Up in arms: Upper extremity compartment syndrome

In 1881, Richard von Volkmann, MD, first described upper extremity compartment syndrome as the cause of hand flexor muscle contractures (also known as Volkmann’s contracture) caused by posttraumatic ischemic muscle injury.1 Acute compartment syndrome occurs when the pressure within the fibro-osseous space increases to a level that decreases tissue perfusion of the components of the compartment leading to muscle edema, ischemia, and necrosis.2

The upper extremity contains 15 compartments from the shoulder to the tips of the fingers. In the upper arm, the flexor and extensor compartments are encircled with the brachial fascia and separated by the medial and lateral intermuscular septa. The forearm contains three compartments: the dorsal, containing the flexor and pronator muscles; the volar, containing the extensor muscles; and the lateral wad, containing the brachioradialis and extensor carpi radialis. Lastly, the hand contains 10 compartments that are separated by the carpal and metacarpal bones.3

Fractures and dislocations cause soft-tissue injury and bleeding into the compartment. Distal radius, distal ulnar fractures, and pediatric supracondylar humeral fractures have a higher incidence of acute upper extremity compartment syndrome.4 Penetrating injuries to the upper extremity with concomitant vascular injury may cause enough bleeding and swelling to result in compartment syndrome as well. The volar compartment of the forearm is the most commonly affected compartment in acute upper extremity compartment syndrome.3

Diagnosis and treatment

Diagnosis of upper extremity compartment syndrome requires a high index of suspicion based on a detailed history and physical exam. Just as in the lower extremity, the classic signs of acute compartment syndrome include the six “Ps”: pain, paresthesia, poikilothermia (differing temperatures between limbs with affected side being cooler), pallor, paralysis, and pulselessness. Pain disproportionate to injury must trigger a workup for compartment syndrome with a suspicious history or mechanism of injury. Pain is often described as a dull, deep, aching pain worsened by passive stretching of the involved muscles. Paralysis and pulselessness are late indicators of compartment syndrome and often present well into the disease process.

Once compartment syndrome of the upper extremity is diagnosed, trauma surgeons should perform a fasciotomy. In the forearm, the technique is a “Lazy S” incision to release the volar and lateral wad compartments and an incision over the dorsum of the forearm to release the dorsal compartment. These incisions give adequate exposure while minimizing postoperative contractures.

To examine the occurrence of upper extremity compartment syndrome in the National Trauma Data Bank® (NTDB®), medical records for admission year 2016 were searched using the International Classification of Diseases, 10th Revision Clinical Modification codes. Specifically searched were records with a diagnosis code of T79.A1 (traumatic compartment syndrome of upper extremity). A total of 476 records were found, 440 of which contained a discharge status, including 360 patients discharged to home, 34 to acute care/rehab, and 26 to skilled nursing facilities; 20 died (see Figure 1). Most of these patients (82 percent) were men, on average 38.4 years of age, had an average hospital length of stay of 9.6 days, an intensive care unit length of stay of 8.8 days, an average injury severity score of 9.0, and were on the ventilator for an average of 9.9 days. Of those patients tested, 28 percent (54 out of 188) tested positive for alcohol.

Figure 1. Hospital Discharge Status

Figure 1. Hospital Discharge Status

Health care professionals should monitor postoperative fasciotomy patients for wound care and potential electrolyte derangements. Patients also should be enrolled in physical and occupational therapy to prevent loss of range of motion. Early therapy is imperative and goes a long way toward preventing a patient from being up in arms about loss of function.

Throughout the year, NTDB data are highlighted in brief reports published monthly in the Bulletin. The NTDB Annual Report can be found on the ACS website as a PDF file. In addition, the website provides information about how to obtain NTDB data for more detailed study. To submit your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at mneal@facs.org.

Acknowledgment

Statistical support for this article was provided by Ryan Murphy, Data Analyst, NTDB.


References

  1. Griffiths DL. Volkmann’s ischaemic contracture. Br J Surg. 1940;28:239-260.
  2. Fantus RJ, Schlanser V. NTDB data points: A slice in time: Lower extremity compartment syndrome. Bull Am Coll Surg. 2018;103(5):85-86.
  3. Prasarn ML, Ouellette EA. Acute compartment syndrome of the upper extremity. J Am Acad Orthop Surg. 2011;19(1):49-58.
  4. Leversedge FJ, Moore TJ, Peterson BC, Seiler JG III. Compartment syndrome of the upper extremity. J Hand Surg Am. 2011;36(3):544-559.

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