What Do We Know About Compartment Syndrome of the Forearm?

» What Do We Know About Compartment Syndrome of the Forearm?
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A group of orthopedic and hand surgeons from the University of Louisville in Kentucky took the time to do a systematic review of the literature on the topic of compartment syndrome. They specifically focused on the forearm and included children and adults. They found 12 acceptable studies and pooled the information from 84 patients to offer us a review of this problem.

First, what is compartment syndrome and what causes it? Injury such as a bone fracture, snakebite, surgery, or stab wound causes swelling inside the entire forearm. This study showed that a supracondylar fracture was the most common cause of forearm compartment syndrome in children. A supracondylar fracture affects the lower portion of the humerus (upper arm bone) just above the elbow.

In adults, a fracture of the distal radius was the problem that resulted in this condition most often. The distal radius is at the end of the radial bone in the forearm just above the wrist. Other reported causes of forearm compartment syndrome included gunshot wounds, hemophilia (blood clotting disorder), phlebitis (inflammation of the veins), use of a tourniquet, and narcotic overdose.

With any compartment syndrome, fluid from swelling is trapped inside the osteofascial envelope. This envelope is a layer of connective tissue around the muscles, tendons, blood vessels, and nerves.

The pressure placed on these sensitive soft tissues can cause death of the tissues. This condition is usually considered an emergency requiring immediate surgery to release the skin and soft tissues and let the fluid drain out. That procedure is called a fasciotomy.

Early diagnosis is important to prevent serious complications. The patient often presents with obvious swelling. The skin around the forearm is so tight it becomes shiny in appearance. Pressure on the nerves can cause nerve impairment. Patients may report numbness, tingling, and even loss of sensation and function.

The surgeon can measure the pressure in the forearm. There are several different techniques for this (e.g., Wick catheter, Stryker device, slit catheter, Whitesides technique). Measurements can be taken from the front of the forearm and the back of the forearm and compared with normal levels of pressure. But this level of testing may not be necessary as studies show that a simple skin measure of sensation is actually very reliable.

Nonsurgical treatment is possible when pressures measure low enough and if there's enough blood circulation to the hand. Complications can occur with either surgical or nonsurgical care. Patients must be observed carefully for any signs of contracture (muscles tighten so much that joints can't move), gangrene, deformity, and complex regional pain syndrome (CRPS).

The authors make note of the fact that the incidence of forearm compartment syndrome following fractures seems to be on the decline. The most likely explanation for this is improved fracture management.

There is evidence that children and young adults (under age 35) with multiple injuries and trauma are at greatest risk for compartment syndrome. Surgeons watch for this now and monitor patients closely. This may be another reason for the decrease in this serious problem.

Reference: Bharati S. Kilyani, MD, et al. Compartment Syndrome of the Forearm: A Systematic Review. In The Journal of Hand Surgery. March 2011. Vol. 36-A. No. 3. Pp. 535-543.

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