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Compartment Syndromes of Hand and Forearm

- Antebrachial Compartment Syndrome: (see compartment syndrome menu)
    - causes:
          - may follow supracondylar fr(x) of humerus, or both bone forearm fractures;
          - compartment syndromes in the forearm after wrist fractures usually involve the volar compartment; 
    - compartment syndrome monitoring
    - technique of forearm fasciotomy(see forearm flexors)
          - requires decompression extending from wrist to midarm including:
                - lacertus fibrosus
                - deep fascial compartments over flexor carpi ulnaris;
                - edge of the flexor superficialis muscles 
          - median nerve involvement:
                - median nerve neuropathy, in addition to carpal tunnel release, requires exploration of nerve in proximal forearm;
                - three main areas of potential nerve compression are:
                       - bicipital aponeurosis (lacertus fibrosis);
                       - proximal edge of pronator teres;
                       - proximal edge of FDS

- Complications:
          - Volkmann's ischemic contracture may result from delayed diagnosis;
                  - results in ischemic contracture with severe muscle fibrosis & neuropathy;
                  - may result in functionless extremity w/ few treatment options for improvement;
                  - examination reveals tense compartment & paresthesias in median nerve distribution;
                  - passive extension of the digits or wrist increases pain;

- Compartment Syndrome of Hand: 
    - may result from:
           - burns of the hand 
           - high Pressure Injection Injuries 
           - occur most often from iatrogenic injuries (A-line or infiltration of IV medications);
    - patients are often ventilated, obtunded, or seriously ill leading to delayed dx;
    - patients symptoms may be non specific as compared to other compartment syndromes;
    - early recognition of this complication is based on physical examination;
    - unlike other compartment syndromes, hand compartment syndromes, lack abnormalities in sensory nerves, as no nerves are found within compartment;
           - diagnosis should be considered when there is a non specific aching of the hand, precipitated by repetitive strenuous activity;
           - increased pain, loss of digital motion, and continued swelling suggest impending compartment syndrome;
    - often the physician will note a tight swollen hand in a intrinsic minus position;
           - digits are found w/ MP extension and PIP flexion;
           - intrinsic tightness becomes evident on exam as motion of PIP joint becomes dependent on position of the metacarpophalangeal joint;
           - more proximal interphalangeal motion is possible w/ MP flexion than with metacarpophalangeal extension;
    - pressure measurement
           - should have a lower threshold than in leg compartments;
           - pressures greater than 15-20 mm is a relative indication for release;
    - surgical treatment of hand compartment syndrome:
           - anatomy: 10 separate osteofascial compartments which typically can be released w/ carpal tunnel release and 1 or 2 dorsal incisions;
                  - dorsal interossei (4 compartments)
                  - palmar interossei (3 compartments)
                  - adductor pollicis
                  - thenar and hypothenar
           - transverse carpal ligament requires release;
           - dorsal metacarpal incisions:
                  - 2 longitudinal dorsal hand incisions are carried over 2nd & 4th metacarpals;
                  - extensor tendons are retracted, allowing access to dorsal and volar interosseous compartments which are separate;
                  - these compartments are opened by longitudinal slits;
                  - dorsal incisions can generally be closed primarily, and delayed primarily closure, w/ or w/o skin grafting, is required for volar surface incision

Compartment syndromes of the forearm: diagnosis and treatment.

Decompression of forearm compartment syndromes.

Compartment syndrome in the forearm following fractures of the radial head or neck in children.

A cadaveric and radiologic assessment of catheter placement for the measurement of forearm compartment pressures.

Compartment syndromes of the hand.

Compartment syndrome associated with distal radial fracture and ipsilateral elbow injury.

Evolving Compartment Syndrome Detected by Loss of Somatosensory- and Motor-evoked Potential Signals During Cervical Spine Surgery