative compartment syndrome: Update on Sakotic G: Compartment syndrome pressure wound therapy with reticulated diagnosis and treatment. J Am Acad following intravenous regional open cell foam for soft tissue Orthop Surg 1996;4(4):209-218. anesthesia. Can J Anaesth 2000;47(11): management after severe musculoskeletal 1094-1098. trauma. J Orthop Trauma 2008;22(10 24. Docker C, Titley OG: A case of forearm suppl):S146-S151. compartment syndrome following a ring 36. Hwang RW, de Witte PB, Ring D: avulsion injury. Injury 2002;33(3):274- Compartment syndrome associated with 46. Yang CC, Chang DS, Webb LX: 275. distal radial fracture and ipsilateral Vacuum-assisted closure for fasciotomy elbow injury. J Bone Joint Surg Am wounds following compartment 25. Cosker T, Gupta S, Tayton K: 2009;91(3):642-645. syndrome of the leg. J Surg Orthop Adv Compartment syndrome caused by 2006;15(1):19-23. suction. Injury 2004;35(11):1194-1195. 37. Olson SA, Glasgow RR: Acute compartment syndrome in lower 47. Hope MJ, McQueen MM: Acute 26. Bacal D, Lampman RM, Hogikyan JV, extremity musculoskeletal trauma. JAm compartment syndrome in the absence of Wolk SW: Compartment syndrome of Acad Orthop Surg 2005;13(7):436-444. fracture. J Orthop Trauma 2004;18(4): the arm and disseminated intravascular 220-224. coagulation. Am J Orthop (Belle Mead 38. Heppenstall RB, Scott R, Sapega A, Park NJ) 2001;30(5):422-423. YS, Chance B: A comparative study of 48. Vaienti L, Vourtsis S, Urzola V: the tolerance of skeletal muscle to Compartment syndrome of the forearm 27. Kleshinski J, Bittar S, Wahlquist M, ischemia: Tourniquet application following an electromyographic Ebraheim N, Duggan JM: Review of compared with acute compartment assessment. J Hand Surg Br 2005;30(6): compartment syndrome due to group A syndrome. J Bone Joint Surg Am 1986; 656-657. streptococcal infection. Am J Med Sci 68(6):820-828. 2008;336(3):265-269. 49. Gelberman RH, Garfin SR, 39. Heppenstall RB, Sapega AA, Scott R, Hergenroeder PT, Mubarak SJ, Menon J: 28. Ramos C, Whyte CM, Harris BH: et al: The compartment syndrome: An Compartment syndromes of the forearm: Nontraumatic compartment syndrome of experimental and clinical study of Diagnosis and treatment. Clin Orthop the extremities in children. J Pediatr Surg muscular energy metabolism using Relat Res 1981;(161):252-261. 2006;41(12):e5-e7. phosphorus nuclear magnetic resonance

58 Journal of the American Academy of Orthopaedic Surgeons