Compartment Syndrome Of Forearm Research Articles

Forearm Injury-Gymnastics

HISTORY A 17-year-old junior elite gymnast sustained a forearm injury during a grip-lock maneuver after a release technique during a high bar exercise. Patient underwent a mid-shaft ulna and radius fracture reduction at the emergency room by the emergency room physician. Patient was released from the emergency room with a splint as the patient did not have significant swelling and pain. Patient's father followed-up with orthopaedic surgeon next day by phone previous to office visit. Patient's father reported that his son is complaining of numbness, tingling, swelling and pain of all fingers. Patient was scheduled to be seen at the surgery center that day. PHYSICAL EXAMINATION Examination revealed severely swollen hand and fingers with severe tenderness to palpation. Tenderness with attempts at passive range of motion of all fingers was noted. After splint removal significant forearm swelling was noted mainly in the volar aspect. Distal vasculature was intact with a 2+ radial pulse. Instability at the fracture site with gross motion of forearm bones was noted. Patient had intact light touch sensation in his fingertips and thumb. DIFFERENTIAL DIAGNOSIS Right ulna and radius shaft fracture. Right forearm compartment syndrome TESTS AND RESULTS Forearm radiographs: -Radius and Ulna mid to distal shaft fracture with comminution and evidence of instability at fracture site. FINAL WORKING DIAGNOSIS -Right both-bone forearm fracture with compartment syndrome TREATMENTS AND OUTCOMES Right both-bone forearm fracture open reduction with internal fixation using plates. Fasciotomy of volar flexor and dorsal extensor compartments with debridement of non-viable muscle tissue. Proximal 80% of volar incision was left open with rubber band stapled in criss-cross manner forming a lattice to not allow the skin to retract. Prophylactic oral antibiotics Whirlpool, wet-to-dry dressing changes, elbow, wrist and hand ROM exercises and home program instruction daily until full skin closure. Right forearm open wound irrigation and muscle debridement with skin closure 6 days after initial surgery. The more proximal 5-cm of dorsoulnar aspect was left open as there would be too much tension on the skin edges. Repeated radiographs of radius and ulna fractures at 5 days, 3 weeks, and 8 and 12 weeks after initial injury showed well-aligned both-bone forearm fracture with hardware in place. 3-cm wound closure 3 weeks later. Plastic surgery to close remaining 2-cm open wound with flap and graft. Strengthening exercises progressing to medicine ball plyometrics and weight bearing activities by 4 months.

Forearm Compartment Syndrome Following Intravenous Thrombolytic Therapy for Acute Ischemic Stroke

Minor and major bleeding complications have occurred following thrombolysis in acute ischemic stroke. However, compartment syndrome has not been reported among these incidences. This article presents a case of a forearm compartment syndrome in a patient with stroke who had fallen at the time of the infarction and was treated with tissue plasminogen activator. We wish to forewarn clinicians who may encounter similar cases. Patients suffering from stroke who fall are at risk of developing a compartment syndrome; the early diagnosis is often difficult, the sequelae can be devastating, and wrestling with the benefits and risks of reversing the coagulopathy in the acute phase of a cerebral infarction is a challenge.

Forearm compartment syndrome: anatomical analysis of surgical approaches to the deep space.

Forearm compartment syndrome is a surgical emergency that usually requires release of the superficial muscle compartments. In some clinical situations it is imperative to also explore the deep muscle compartments. There are no anatomical guides for surgical exploration of the deep compartments that would minimize collateral damage to surrounding vessels, nerves, and muscles. Surgical injury in the setting of ischemia, especially vascular injury, compounds the tissue damage that has already occurred. The authors evaluated four surgical approaches (three volar and one dorsal) to the deep forearm by performing detailed anatomical dissections on 10 embalmed and plastinated cadavers. They used a scoring system to rate the approaches for their ability to visualize the deep space without causing iatrogenic injury to superficial muscles, arteries, and nerves. In the volar forearm, an ulnar approach to the deep space is simple, causes the least iatrogenic surgical injury, and provides access to the deep volar forearm structures. The plane of dissection is between the flexor carpi ulnaris and the flexor digitorum superficialis. Dividing one or two distal segmental branches of the ulnar artery to the distal flexor digitorum superficialis exposes the pronator quadratus. Lifting the ulnar neurovascular bundle with the flexor digitorum superficialis in the middle third of the forearm exposes the flexor digitorum profundus and the flexor pollicis longus. This approach to the deep space requires no sharp dissection. In the dorsal forearm, a midline approach between the extensor digitorum communis and the extensor carpi radialis brevis is simple and safe.

Acute compartment syndrome after transradial coronary angioplasty

In the May 15, 1998 issue of Int. J. Cardiol., HildickThe injured radial artery was repaired. She was discharged 1 Smith et al. [1] demonstrated the high success rate of coronary angiography from the radial artery. Transradial cardiac catheterization is widely accepted now. The nearly absence of local vascular complication is one of its characteristics. The use of enoxaparin in patients with acute coronary syndrome became more and more popular. In the August 2001 issue of Int. J. Cardiol., Collet et al. [2] suggested that the dosage of subcutaneous low molecular weight heparin enoxaparin should be reduced in patients with severe renal failure. We reported a case of acute compartment syndrome within 24 h after transradial coronary intervention. Enoxaparin was prescribed in this patient. This 84-year-old female patient had hypertension and diabetes mellitus for 20 years. She was admitted for acute non-ST elevation myocardial infarction on March 24, 2002. Balloon angioplasty was performed smoothly by right radial artery approach on March 28, 2002. The arterial sheath was removed immediately after angioplasty. The puncture site was compressed by the hemostasis device SteptyP (Nichiban) for 6 h and plastic bandage till the next morning. We gave 60 mg enoxaparin every 12 h after angioplasty. Her body weight was only 45 kg. However, local swelling and hematoma at puncture site developed abruptly the next morning. Patient complained of right forearm pain. Even under the direct manual compression and administration of fresh frozen plasma, it progressed and extended to the elbow. Hypotension developed later. Under the diagnosis of radial artery bleeding with acute compartment syndrome of right forearm, she received fasciotomy. The operative finding confirmed the diagnosis.

DIAGNOSING ACUTE COMPARTMENT SYNDROME

Compartment syndrome has been defined as “a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space”.1 It is most commonly seen after injuries to the leg2-5 and forearm6-8 but may also occur in the arm,9 thigh,10 foot,11-13 buttock,14 hand15 and abdomen.16 It typically follows traumatic injury, but may also occur after ischaemic reperfusion injuries,17 burns,18 prolonged limb compression after drug overdose19 or poor positioning during surgery.20-24 Furthermore, subclinical compartment syndromes may explain the occurrence of a variety of postoperative disabilities which have been identified after the treatment of fractures of long bones using intramedullary nails.25 Approximately 40% of all acute compartment syndromes occur after fractures of the tibial shaft26 with an incidence in the range of 1% to 10%.26-30 A further 23% of compartment syndromes are caused by soft-tissue injuries with no fracture and fractures of the forearm account for 18%.26 Acute compartment syndrome is seen more commonly in younger patients, under 35 years of age31 and therefore leads to loss of function and long-term productivity in patients who would otherwise contribute to the country’s workforce for up to 40 years.

Atraumatic forearm compartment syndrome: alert patients taking neuroleptics are at risk

Atraumatic forearm compartment syndrome: alert patients taking neuroleptics are at risk

FOREARM INJURY IN COLLEGIATE GYMNAST

HISTORY A 20-year-old, Division 1, collegiate gymnast was performing his high bar routine in practice when he sustained an acute traumatic injury to his forearm. According to the athlete, his well-used grip locked on the bar during a giant swing. As his wrist and forearm locked in position, his body continued forward until he felt a snap, had acute pain, and fell to the mat. He did not injure his head or neck. Past medical history was pertinent for other gymnastics mishaps but no forearm or wrist complaints. He had no prodrome of pain. PHYSICAL EXAMINATION Immediate evaluation on site by the trainer revealed a grossly deformed (angulated) forearm with a dorsal area of bleeding on the mid aspect of his forearm. Pulses were intact. Sensation was slightly decreased in the small finger but otherwise neurologically intact. Compartments were soft but tender, there was no complaint of head, neck, shoulder, or elbow problems. DIFFERENTIAL DIAGNOSIS Fracture-dislocation of the wrist Open both bone forearm fracture secondary to equipment failure Closed both bone forearm fracture with a superficial abrasion Pathologic fracture of the forearm Compartment syndrome of the forearm TEST AND RESULTS Radiographic studies revealed a severely angulated both bone forearm fracture with some comminution and plastic deformation of the radius. Images did not reveal any suspicion of underlying pathology. Further evaluation confirmed exposed bone and the open nature of the fracture. FINAL/WORKING DIAGNOSIS Open both bone forearm fracture secondary to equipment failure. TREATMENT AND OUTCOMES Due to intact neurovascular function, athlete was splinted with no reduction and transported to the emergency room. Subsequently he was taken emergently to surgery for irrigation, oepn reduction and internal fixation. Perioperatively he was treated with antibiotics. Range of motion was allowed immediately in the forearm and wrist. No return to sport until adequate healing has occurred, full functional strength and motion, and awareness of mildlyh elevated risk of refracture above or below the plate. The quality of all grips was inspected for the team. IMPORTANCE Understanding the on-site treatment of open fractures is important for all professionals caring for athletes. This unusual case also increases the awareness of a unique problem associated with gymnastics; the risk of forearm injury secondary to a failure of equipment to function. Equipment should be checked routinely to be in working order.

Forearm Compartment Syndrome from Intravenous Mannitol Extravasation During General Anesthesia

Compartment syndrome from extravasation of mannitol is rarely reported (1). The pathophysiology and potential therapeutic options for mannitol extravasation are not well known. We describe a case of upper-extremity compartment syndrome resulting from mannitol extravasation in a patient under general anesthesia. Case Report A 49-yr-old woman, ASA physical status IV, weighing 80 kg, with a severe headache from a posterior communicating aneurysm rupture was scheduled for aneurysm clipping. Her neurologic examination was normal. In the operating room, the usual monitors were placed, anesthesia was induced with thiopental 400 mg, lidocaine 100 mg, fentanyl 250 μg, and rocuronium 50 mg via a preexisting right antecubital 18-gauge IV catheter. The trachea was intubated, and ventilation was controlled. General anesthesia was maintained with isoflurane and remifentanil 0.125 μg · kg−1 · min−1 via a 20-gauge IV catheter in the left hand. A 20-gauge right radial arterial cannula was inserted. The right arm was laterally tucked and pressure points were padded. Sixty minutes after scalp incision, mannitol was given through the right antecubital IV at approximately 5 g/min. The surgeon noted that the brain bulk had decreased. Forty-five minutes after the initial administration of mannitol, the arterial pulse-pressure waveform and the ipsilateral pulse oximeter tracing dampened. After undraping, the forearm was discovered to be tensely swollen and cyanotic, with delayed capillary refill. There was a free flow of blood from the arterial cannula and a pulse was palpable. A hand surgeon performed a fasciotomy extending from the wrist to the forearm, after clipping of the aneurysm. The patient awoke in the operating room and was tracheally extubated. In the postanesthesia recovery unit, physical examination revealed weakness in the left lower extremity, palpable radial arterial pulses, normal capillary filling, and a normal upper-extremity neurologic examination. In the intensive care unit, forearm edema gradually decreased, over several days. She was discharged with full function of her right arm, and a well healed fasciotomy scar. Discussion Complications of IV mannitol administration range from phlebitis to extensive tissue necrosis, leading to a loss of function (1). Compartment syndromes related to anesthesia have been reported to occur with diazepam extravasation (2), pressurized IV fluids (3,4), hypertonic saline (5), packed red cells (6), radial artery cannulation (7), positioning (8), intraarterial barbiturates (9), and manual blood pressure cuffs (10). Compartment syndrome resulting from mannitol extravasation can be severe and warrant immediate surgical fasciotomy (1). Stahl and Lerner (1) proposed that the high osmolarity of mannitol (1098 mOsm/L) may cause a compartment syndrome, secondary to fluid moving out of the vasculature and cells, resulting in increased compartment pressures and eventually cell death. It is possible that mannitol extravasated from this patient’s antecubital vein, as a result of previous needle-stick trauma or during cannulation of the vein. Diagnosis of compartment syndrome is difficult in the unconscious patient (1). Increased pressure, with a palpably tense compartment, is pathognomonic of compartment syndrome (2). Compartment syndrome is considered significant if there is neurologic dysfunction and the compartmental pressures are more than 30 mm Hg (1). Peripheral arterial pulses may not be absent if arterial pressure is greater than the critical closing pressure of veins and arteries supplying that extremity (1). Elevation of the affected limb can reduce arterial pressure sufficiently to arrest circulation (8); therefore, limb elevation may be contraindicated. Frequent examination of the extremities is crucial in making a timely diagnosis and minimizing risk of permanent injury. This is critical in obtunded or anesthetized patients (11). Emergent fasciotomy is the recommended treatment for severe compartment syndrome. Early recognition, diagnosis, and surgical intervention averted potential neural and functional impairment in our patient. This is the first report of compartment syndrome after mannitol administration, in a patient under general anesthesia. Mannitol is infused frequently during neurosurgical and other operations. Although extravasation injury attributed to mannitol seldom is described, anesthesiologists may encounter this problem and should recognize potential complications. Awareness may decrease the likelihood of extravasation injury. We recommend infusing mannitol in an observed IV site, if possible, or alternatively, via a central venous catheter. Tucking of the extremities should be avoided, if possible. Systematic monitoring of an observed extremity will permit discontinuation of the infusion at the first sign of extravasation (12). Monitoring of the upper extremities with intraarterial pressure wave and pulse oximetry may lead to earlier detection of increased compartmental pressures. We are grateful to John B. Downs, MD, for his advice on manuscript preparation and Mr. Peter Shea for his editorial assistance.

Forearm Compartment Syndrome Following Puncture of Haemodialysis Access Fistula

An 88-year-old female with end stage renal failure secondary to hypertension had a left radiocephalic AV fistula formed in December 2000. At 8 weeks, following single needle haemodialysis she rapidly developed swelling of the forearm despite pressure over the presumed site of venepuncture. The forearm and the hand were very painful at two hours. Examination revealed a tense swollen forearm with blistering of skin, decreased sensation of the hand and reduced capillary return in fingers. Her APTT ratio was found to be greater than 10. A diagnosis of compartment syndrome was made. Emergency exploration was undertaken via a single volar incision. At operation a large intermuscular and subcutaneous haematoma was evacuated. The bleeding was found to be from the site of venepuncture and the bleeding site was oversewn and superficial and deep flexor compartment decompression was undertaken. The forearm wound was debrided and a split skin graft

A case of forearm compartment syndrome following a ring avulsion injury

A case of forearm compartment syndrome following a ring avulsion injury

Forearm Compartment Syndrome Secondary to Radial Neck Fracture in a Child

We report a case of unusual presentation of compartment syndrome in a child's forearm following radial neck fracture. Review of the literature has confirmed our findings that development of compartment syndrome in children is often silent and delayed with few clinical signs.

Acute compartment syndrome. Who is at risk?

We have analysed associated factors in 164 patients with acute compartment syndrome whom we treated over an eight-year period. In 69% there was an associated fracture, about half of which were of the tibial shaft. Most patients were men, usually under 35 years of age. Acute compartment syndrome of the forearm, with associated fracture of the distal end of the radius, was again seen most commonly in young men. Injury to soft tissues, without fracture, was the second most common cause of the syndrome and one-tenth of the patients had a bleeding disorder or were taking anticoagulant drugs. We found that young patients, especially men, were at risk of acute compartment syndrome after injury. When treating such injured patients, the diagnosis should be made early, utilising measurements of tissue pressure.

Compartment syndrome after simple venipuncture in an anticoagulated patient

An excessively anticoagulated 52-year-old man on chronic warfarin therapy developed a forearm compartment syndrome after venipuncture in an antecubital vein. At fasciotomy, active venous bleeding into the forearm from the venipuncture site was noted, and a large forearm hematoma was evacuated. Anticoagulated patients or those with coagulopathies are at risk for compartment syndrome after percutaneous needle punctures and should be warned of this possibility. Such individuals should be instructed to seek immediate medical attention if any signs or symptoms of this complication occur.

The significance of the three volar spaces in forearm compartment syndrome: A clinical and cadaveric correlation

The goal of this study was to assess the importance of the 3 volar spaces in forearm compartment syndrome in a prospective manner. A cadaveric model was developed to correlate with our clinical experience. All but 1 of 21 volar compartments (superficial volar, deep volar, and pronator quadratus spaces) in 7 patients in our clinical series decompressed adequately after release of the superficial volar fascia. One patient needed further release of the pronator quadratus compartment; he had suffered a combined crush and vascular injury. All volar compartments in our cadaveric model decompressed with superficial fasciotomy. Prefasciotomy and postfasciotomy pressures should be obtained from all 3 compartments of the volar forearm. Superficial fasciotomy usually adequately decompresses the entire volar forearm; however, in the event that deep compartment pressures remain high after superficial fasciotomy, release of the affected space is indicated.

ACUTE COMPARTMENT SYNDROME OF THE FOREARM

The forearm is the most common site for compartment syndrome in the upper extremity. The three compartments of the forearm include the volar (anterior or flexor), the dorsal (posterior or extensor), and the mobile wad. Both-bone forearm fractures and distal radius fractures are common initial injuries in adults that lead to acute forearm compartment syndrome. Supracondylar fractures, especially those with associated vascular injuries, are frequent causes of compartment syndrome in children. The flexor digitorum profundus and flexor pollicis longus are among the most severely affected muscles because of their deep location, adjacent to bone. Initial treatment consists of removal of occlusive dressings or splitting or removal of casts. If symptoms do not resolve rapidly, fasciotomy is indicated. Decompression fasciotomy of the forearm is performed through volar or dorsal approaches. The medial nerve is decompressed throughout its course, including high-risk areas deep to the lacertus fibrosus; between the humeral and ulnar heads of the pronator teres, the proximal arch, and deep fascial surface of the flexor digitorum superficialis; and the carpal tunnel.

Compartment Syndrome of the Upper Extremity Following Cutaneous Laser Surgery

Cosmetic tattoo removal by laser is commonplace and is followed by recognized complications. We report a previously unrecognized complication: a case of forearm compartment syndrome following Q-switched Nd:YAG laser for treatment of a decorative tattoo.

CHRONIC MONTEGGIA LESIONS IN CHILDREN. COMPLICATIONS AND RESULTS OF RECONSTRUCTION

We retrospectively reviewed the results of operative treatment of chronic Monteggia lesions (Bado type I or the equivalent) with anterior radiocapitellar dislocation in seven patients. The mean age at the time of the reconstruction was six years and nine months (range, eleven months to twelve years), and the mean time from the injury to the operation was twelve months (range, five weeks to thirty-nine months). The mean duration of follow-up was four years and six months (range, two years to eleven years and three months). There were fourteen complications, including malunion of the ulnar shaft in one patient; residual radiocapitellar subluxation in two patients (one anterior and one posterolateral); radiocapitellar dislocation (dynamic anterior subluxation of the radial head in supination) in one patient; transient ulnar-nerve palsy in three patients (with residual weakness in two); partial laceration of the radial nerve in one patient; loss of the fixation in two patients; and non-union of the ulnar osteotomy site, compartment syndrome, conversion reaction, and possible fibrous synostosis of the forearm in one patient each. The patients lost a mean of 36 degrees of pronation and a mean of 27 degrees of supination of the forearm compared with the contralateral, uninjured extremity. Two patients demonstrated a loss of flexion of the elbow of 8 and 13 degrees and three had a loss of extension (mean, 15 degrees) compared with the contralateral side. There were three good, two fair, and two poor results.

Case Report: Forearm Compartment Syndrome Due To Automated Injection of Computed Tomography Contrast Material

Automated injection of computed tomography contrast material can produce a compartment syndrome if extravasation occurs. Unconscious patients and the elderly may be at particular risk. Selection of nonionic contrast material, careful evaluation of the intravenous administration site, and close monitoring of the patient during use of a power injector may help minimize or prevent extravasation injuries.

Transient Compartment Syndrome of the Forearm After Attempted Radial Artery Cannulation

Transient Compartment Syndrome of the Forearm After Attempted Radial Artery Cannulation

Bilateral forearm compartment syndromes resulting from neuroleptic malignant syndrome

Neuroleptic malignant syndrome (NMS) is an idiosyncratic reaction to the administration of neuroleptic drugs. The primary manifestations of this syndrome are hyperthermia, rhabdomyolysis, muscle rigidity, autonomic dysfunction, and altered level of consciousness. Because rhabdomyolysis and muscle rigidity can lead to swelling within a closed compartment, an unusual complication of NMS is compartment syndrome. 1 We report a case of a patient with neuromuscular malignant syndrome who developed bilateral forearm compartment syndromes.