Compartment syndrome of the hand is an uncommon but acute surgical issue. With reference to 41 peer-reviewed publications, this article discusses the definition, pathophysiology, diagnosis and treatment of compartment syndrome.
In this Article
Definition of Compartment Syndrome
Compartment syndrome is defined as an increase in a compartment’s pressure causing neurovascular compromise.
The pathophysiology of Compartment Syndrome is best described by Matsen’s Unified Hypothesis1. The Unified concept proposes that:
- The clinical features of compartment syndrome are the same, irrespective of etiology or location.
- Increased tissue pressure is the central pathogenic factor, which may be due to a decrease in compartment size or increase in the volume of its contents.
Current literature focuses on 3 pressure variables: interstitial tissue, venous pressure, arterial pressure. All of which are influenced by each-other in a positive-feedback loop. This feed-back loop creates the progressive nature of compartment syndrome and results in a spectrum of clinical findings, as illustrated in the diagram above1–5.
Stages of Compartment Syndrome
Compartment syndrome is a progressive clinical condition dependent on: the amount of pressurisation, duration of pressurisation and extent of soft tissue injury6. With these 3 factors in mind, a classification system has been proposed7
|Acute Incipient||– Early period after injury during |
– Pressures ≤ critical pressure
|Acute Established-reversible||– Less than 8 hours|
– Urgent decompression avoids injury
|Acute Established-irreversible||– More than 8 hours|
– Cellular death
– Fasciotomy may still be useful
|Late Established||– More than 8 hours|
– Prior to fibrous replacement of normal
|Volkmann’s ischaemic contracture||– Fibrosis and contracture of affected compartment|
|Chronic exertional compartment syndrome||– Recurrent pressure increases |
– Transient symptoms
– Usually during exercise & resolved with rest.
Causes of Compartment Syndrome
Compartment syndrome can be caused by an increase in compartmental content or a decrease in compartmental size.
The aetiology of a compartment syndrome can be classified by the mechanism of the injury (traumatic vs non-traumatic) or the pathophysiology of the injury. Regardless of these classifications, injuries result in either an increase compartmental contents or decrease compartmental size.
The table outlines some of the causes of compartment syndrome:
|Fractures (e.g: carpometacarpal fracture-dislocation, distal radius or ulna, or a pediatric supracondylar humerus)||Muscle Overuse (e.g: Seziures)|
|Crush Injury||Infection (e.g: Abscess)|
|High-pressure injury||Reperfusion Injury|
Diagnosis of Compartment Syndrome
Compartment syndrome is a clinical diagnosis, which may be assisted by compartment pressure readings.
The diagnosis of compartment syndrome has traditionally focused on the 5P’s mnemonic:
The diagnostic sensitivity and specificity of the signs and symptoms are such that they cannot be used in isolation to make the diagnosis of an acute compartment syndrome.
This table summaries current evidence for clinical signs of compartment syndrome.
|Pain||– Disproportionate to physical findings|
– Exacerbated by passive stretching
– Peaks at 2-6 hours of ischemia and then subsides with necrosis
– The most reliable sign
|Pallor||– Less reliable |
– Can have good skin colour overlying a pressurised compartment due to way blood is supplied to skin.
|Pressure||– Tense, swollen compartment|
– Intrinsic minus position
|Paraesthesia||– Progressive neurologic changes|
– Can be confounded by injury
|Late Signs||Paralysis and pulselessness are late signs. Irreversible tissue damage can occur in the presence of palpable pulse – the critical compartment pressure is capillary filling pressure, which is lower than arterial pressure.|
In a paediatric population, the rule of “A’s” has been suggested: analgesia, anxiety, agitation
There is an ongoing debate regarding the role of interstitial pressure measurements. There is a general consensus on their accuracy if performed correctly, but differing opinions on its utility.
Indications include an unresponsive patient, polytrauma, inconclusive clinical examination. Limitations of interstitial pressure measurements include:
- Differences in pressure depending on location of measurement21
- Fracture-related injuries can cause high pressures than other types of injuries22
- Several different techniques, with no convincing superiority study23–26
Newer techniques have been described to overcome these limitations:
- Laser Doppler flowmetry27
- 99Tcm-methoxy-isobutryl isonitril scintigraphy28
There is no exact pressure value to diagnose compartment syndrome. On reviewing the literature, there appears to be 3 schools of thought for diagnosis:
- Absolute interstitial pressure between 30-50mmHg25,29,30
- Delta Pressure ≤ 30mmgHg (difference between the diastolic blood pressure and the compartment pressure)31,32
- Interstitial tissue pressures within 30 mmHg of the mean arterial pressure or 20 mmHg of the diastolic blood pressure33
On a physiological level, the following numbers are important:
- Normal interstitial fluid pressures between 0 and 25.2 mm Hg34,35
- Axonal transport slows with a pressure of 30mmHg36
- Arteriole collages occurs at 30-40mmHg2
- Motor and sesonry conduction stops at 50mmHg37.
Initial Management of Compartment Syndrome
Early recognition and high index of suspicion is vital to minimize tissue necrosis and functional loss. Initial management can often be done at the bedside whilst awaiting theatre.
At the Bedside
- Remove all constrictive dressings
- Elevation of the limb to heart level38
- Frequent clinical assessments
- Consider Pressure Measurements
- Knowledge and optimisation of comorbidities
- Fluid and electrolyte management
- Monitoring of renal function and for signs of coagulopathy are important.
- Urinalysis for myoglobinuria
- Elevated levels of serum creatinine phosphokinase may indicate severe muscle damage.
This is a case-by-case basis guided by history and clinical examination. Post-decompression, there are case reports describing the use of MRI to assess degree of myonecrosis 39
Surgical Fasciotomy of the Hand
Urgent surgical decompression through well-planned fasciotomy incisions is the surgical management for compartment syndrome.
The hand has 10 separate compartments. It is rarely necessary to release all 10 compartments, and intraoperative assessment and/or measurement of compartment pressures should be used to determine the extent of release needed. If possible, pre-operatively consent patient in relation to scars
Compartments of the Hands and the Incision
The following table describe the compartment, muscles and their respective incisions for decompression.
For more information on flexor tendon anatomy, click here.
Abductor digiti minimi
Flexor digiti minimi
Opponens digiti minimi
|Ulnar border of hand|
Abductor pollicis brevis
Flexor pollicis brevis
|Radial margin of thenar eminence|
|Dorsal over first webspace|
|Between 2-3rd & 4-5th metacarpals.|
|Extended carpal tunnel incision|
3 Volar Fasciotomy Incisions
Incision 1: Extended carpal tunnel incision
The aim of this incision is to release:
- Ulnar Neurovascular structures: release of Guyon’s Canal
- Adductor Pollicis: extend incision into second volar web space.
- Volar Interosseous Muscle: separate fascia between middle finger metacarpal and palmar fascia
Incision 2 and 3: Radial and Ulnar Incisions
- The thenar muscles are released via a longitudinal incision on radial margin of thenar eminence
- The hypothenar muscles are released via a longitudinal incision on ulnar border of the hand.
3 Dorsal Fasciotomy Incisions
Incision 1: Longitudinal Incision in 1st Webspace
- First dorsal interosseous muscle – incision in first webspace (can also release the dorsal fascia of the adductor pollicis)
Incision 2 & 3: Longitudinal Incision in 2nd-3rd, 4-5th Metacarpal spacepace
- Remaining dorsal interosseous muscles – incision between 2nd-3rd, 4th-5th metacarpals (can also decompression volar interosseus muscles)
Release of Fingers
Dermotomies are not always indicated but should be performed if tense & swollen fingers The tight fibers of Cleland and Grayson ligaments can compression and obstruct the Digital arteries. These ligaments compartmentalise the digits.
Ideally, a dermotomy should be a mid-axial incision (ulnar for index, long and ring, radial for thumb and little finger).
In the post-operative setting for hand fasciotomies, key principles are:
- Limb should be splinted in a position of function and elevated with avoidance of constrictive dressings.
- Careful monitoring of adjacent compartments for emerging pathology
- Re-evaluate the wound every 24-48 hours
- Debridement of all nonviable tissue
- Consider use of Negative-pressure wound therapy
- Optimisation medically and control pain
- Therapy should be started immediately promote maximum range of movement
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