Compartment Syndromes of the Forearm and Hand Chris Oliver DM FRCS (Tr & Orth) Consultant Trauma Surgeon Edinburgh Orthopaedic Trauma Unit Part-Time Orthopaedic Senior Lecturer

History Volkmann 1881 (described) Petersen 1888 (treatment) Hildenbrand 1906 (ischaemic contracture) Rowlands 1910 (reperfusion) Murphy 1914 (fasciotomy) WW2 (arterial spasm) Kelly & Whitesides (1967) 4 Compartment Leg McQueen & Court-Brown (1990’s)

Volkmann 1881 (described)

Petersen 1888 (treatment)

Hildenbrand 1906 (ischaemic contracture)

Rowlands 1910 (reperfusion)

Murphy 1914 (fasciotomy)

WW2 (arterial spasm)

Kelly & Whitesides (1967) 4 Compartment Leg

McQueen & Court-Brown (1990’s)

Definition Compartment Syndrome is a condition characterised by raised pressure within a closed space with a potential to cause irreversible damage to the contents of the closed compartment

is a condition characterised by raised pressure within a closed space with a potential to cause irreversible damage to the contents of the closed compartment

Most Common Aetiology iatrogenic tight cast +/- dressing medico-legal problem

iatrogenic

tight cast +/- dressing

medico-legal problem

Aetiology burns high pressure injection trauma fractures crush (behaves differently) reperfusion injuries medical: coagulation, dialysis, traction Drug addicts

burns

high pressure injection

trauma

fractures

crush (behaves differently)

reperfusion injuries

medical: coagulation, dialysis, traction

Drug addicts

Pathophysiology volume ~ pressure in a closed space arterial > venous not comparable to acute ischaemia “ zone of Injury” age rigidity of fascia

volume ~ pressure in a closed space

arterial > venous

not comparable to acute ischaemia

“ zone of Injury”

age

rigidity of fascia

Diagnosis may not be obvious open wounds do not exclude lack abnormalities in sensory nerves if consider diagnosis must monitor polytrauma, head injury, chemical overdose

may not be obvious

open wounds do not exclude

lack abnormalities in sensory nerves

if consider diagnosis must monitor

polytrauma, head injury, chemical overdose

Differential Diagnosis arterial occlusion crush syndrome injury to peripheral nerve

arterial occlusion

crush syndrome

injury to peripheral nerve

Clinical Features disproportionate pain swelling, hard shiny skin passive stretch pulses (BP) sensory deficit (late) muscle weakness (late) deep flexor compartments

disproportionate pain

swelling, hard shiny skin

passive stretch

pulses (BP)

sensory deficit (late)

muscle weakness (late)

deep flexor compartments

Tissue Pressure Monitoring tissue versus compartment techniques needle, wick, slit catheter modern transducers Trend is the most important factor

tissue versus compartment

techniques

needle, wick, slit catheter

modern transducers

Trend is the most important factor

Pressure difference - Delta P difference between diastolic pressure and measured compartment pressure 30mm Hg McQueen, Court-Brown 1996 “ Zone of Peak Pressure”

difference between diastolic pressure and measured compartment pressure

30mm Hg

McQueen, Court-Brown 1996

“ Zone of Peak Pressure”

Incipient Compartment Syndrome high fasciotomy rates monitor bivalve cast and remove dressing limb position

high fasciotomy rates

monitor

bivalve cast and remove dressing

limb position

Treatment Goals must decompress all compartments at risk skin, fat, fascia widely decompressed debridement of necrotic tissue do not use elastic bands

must decompress all compartments at risk

skin, fat, fascia widely decompressed

debridement of necrotic tissue

do not use elastic bands

Upper Limb Compartment Syndromes hand forearm elbow

hand

forearm

elbow

Compartment Syndrome of Hand occur most often from iatrogenic injuries arterial-line or IV medications

occur most often from iatrogenic injuries

arterial-line or IV medications

Hand Compartment Syndrome Physical signs non specific aching of the hand disproportionate pain loss of digital motion & continued swelling MP extension and PIP flexion “intrinsic position” difficult to measure tissue pressure

non specific aching of the hand

disproportionate pain

loss of digital motion & continued swelling

MP extension and PIP flexion “intrinsic position”

difficult to measure tissue pressure

Anatomy of Hand Compartments 10 separate osteofascial compartments dorsal interossei (4) palmar interossei (3) adductor pollicis - thenar and hypothenar (2) transverse carpal ligament (1)

10 separate osteofascial compartments

dorsal interossei (4)

palmar interossei (3)

adductor pollicis - thenar and hypothenar (2)

transverse carpal ligament (1)

Hand Decompression of Compartments dorsal metacarpal incisions 2 longitudinal dorsal incisions 2nd & 4th metacarpals extensor tendons are retracted, allowing access to dorsal and volar interosseous compartments which are separate longitudinal slits thenar, hypothenar, CTD

dorsal metacarpal incisions

2 longitudinal dorsal incisions 2nd & 4th metacarpals

extensor tendons are retracted, allowing access to dorsal and volar interosseous compartments which are separate

longitudinal slits

thenar, hypothenar, CTD

Forearm Compartment Syndrome common after high energy injury wrist, forearm # may follow supracondylar # of humerus may result in functionless extremity

common after high energy injury

wrist, forearm #

may follow supracondylar # of humerus

may result in functionless extremity

Anatomy of Forearm Compartment Syndrome three osseofascial compartments superficial Flexor deep Flexor extensor antecubital aponeurosis - lacertus fibrosus

three osseofascial compartments

superficial Flexor

deep Flexor

extensor

antecubital aponeurosis - lacertus fibrosus

Forearm Decompression of Compartments volar Henry approach superficial and deep flexor volar ulna approach extensor no tourniquet

volar Henry approach

superficial and deep flexor

volar ulna approach

extensor

no tourniquet

Volar Henry Approach medial to biceps to carpal tunnel superficial radial nerve FCR , brachioradialis must decompress deep muscles watch proximal edge of pronator teres

medial to biceps to carpal tunnel

superficial radial nerve

FCR , brachioradialis

must decompress deep muscles

watch proximal edge of pronator teres

Volar Ulna Approach similar to Henry FCU, FDS watch proximal edge of FDS decompress ulnar nerve at wrist

similar to Henry

FCU, FDS

watch proximal edge of FDS

decompress ulnar nerve at wrist

Dorsal Approach determine by pressure measurements pronate arm lateral epicondyle to midline of wrist ECRB and EDC

determine by pressure measurements

pronate arm

lateral epicondyle to midline of wrist

ECRB and EDC

Volkmann’s Ischaemic Contracture children disaster advancement of flexor muscles

children

disaster

advancement of flexor muscles

Aftercare Fasciotomy Wounds disfiguring re-inspect at 48 hours further debridement DPC or SSG

disfiguring

re-inspect at 48 hours

further debridement

DPC or SSG