Hand Compartment Syndrome

In this Article

• Definition
• Causes
• Diagnosis
• Initial Management
• Surgical Fasciotomy of the Hand
• References

Definition of Compartment Syndrome

Compartment syndrome is defined as an increase in a compartment’s pressure causing neurovascular compromise.

Pathophysiology

The pathophysiology of Compartment Syndrome is best described by Matsen’s Unified Hypothesis^​1​. 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 above^​1–5​.

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 injury^​6​. With these 3 factors in mind, a classification system has been proposed^​7​

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:

Diagnosis of Compartment Syndrome

Compartment syndrome is a clinical diagnosis, which may be assisted by compartment pressure readings.

Clinical Diagnosis

The diagnosis of compartment syndrome has traditionally focused on the 5P’s mnemonic:

• Pain
• Pallor
• Paraesthesia
• Paralysis
• Pulselessness.

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.

In a paediatric population, the rule of “A’s” has been suggested: analgesia, anxiety, agitation

Pressure Measurements

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 measurement^​21​
• Fracture-related injuries can cause high pressures than other types of injuries^​22​
• Several different techniques, with no convincing superiority study^{​23–26​}

Newer techniques have been described to overcome these limitations:

• Laser Doppler flowmetry^​27​
• 99Tcm-methoxy-isobutryl isonitril scintigraphy^​28​

Pressure Values

There is no exact pressure value to diagnose compartment syndrome. On reviewing the literature, there appears to be 3 schools of thought for diagnosis:

1. Absolute interstitial pressure between 30-50mmHg^{​25,29,30​}
2. Delta Pressure ≤ 30mmgHg (difference between the diastolic blood pressure and the compartment pressure)^​31,32​
3. Interstitial tissue pressures within 30 mmHg of the mean arterial pressure or 20 mmHg of the diastolic blood pressure^​33​

On a physiological level, the following numbers are important:

• Normal interstitial fluid pressures between 0 and 25.2 mm Hg^​34,35​
• Axonal transport slows with a pressure of 30mmHg^​36​
• Arteriole collages occurs at 30-40mmHg^​2​
• Motor and sesonry conduction stops at 50mmHg^​37​.

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 level^​38​
• Frequent clinical assessments
• Consider Pressure Measurements

Medical Optimisation

• 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.

Radiological Investigations

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.

3 Volar Fasciotomy Incisions

Incision 1: Extended carpal tunnel incision

The aim of this incision is to release:

1. Ulnar Neurovascular structures: release of Guyon’s Canal
2. Adductor Pollicis: extend incision into second volar web space.
3. Volar Interosseous Muscle: separate fascia between middle finger metacarpal and palmar fascia

Incision 2 and 3: Radial and Ulnar Incisions

1. The thenar muscles are released via a longitudinal incision on radial margin of thenar eminence
2. 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).

Post-Operatively

In the post-operative setting for hand fasciotomies, key principles are:

1. Limb should be splinted in a position of function and elevated with avoidance of constrictive dressings.
2. Careful monitoring of adjacent compartments for emerging pathology
3. Re-evaluate the wound every 24-48 hours
4. Debridement of all nonviable tissue
5. Consider use of Negative-pressure wound therapy
6. Optimisation medically and control pain
7. Therapy should be started immediately promote maximum range of movement

References

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