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© 1996 The Journal of Bone and Joint Surgery, Inc. Compartment Syndromes of the Hand*  , MIAMI, FLORIDAInvestigation performed at the Department of Orthopaedics and Rehabilitation, University of Miami School of Medicine, Miami
We retrospectively reviewed the records of nineteen patients who had been managed with fasciotomy because of compartment syndrome of the hand. The patients were five months to sixty-seven years old and included ten adults and nine children. Seventeen patients were followed for an average of twenty-one months (range, one to fifty-eight months), one patient was lost to follow-up after discharge, and one patient died four days postoperatively. All of the patients had a tense, swollen hand and elevated pressure in at least one interosseous compartment. Eight patients also had a compartment syndrome of the forearm. The compartment syndromes developed after intravenous injections (eleven patients); after a gunshot wound, a crush injury, or a complication related to the use of an arterial line (two patients each); and after a complication related to an arthrodesis of the wrist or a crush injury due to prolonged pressure on the upper extremity secondary to a drug overdose (one patient each). Fifteen patients had an obtunded sensorium—either because of a serious illness or injury or secondary to prolonged anesthesia—when the compartment syndrome was recognized. In thirteen of these patients, including eight children and five adults, the compartment syndrome developed because of a complication related to the intravenous or intra-arterial administration of drugs. Carpal tunnel release and decompression of the involved compartments led to a satisfactory result for thirteen of the seventeen patients who were followed. The remaining four patients (including two children who had an amputation, one child who had impaired function of the hand secondary to brain damage, and one adult who had extensive involvement of the forearm and complete loss of function of the hand) had a poor result. All four of these patients had been obtunded when the compartment syndrome developed. The treating physician should maintain a high index of suspicion for a compartment syndrome of the hand when managing seriously ill, obtunded patients—particularly children—who are receiving multiple intravenous or intra-arterial injections.
Compartment syndromes of the hand and forearm can result in tissue necrosis, which can lead to a devastating loss of function6,7. Although compartment syndromes of the leg and forearm (the two most common types of this condition) have been well described3,4,7,8, previous reports on compartment syndrome of the hand have focused primarily on the sequelae of the increased intracompartmental pressure rather than on its pathomechanics and their relationship to the outcome of treatment1,5,6,11-13. Bunnell et al. described compartment syndrome of the hand in 1948, long before the technology for the measurement of intracompartmental pressure became available. Spinner et al., in 1972, described the electromyographic and pathological findings in the involved muscles of fourteen patients who had a compartment syndrome of the hand, but they did not document intracompartmental pressure, the time to decompression, or other risk factors that may have affected the outcome. The etiological agents that have been associated with compartment syndromes of the hand have included multiple closed fractures, snakebites, crush injuries, soft-tissue and arterial injuries, and burns1,11-13 as well as intravenous injections of contrast medium for computerized tomographic studies5. The purpose of the present study was to investigate the pathophysiology of compartment syndrome of the hand and to determine its effect on the outcome of treatment.
We retrospectively reviewed the records of nineteen consecutive patients who had been managed with fasciotomy because of increased intracompartmental pressure in the hand at Jackson Memorial Hospital and the University of Miami Affiliated Hospitals between April 1985 and January 1990. The diagnosis at the time of admission, the side of involvement, the number and location of incisions, the time from the diagnosis of the compartment syndrome to the fasciotomy, the preoperative and postoperative measurements of intracompartmental pressure, the etiology of the compartment syndrome, and the relationship of these factors to the outcome were analyzed for each patient. One patient (Case 14), who had bilateral compartment syndrome in association with the intravenous administration of fluids during seventeen hours of operative treatment for injuries sustained in a motor-vehicle accident, died four days postoperatively. The acute data for this patient are included in the study. The patients were five months to sixty-seven years old and included ten adults and nine children. Eleven patients were male and eight were female. Twelve patients had involvement of the right hand only; six, of the left hand only; and one, of both hands. The patients were admitted for a variety of reasons (Table I). The children were admitted because of pneumonia, meningitis, or a gunshot wound (two patients each) or because of a brain tumor, a cerebral aneurysm, or injuries sustained in a motor-vehicle accident (one patient each). Eight children were managed in the intensive-care unit because of a life-threatening disease or injury and had an obtunded sensorium; the other child had a gunshot wound to the hand. The adults were admitted because of injuries sustained in a motor-vehicle accident (two patients) or for an operation for prostatic hypertrophy, seizures secondary to a head injury sustained in a motor-vehicle accident, a laminectomy and shunting because of a cyst of the spinal cord, injuries sustained in a bicycle accident, a crush injury to the hand, a gunshot wound to the hand, an arthrodesis of the wrist, or loss of consciousness secondary to a drug overdose (one patient each). Seven of the ten adults had an operative procedure that led to an altered sensorium during anesthesia. The other three adults (two of whom had a crush injury and one of whom had a gunshot wound) were admitted specifically because of the compartment syndrome.
The compartment syndrome was iatrogenic in fourteen of the nineteen patients; specifically, it developed because of a complication related to the intravenous administration of drugs (eleven patients), the use of an arterial line (two patients), or an arthrodesis of the wrist (one patient). In two other patients, the compartment syndrome developed because a small-caliber bullet had lacerated muscles or arteries in the hand, resulting in a hemorrhage within a closed space; decompression had not occurred spontaneously because of the small size of the exit wound. In the remaining three patients, one of whom had had a loss of consciousness with compression of the upper extremity for more than twenty-four hours, the compartment syndrome was associated with a crush injury. The most consistent clinical finding was a tense, swollen hand in an intrinsic minus position (extension of the metacarpophalangeal joints and flexion of the interphalangeal joints). Pain could not be elicited by means of passive stretching of the involved muscles in seventeen patients, fifteen of whom had an obtunded sensorium; it was elicited only in the two patients who had sustained a gunshot wound to the hand and in whom the compartment syndrome had developed over a period of more than twelve hours. The indication for a fasciotomy was the presence of clinical signs and symptoms of a compartment syndrome and an intracompartmental pressure of fifteen to twenty-five millimeters of mercury (2.00 to 3.33 kilopascals) or, in the absence of clinical signs and symptoms, an intracompartmental pressure of more than twenty-five millimeters of mercury (3.33 kilopascals). Preoperatively, an arterial line and a pressure transducer were used to obtain a single measurement of the pressure in each compartment. The method was the same as the continuous-infusion technique described by Matsen, except that the infusion pump was eliminated from the setup. Measurements were obtained either at the bedside or in the operating room before the release of the involved compartments. The same technique was used to obtain measurements in the operating room after the fasciotomy. Preoperative and postoperative intracompartmental pressures were recorded for thirteen patients, only preoperative pressures were recorded for four patients, only postoperative pressures were recorded for one patient (Case 11), and neither preoperative nor postoperative pressures were recorded for another patient (Case 13). There was little difference between the adults and the children with regard to preoperative pressure (Table I). The average preoperative pressure was more than fifty millimeters of mercury (6.67 kilopascals) (range, fifty-three to ninety-three millimeters of mercury [7.06 to 12.40 kilopascals]) in five of the nine children and five of the eight adults for whom such information was available. The pressure ranged from sixteen to 136 millimeters of mercury (2.13 to 18.13 kilopascals) in the thenar compartment, from eighteen to 102 millimeters of mercury (2.40 to 13.60 kilopascals) in the hypothenar compartment, from twenty to 110 millimeters of mercury (2.67 to 14.66 kilopascals) in the dorsal interosseous compartments, from five to seventy millimeters of mercury (0.67 to 9.33 kilopascals) in the volar compartment of the forearm, and from ten to more than sixty millimeters of mercury (1.33 to more than 8.00 kilopascals) in the dorsal compartment of the forearm. Pressure in the mid-palmar space, measured for four patients, ranged from thirty-two to 265 millimeters of mercury (4.27 to 35.32 kilopascals). The average postoperative pressure was less than eleven millimeters of mercury (1.47 kilopascals) in twelve of the fourteen patients for whom such information was available; in the remaining two patients (one child and one adult), it was fourteen and seventeen millimeters of mercury (1.87 and 2.27 kilopascals), respectively. The time from the onset of the symptoms to the fasciotomy was less than one hour for three patients; less than three hours for five patients; less than six hours for four patients; more than six, more than twelve, more than seventeen, and more than eighteen hours for one patient each; and more than twenty-four hours for three patients. Fifteen patients had an obtunded sensorium because of a serious illness or injury or secondary to prolonged anesthesia, and this may have led to a delay in the diagnosis of the compartment syndrome. All of the patients had a carpal tunnel release and decompression of one or two dorsal interosseous compartments. The decision regarding the number and location of incisions was based on clinical findings as well as intraoperative measurements of pressure. Overall, there were thirty-seven incisions over the dorsal interosseous compartments, sixteen incisions over the thenar compartment, nine incisions over the volar compartment of the forearm, five mid-axial releases of the fascia over the muscles of the fingers, and three incisions over the dorsal compartment of the forearm (Table I). Seventeen patients were followed for an average of twenty-one months (range, one to fifty-eight months). Thirteen patients were examined clinically at the time of the latest follow-up, and four were interviewed by telephone. One adult (Case 14), who had bilateral compartment syndromes in association with the intravenous administration of fluids during seventeen hours of operative treatment for injuries sustained in a motor-vehicle accident, died four days postoperatively. One child (Case 5), who had received intravenous fluids during the operative treatment of a gunshot wound of the chest and abdomen, had a normal range of motion of the hand at the time of discharge (three days postoperatively) but subsequently was lost to follow-up.
Thirteen of the seventeen patients who were evaluated had normal function of the hand at the time of the most recent follow-up. One patient (Case 10) had numbness in the distribution of the median nerve in the immediate postoperative period, but this condition had resolved by the time of the four-month evaluation. The patient had triggering of the long finger at that evaluation. Two patients had a secondary procedure for the release of a contracture in the hand and subsequently regained normal function. The first patient (Case 1), a six-month-old boy who had meningitis, had been receiving dopamine intravenously when the compartment syndrome developed. He was managed with the release of a contracture in the hand thirty months after the fasciotomy. The second patient (Case 2), a nine-year-old girl who had been managed with a craniotomy and the resection of a cerebral aneurysm, had been receiving Dilantin (phenytoin) through an arterial line when the compartment syndrome developed, one day postoperatively. She was managed with the release of a contracture in the hand and full-thickness skin-grafting six months after the fasciotomy. Four patients (one adult and three children) had a poor result; all four had had an obtunded sensorium because of a serious illness or injury or had been under anesthesia when the compartment syndrome developed, and the time from the recognition of the compartment syndrome to the fasciotomy exceeded six hours. Two of these patients, both of whom were infants, had an amputation. The first patient (Case 4) was a seven-month-old girl in whom a compartment syndrome developed secondary to infiltration of the soft tissues with fluid from an arterial line one day after the excision of a brain tumor. Four weeks after the fasciotomy, she had a below-the-elbow amputation. The second patient (Case 6), a five-month-old girl, had meningitis and was only somewhat responsive to deep pain when the compartment syndrome developed secondary to infiltration of the soft tissues with Dilantin from an intravenous line. Nine weeks after the fasciotomy, she had an amputation of the fingers proximal to the metacarpophalangeal joints. The third patient (Case 13) was a thirty-four-year-old woman who had been comatose and had been lying on the upper extremity for more than twenty-four hours after a drug overdose; the continuous pressure had resulted in a Volkmann ischemic contracture. Despite three reconstructive operations, she still had not regained functional use of the hand by two years after the fasciotomy. The fourth patient (Case 3) was an eleven-year-old boy who had sustained a closed head injury and multiple trauma in a motor-vehicle accident one month earlier and was responding only to deep pain when the compartment syndrome developed secondary to infiltration of the soft tissues after the intravenous administration of fluid. (The drug could not be identified from the record.) At the latest follow-up examination, thirty-nine months after the episode, the patient still had a spastic hand secondary to brain damage. The loss of the function of the hand in the latter two patients (Cases 3 and 13) was due to circumstances beyond our control. Analysis of the preoperative intracompartmental pressures according to the outcome for the fourteen patients for whom these measurements had been made and for whom follow-up evaluations had been performed did not reveal any important differences between the eleven patients who had normal function of the hand at the time of the most recent follow-up and the three who did not. The age of the patient appeared to influence the result of treatment. Eight of nine adults had normal function of the hand at the time of the most recent follow-up, compared with only five of eight children. Both of the amputations in the present study had been performed for infants who were less than eight months old, and both of the soft-tissue contractures that necessitated secondary procedures were in children and were due to infiltration of the soft tissues with fluid from an intravenous or arterial line.
Previous authors who have reported on compartment syndrome of the hand have described etiological agents such as multiple closed fractures, snakebites, traumatic crush injuries, crush injuries secondary to drug overdose, soft-tissue and arterial injuries, and burns1,11-13. Halpern and Mochizuki reported the case of one patient in whom a compartment syndrome of the hand developed secondary to the intravenous injection of contrast medium into the dorsum of the hand before a computerized tomographic scan was made. In most of our patients, the compartment syndrome was iatrogenic. The ten compartments of the hand include the hypothenar, thenar, and adductor pollicis compartments; the four dorsal interosseous compartments; and the three volar interosseous compartments. The fascial compartments of the fingers, which are bound by Cleland and Grayson ligaments, are unyielding. It has been suggested that compartment syndromes are more likely to occur on the radial side of the hand than on the ulnar side, as the former is supplied by more end-arteries13. The anatomy of the fascial compartments of the hand determines the incision and approach that should be used. Every patient in the present study had a carpal tunnel release and decompression of one or two dorsal interosseous compartments. Only two patients (Cases 11 and 18) were managed with fasciotomy in the fingers. A fasciotomy of each individual compartment in the hand was not necessary to decompress the hand completely, and we measured the pressures after decompression to monitor the need for additional treatment. The compartments of the forearm were decompressed only if the signs and symptoms, as well as the intracompartmental pressures, indicated the need for a fasciotomy1-4. Several authors have noted that it is important to measure intracompartmental pressure when a compartment syndrome is suspected in a patient who is uncooperative, who has an altered mental status, or whose young age renders the clinical examination inadequate7,10,15. We know of three methods for the clinical measurement of intracompartmental pressure: the injection technique developed by Whitesides et al.14, the wick-catheter technique developed by Mubarak et al.9, and the continuous-infusion technique developed by Matsen. In the injection technique, a mercury manometer is used to measure the pressure necessary to inject a small quantity of fluid into the tissue through a needle. Although the advantage of this technique is that it involves the use of inexpensive equipment, it does not provide a steady-state reading and it can be difficult to observe the mercury manometer and the air-water meniscus simultaneously to detect the pressure at which fluid first begins to flow into the tissue. The wick-catheter technique involves the use of strands of wettable material that extend into the tissue from a fluid-filled catheter that is connected to a pressure transducer. The wick increases the surface area that is in contact with the tissue, and heparin is added to the fluid to minimize clotting around the fibers. With the continuous-infusion technique, a standard blood-pressure monitor is used to measure the pressure of the fluid within an ordinary hypodermic needle or intravenous catheter that has been inserted into the tissue. Continuous infusion of fluid is maintained with an infusion pump to permit ongoing measurement of pressure. We used this technique without the infusion pump because it is simple, it involves the use of equipment that is readily available in the hospital, it provides steady-state readings, and it does not necessitate the addition of heparin to the saline solution. Spinner et al. suggested that children can be expected to have a better result than adults because they heal more easily and rapidly and because they have greater suppleness of the joints; however, those authors did not provide details on their fourteen patients. Our data contradict their conclusions; it is possible that there are several reasons for the difference. It is particularly difficult to diagnose compartment syndromes early in young children, and the difficulty is compounded when the mental status of the patient is altered because of illness or anesthesia. Eight of the nine children, including the three children (Cases 3, 4, and 6) who had a poor result, were hospitalized because of a life-threatening disease or injury and had an obtunded sensorium when the compartment syndrome developed. The time from the recognition of the compartment syndrome to the fasciotomy exceeded six hours for all three children. Even when the compartment syndrome was recognized early and decompression was performed within six hours, contractures that necessitated a secondary procedure developed in two children (Cases 1 and 2). The results of the present study suggest that the degree of elevation of the preoperative pressure does not affect the outcome. We suggest that the treating physician should maintain a high index of suspicion for a compartment syndrome of the hand when managing critically ill, obtunded patients—particularly children—for whom multiple intravenous or intra-arterial injections are necessary.
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
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