Forearm Compartment Research Articles

An extensive infiltrative diffuse tenosynovial giant cell tumor in both compartment of the forearm: A case report

Diffuse tenosynovial giant cell tumors are relatively rare but second most common tumor effecting the synovial containing tissues. The study aim was to present a case involving a 40-year-old male patient with a complaint of a progressively enlarging swelling on the radial side of right wrist. On local examination, there was a bi-lobed swelling 7×9 and 6×5 cm on the dorsolateral and anterolateral aspect of right wrist respectively. Through Hennery’s modified approach tumor was exposed. It was extending from dorsolateral to anteromedial wrist encasing the flexors, extensor and abductor tendons of thumb and radial neurovascular bundle and adjacent wrist and finger flexors. The tumor surrounding the tendons was carefully removed, and carpal tunnel release was performed to address the tingling sensation. The patient managed was having lobulated diffuse type tumor involving the both flexor and extensor compartment. Better outcome, less morbidity and least chance of recurrence can be expected if the tumor had been operated earlier.

Anconeus Exertional Compartment Syndrome and Posterolateral Rotatory Elbow Instability: A Clinical Association and Rare Cause of Elbow Pain

Background: Anconeus compartment syndrome is a rarely reported compartment syndrome in the anconeus muscle compartment of the forearm. It has anatomic and pathophysiological associations with posterolateral rotatory instability (PLRI) of the elbow. Purpose: To present the history, management, and outcomes of 4 patients with anconeus compartment syndrome. Secondary aims were to (1) establish normative anconeus pressures and (2) measure the volume of this compartment with and without PLRI in cadavers. Study Design: Case series; Level of evidence, 4. Methods: Four patients with clinical signs of anconeus compartment syndrome (2 gymnasts, 1 swimmer, and 1 footballer/weightlifter) were identified over a 3-year period (2015-2017 inclusive). Patient history, sporting activity, physical examination, anconeus compartment pressures, and treatment outcomes were recorded. Manometry of the anconeus compartment in 2 healthy male controls was performed to establish normative compartment pressures. Anconeus volumetric anatomy and the effect of creating PLRI on compartment volume was investigated in 4 cadaveric elbows. Results: All 4 patients had microtraumatic PLRI, and 2 patients had anconeus hypertrophy. Anconeus compartment pressures at rest and at 2-minutes postexercise were median 28.0 and 67.5 mm Hg, respectively, in the patients and mean 16.5 and 18 mm Hg, respectively, in the controls. Simultaneous fasciotomy and PLRI reconstructive procedures were performed in 2 patients, with outcomes showing full return to competition. Fasciotomy alone was performed in 2 patients to allow return to competition, with both requiring later reconstruction to address PLRI. Cadaver dissection revealed that the anconeus compartment was extremely small and that creation of PLRI reduced the direct volume of the compartment and increased the distance between the anconeus origin and insertion. Conclusion: Our case series demonstrated that anconeus compartment syndrome can occur in upper limb-dominant athletes in the presence of PLRI and anconeus hypertrophy. Pain is relieved by fasciotomy, but definitive treatment of the underlying instability prevents further symptomatology.

A Look is Worth a Thousand Words!! - Case Series of Forearm Compartment Syndrome after Transradial Coronary Intervention.

A Look is Worth a Thousand Words!! - Case Series of Forearm Compartment Syndrome after Transradial Coronary Intervention.

Bilateral Variations of Pronator Teres in the Upper Limb.

During clinical practice, physicians need to have a sound knowledge of vascular and nerve variations in the body. Patients presenting with various clinical signs and symptoms need to be thoroughly investigated with anatomic variations in mind to prevent misdiagnosis. Most nerve variations are related to their formation or their course and are frequently associated with the variability of structures that surround them. These structures most commonly include blood vessels, ligaments, and muscles. Such variations should be foremost in a physician's mind when analyzing clinical symptoms. This will aid in accurate diagnosis, and if surgical intervention is warranted, such awareness would minimize intraoperative errors. This article discusses a variation in the pronator teres muscle, the branching pattern of the brachial artery, and the median nerve. During the dissection of 11 cadaveric specimens within the Geisinger Commonwealth School of Medicine, an elderly female cadaver exhibited bilateral variations in the pronator teres muscle, which originated from the mid-humerus, instead of the medial epicondyle. Careful dissection revealed associated neurovascular variations in the arm, elbow, and forearm in relation to the muscle. The pronator teres muscles in the remaining 10 cadavers in the lab were examined for variations and their lengths were measured and compared with the cadaver under study. Unlike the normal origin at the medial epicondyle as described in textbooks, it was observed that the humeral heads of the pronator teres muscle originated at mid-humerus level bilaterally,associated with the passage of the median nerve and ulnar artery posterior to it. This muscle was 19 cm in length bilaterally, approximately 5.5 cm longer than the average lengths of pronator teres measured bilaterally in the other cadavers. The abnormally high origin of this muscle was associated with the finding of a median nerve coursing posterior to it to the forearm, failing to appear in the antecubital fossa. Although the ulnar head appeared normal, there were bilateral variations in the median nerve during its passage between the two heads of the pronator teres at the proximal forearmas it proceeded to the deeper compartment of the forearm. The brachial artery was observed to divide into radial and ulnar arteries at the mid-humerus level. The radial artery replaced the brachial artery in the antecubital fossa and the ulnar artery accompanied the median nerve posterior to pronator teres into the forearm. Such variations observed bilaterally have not yet been reported in the literature. Knowledge of these variations in the origin of pronator teres muscle, the absence of specific neurovascular structures as expected within the cubital fossa, and the awareness of early bifurcation and variation in their course can be very profound for physicians, as this region is often involved in the creation of arterio-venous fistulas for medical procedures, surgical treatment options for supracondylar and radial head fractures, and to differentiate median nerve compression in pronator teres syndrome versus carpal tunnel syndrome.

The brachioradialis longus: an unreported accessory form of the brachioradialis muscle.

The brachioradialis muscle (BR) belongs to the lateral forearm muscle. Typically, the radial nerve innervates it. BR morphological variability, such as split muscular belly, split tendon, or accessory BR (ABR), has been described in the current literature. A 68-year-old female donated cadaver was routinely dissected for research and educational purposes. A variant muscle was identified extending at the right arm's lateral and forearm compartments. It originated from the humerus lateral surface between the deltoid and the triceps brachii lateral head, joined the second muscular head from the brachialis muscle, and inserted into the radius styloid process. According to its origin, course, and insertion, the variant muscle probably corresponded to the BR accessory form. However, in the current literature, the ABR morphology corresponds to an accessory muscle originating adjacent to the typical BR and inserted into the radial tuberosity. At the same time, it was defined as "brachioradialis brevis." In the current case, the variant muscle differed significantly from the current literature due to the origin, insertion, length, and relationship with the typical BR; therefore, the term "brachioradialis longus" seemed adequate to describe this variant muscle.

An Atypically Displaced Scaphoid Fracture With Proximal Fragment in the Flexor Compartment of the Forearm

An Atypically Displaced Scaphoid Fracture With Proximal Fragment in the Flexor Compartment of the Forearm

A case series of forearm compartment syndrome complicating transradial cardiac catheterization

BackgroundAcute compartment syndrome following a transradial coronary approach is rare. However, as the incidence of coronary arterial disease increases due to lifestyle factors and multiple comorbidities, transradial coronary angiography has become more common for diagnostic and therapeutic purposes in cardiovascular centers. Despite its rarity, we encountered two cases of acute compartment syndrome within a 1-week interval in the cardiology unit of a tertiary hospital.Case presentationThe first case involved a 75-year-old woman diagnosed with non-ST elevation myocardial infarction (NSTEMI). A coronary angiogram was performed via an uncomplicated right radial artery puncture. Following the procedure, the patient experienced significant swelling in the right forearm. An emergency fasciotomy release of the right forearm was conducted, revealing a gushing hematoma upon entering the flexor compartment. Fortunately, the wound healed well two months postoperatively with no functional deficits. In the second case, an 80-year-old man presented with severe angina pectoris upon exertion and was diagnosed with NSTEMI. The following day, he developed compartment syndrome in the left forearm, necessitating an emergency fasciotomy. Intraoperative examination revealed muscle bulging within the forearm compartments accompanied by extensive hematoma. Postoperatively, a deranged coagulation profile caused oozing from the wound. However, since there was no arterial bleeding, a compression dressing was applied. This led to a gradual drop in hemoglobin levels and worsened his heart condition. Despite resuscitative efforts and attempts to correct the coagulopathy, the patient experienced cardiorespiratory arrest and succumbed to ischemic heart disease in failure.ConclusionClinicians must remain vigilant in identifying this potentially limb-threatening condition. Patients with pre-existing anticoagulant therapy and underlying atherosclerotic disease are at a higher risk of bleeding complications. Implementing effective hemostasis techniques and promptly managing swelling can help prevent the occurrence of compartment syndrome. Timely assessment and maintaining a high level of clinical suspicion are paramount. If necessary, early consideration of decompressive fasciotomy is essential to avert catastrophic outcomes.

Ultrasound-guided fasciotomy in forearm chronic exertional compartment syndrome: Preliminary results in 12 cases

IntroductionForearm chronic exertional compartment syndrome is a rare condition in athletes and musicians who perform repeated prolonged forced gripping movements. It mainly affects young men, and presents with cramp-like pain, beginning on the anteromedial side of the forearm and progressively extending to the entire circumference, and may be associated with muscle weakness and neurologic symptoms. The objective of this study was to report preliminary results of ultrasound-guided fasciotomy in the treatment of forearm chronic exertional compartment syndrome. Material and methodsA single-center retrospective observational study was conducted. Forearm chronic exertional compartment syndrome was diagnosed on clinical presentation and pathological intramuscular pressure measurement, defined as >30 mmHg at 1 min after effort. The series comprised 7 men, with bilateral involvement. Mean age was 30 years. All patients were motorcyclists. The mean preoperative intramuscular pressure at 1 min after effort was 60.75 mmHg (range: 30−81 mmHg). The main study endpoint was change in pain on visual analogic scale. Secondary endpoints comprised patient satisfaction, change in competitive sports level, and time to return to sport. Complications were noted. ResultsSix patients (12 forearms) were evaluated. Mean follow-up was 22.5 months (range: 3–48 months). Mean pain rating was 7.3/10 (range: 6–9) preoperatively, and 0/10 postoperatively. All patients were satisfied with the procedure. Mean time to return to sports was 25.5 days (range: 21–30 days). No patients decreased their competitive sports level after the procedure. One patient presented a postoperative hematoma, not requiring surgery. ConclusionUltrasound-guided fasciotomy in the treatment of Forearm chronic exertional compartment syndrome is an innovative technique with promising preliminary results. Level of EvidenceIV; retrospective cohort.

Flow-Through Procedure in Sequela After Complex Injuries of the Hand With Fingers’ Amputation

PurposeComplex injuries of the hand with finger amputation can result in important functional impairment. If the amputated fingers cannot be replanted, the developed sequelae should be further evaluated. Sometimes, in the presence of a few remaining local vascular resources, the use of the flow-through technique can help in solving the problem. MethodsThis study retrospectively reviews 4 cases who underwent single or multiple fingers reconstruction with toe transfers by using true flow-through or flow-through conduit flaps. A thorough description of the two methods is done, and the quality of the regained functionality of the hand is presented. ResultsAll the patients were males, aged between 21 and 45 (median age 31.75). One of them injured the left dominant hand, and the other three their right dominant hand. The median time between the accident and reconstructive surgery was 14.5 months (range, 3 months-36 months). All the initial lesions were work-related trauma. One patient had severe sequela after forearm compartment syndrome and amputation of the thumb and fifth finger; one patient had a metacarpal hand, one patient had amputation of two fingers (2nd and 4th); and one patient had three fingers amputated (2nd, 3rd, and 4th). In the first patient, a true flow-through flap and a second toe transfer was done, and in the other three patients multiple toe transfers by using the flow-through conduit technique were used. A good functionality of the reconstructed hand was obtained in all the patients. ConclusionsToe transfer remains one of the best methods in the reconstruction of hands with missing fingers. The use of both true flow-through flap and flow-through conduit methods are very useful, especially in cases with few vascular resources.

Updates in Diagnosis and Management of Forearm Compartment Syndrome

In children, compartment syndrome of the forearm often arises from supracondylar fractures, whereas in adults, distal radius fractures are the predominant cause. In 48% of instances, diagnosis was based exclusively on clinical assessment, while in the remaining 52% of cases, a combination of intracompartmental pressure measurement and clinical assessment was used. Several methods, including wick catheters, slit catheters, the Whitesides method, and the Stryker compartment pressure measurement device, were employed to measure intracompartmental pressure. The treatment approach of choice was fasciotomy, with a preference rate of 73%. Out of all the patients that needed wound management, postfasciotomy skin grafting was essential in 61% of them, while secondary closure was done in 39% of cases. The most prevalent consequence, observed in 21% of patients, was neurological impairment.

Pediatric extremity rhabdomyosarcoma–A diagnostic dilemma

Rhabdomyosarcoma (RMS) is a common soft-tissue malignancy of childhood, accounting for approximately 7% of cancers in children. They arise from primitive mesenchymal cells of skeletal muscle differentiation and occur most commonly in the head-and-neck region. Despite aggressive approaches, the overall outcome remains poor. Here, we present the case of a 9-year-old girl who presented with complaints of swelling over the left forearm for 2 months. Magnetic resonance imaging revealed a well-defined lobulated mass in the flexor compartment of the left forearm, suggestive of soft-tissue neoplasm. A biopsy done of the mass showed a malignant round blue cell tumor. Immunohistochemistry led to the diagnosis of RMS. The patient was started on multimodal therapy and is doing well on follow-up. Extremity swelling in the pediatric age group with malignant round cell morphology can pose diagnostic difficulty. A detailed work-up is essential for an accurate diagnosis. This case report emphasizes the role of a multimodality approach to the diagnosis and treatment of pediatric RMS.

Nylon cable ties–assisted delay primary closure of fasciotomy wound in patients of forearm compartment syndrome

Abstract Background Forearm compartment syndrome is a rare condition that requires forearm fasciotomy to release compartment pressure. In most cases, there is little to no skin damage initially, but after the fasciotomy, the skin flap may gradually retract. Traditional methods for reconstructing fasciotomy wounds, such as skin grafts or flaps, often result in an unpleasant appearance and require donor sites. Materials and Methods We present a method using nylon cable ties for delayed primary closure of forearm fasciotomy wounds. We retrospectively reviewed patients who underwent fasciotomy of forearms for compartment syndrome and nylon cable ties–assisted closure in a medical center from January 2017 to December 2022. Results Of the 7 eligible patients, 4 suffered from compartment syndrome of the forearm because of iatrogenic vascular rupture after procedures, whereas the other reasons included open-type fracture and fasciitis. For all the patients, nylon cable ties were applied for delayed primary wound closure after emergent fasciotomy. Six of them achieved successful wound closure by nylon cable ties without skin grafts or flaps on median day 12 (days 6–19). Only 1 patient required skin graft reconstruction after the application of nylon cable ties for 10 days. Conclusions Nylon cable ties, which are inexpensive and readily available, can be adjusted according to the different tension along the wound edges. They provide a simple, effective, and safe way to close difficult forearm fasciotomy wounds, which often result in a retracting skin flap after the procedure.

Forearm Compartment Syndrome due to Transradial PCI in STEMI: Case Series of What Can Go Wrong and Lesson Learned

The trans-radial approach (TRA) is shown to be superior in reducing bleeding complications and associated with lower mortality with a similar procedural success rate in ST-Elevated Myocardial Infarction (STEMI) patients compared to the trans-femoral approach. Nevertheless, complications such as forearm hematoma and, in rare cases, acute compartment syndrome (ACS) may develop, thus requiring a prompt surgical procedure. Here, we present two successful emergency fasciotomy cases as ACS treatment following primary percutaneous coronary intervention after STEMI. Both patients show normal neurological and muscular function and normal artery flow on both hands afterward.

The Pressure Is on: Dorsal Versus Volar Univalves for Long-arm Casts.

Fiberglass casts are routinely used to treat fractures of the upper extremity. When posttraumatic edema is anticipated, the cast is often valved to hopefully prevent potential complications, especially compartment syndrome. Due to volar forearm compartments being most involved with upper extremity compartment syndrome, volar skin surface pressures (SSP) are paramount. Despite past literature showing that a univalved cast will retain a 3-point mold better than a bivalved cast, there is a paucity of information analyzing the effects of univalving on the volar SSP. We hypothesized that a volar univalve technique would have a greater decrease in the volar skin surface pressures compared to a dorsal univalve in long-arm casts. A 100-mL saline bag attached to an arterial line pressure transducer was placed between a long-arm cast and the skin along the volar forearm of a single adult volunteer. Fourteen casts were applied by a single certified orthopaedic technologist with 30 years of experience and assigned randomly to receive either a volar or dorsal univalve. We calculated the change in volar forearm SSP on each cast in 4 stages: isolated univalve, with a 3-mm cast spacer, with a 6-mm spacer, and with bivalve. Statistical analysis of the data was performed using a Mann-Whitney U test. When comparing volar versus dorsal univalve, volar SSP significantly dropped by a mean of 32.00 versus 20.43mmHg (P value=0.001) in stage I, 45.14 versus 38.00mmHg in stage II (P value=0.026), and 56.53 versus 49mmHg in stage III (P value=0.001). There was no significant difference between the 2 groups after a bivalve was performed at stage IV (P value=0.318). Our findings support that a volar univalve with a 6-mm spacer will provide the greatest reduction of skin surface pressure while theoretically maintaining the cast's structural integrity and biomechanical properties when compared to a bivalved cast. Level II, prospective comparative study.

Edematous Dermal Thickening on Magnetic Resonance Imaging as a Biomarker for Lymphatic Surgical Outcomes.

Background and Objectives: One of the surgical treatments for breast cancer-related lymphedema (BCRL) is debulking lipectomy. The aim of this study is to investigate whether dermal thickness could be utilized as an objective indicator of post-operative changes following debulking. Materials and Methods: A retrospective review of BCRL patients who underwent debulking lipectomy was conducted. MRI-based dermal thickness was measured by two separate trained readers at 16 regions of the upper extremity. Pre- and post-operative reduction in dermal thickness was compared across the affected and unaffected (control) arms for each patient. The Wilcoxon rank sum test was used to assess for significant change. Univariate linear regression was used to assess the relationship between dermal thickness reduction and changes to LYMPH-Q scores, L-Dex scores, and relative volume change. Results: Seventeen patients were included in our analysis. There was significant reduction in dermal thickness at 5/16 regions in the affected arm. Dermal thickness change was significantly correlated with LYMPH-Q scores, L-Dex scores, and relative volume change in 2/16 limb compartments. There was predominant dermal thickening in the dorsal compartment of the upper arm and in the ventral and ulnar compartments of the forearm. Conclusions: Dermal thickness shows promising utility in tracking post-operative debulking procedures for breast cancer-related lymphedema. Further studies with larger patient populations and a variety of imaging modalities are required to continue to develop a clinically objective and reproducible method of post-surgical lymphedema staging and monitoring.

Agnikarma and Dashamoola Kwatha in the Management of De Quervain’s Tenosynovitis – Case Series

ABSTRACT De Quervain’s tenosynovitis is a common painful orthopedic entity that involves a thickening of retinaculum sheaths of tendons, which covers the first dorsal compartment of the forearm. This study is to explore noninvasive Ayurvedic management for De Quervain’s disease. In this series of cases, Ayurveda management of four diagnosed cases of Quervain’s disease (Snayugata Vata) was found to be effective. All patients were treated with four sittings of Agnikarma by Shalaka (~thermal cauterization) at the interval of 7 days. Dashmoola Kwatha 20 ml orally twice a day empty stomach for 1 month was prescribed to each patient. Results showed significant improvement in pain relief and functional movement of the thumb was achieved in all four patients. The quality of work of all four patients was not affected after 18 months of treatment, and they are now living symptom-free and without any recurrence. Based on this case series, it can be said that parasurgical management along with adjuvant Ayurvedic drugs showed a promising role in the management of De Quervain’s disease.

Coexistence of rare varieties of palmaris profundus and flexor superficialis muscle.

The superficial layer of the anterior compartment of the forearm is characterized by different morphological variations. During standard anatomical dissection, two morphological variations in the superficial compartment of the forearm were observed. The first one was the palmaris profundus, which originated from the radius and distally fused with the tendon to 3rd digit (from the flexor digitorum superficialis muscle) inserted on the medial phalanx of the third digit. The second variation was a distinct superficial flexor of the 4th digit represented by one muscle belly with originated from a common mass from the medial humeral epicondyle, passes through the carpal tunnel, and is inserted into the medial phalanx of the fourth digit. The flexor digitorum superficialis muscle was located deeply to it and it was divided only into three tendons (to 2nd, 3rd, and 5th digits). Tendons connected to the 2nd and 3rd digits were crossed with each other at the level of carpal tunnel. From the humeroulnar head of the flexor digitorum superficialis muscle, an additional muscle belly was arising and its tendon was fused with the superficial flexor of the fourth digit. Knowledge about morphological variations in this region is clinically important because of the direct correlation with the median nerve, and the possibility to cause carpal tunnel syndrome.

Surgical site infection following fasciotomy in patients with acute forearm compartment syndrome: a retrospective analysis of risk factors.

Fasciotomy, a standard therapy for acute forearm compartment syndrome (AFCS), can prevent serious complications, but there may be significant postoperative consequences. Surgical site infection (SSI) may cause fever, discomfort, and potentially fatal sepsis. This study aimed to identify risk factors for SSI in AFCS patients who had undergone fasciotomy. Patients with AFCS who had fasciotomies between November 2013 and January 2021 were recruited. We collected demographic information, comorbidities, and admission laboratory results. Analyses of continuous data were conducted using the t-test, the Mann-Whitney U test, and logistic regression analysis, while analyses of categorical data were conducted using the Chi-square and Fisher's exact tests. Sixteen AFCS patients (13.9%) suffered infections that need further therapy. Using the logistic regression analysis, we identified that patients with a history of diabetes (p = 0.028, OR = 16.353, 95% CI (1.357, 197.001)), open fractures (p = 0.026, OR = 5.239, 95% CI (1.223, 22.438)), and a higher level of TC (p = 0.004, OR = 4.871, 95% CI (1.654-14.350)) were the best predictors of SSI, while ALB levels (p = 0.004, OR = 0.776, 95% CI (0.653-0.924)) were protective for SSI in AFCS patients. Our results showed that open fractures, diabetes, and TC levels were relevent risk factors for SSI following fasciotomy in patients with AFCS, allowing us to personalize the risk assessment and apply early targeted interventions.

Acute forearm compartment syndrome presenting 2 weeks after penetrating arterial trauma.

Acute forearm compartment syndrome presenting 2 weeks after penetrating arterial trauma.

Ultrasound-guided fasciotomy for chronic exertional forearm compartment syndrome: a cadaveric feasibility study

ObjectivesChronic exertional forearm compartment syndrome is observed in patients who engage in physical activity requiring repetitive isometric muscular effort of the wrist during prolonged grasping. Open fasciotomy was considered as the gold-standard treatment, for its ability to release all compartments. However, its invasiveness means that high-level athletes have to abstain from competition for a long period of time. For this reason, minimally invasive techniques have been developed, to allow faster recovery.The objective of this cadaveric study was to evaluate the feasibility and reproducibility of ultrasound-guided palmar fasciotomy in the treatment of chronic exertional forearm compartment syndrome. MethodsSurgery consisted in ultrasound-guided palmar fasciotomy of the superficial anterior compartment, using a single minimally invasive approach. Twenty forearms were then dissected by an independent operator, (1) to check complete fasciotomy and (2) to screen for iatrogenic lesions on the tendons, veins and superficial sensory branches. ResultsSixteen fasciotomies were total and 4 partial: i.e., a release rate of 80%. The superficial sensory branches were intact, and notably the branches of the medial cutaneous nerve of the forearm. Mean surgery time was 9 min, progressively decreasing with the repetition of the ultrasound-guided procedure. ConclusionsUltrasound-guided fasciotomy in the management of chronic exertional forearm compartment syndrome appears to be a simple, effective, safe and reproducible technique.