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COMPARTMENT SYNDROME, FOREARM

Introduction

Compartment syndrome in the upper volar forearm is the most common compartment syndrome.  Compartment syndrome occurs when edema associated with an insult or injury increases interstitial pressure in a closed fascial compartment, which in turn, disrupts normal microvascular circulation. The greater the initial soft tissue injury, the greater the intracompartmental pressure.  The longer the compartment pressure is elevated the greater the tissue damage and necrosis. Depending on the duration of the microvascular circulatory disruption and the pressure levels reached, the tissue ischemia, cell death and functional loss can be mild or very severe. After injury, it can take 12-16 hours before the signs of a compartment syndrome are evident. However, prompt recognition and treatment of compartment syndrome is essential for preserving upper extremity function.3,4

Related Anatomy

  • 3 forearm compartments
    • Volar Compartment - This compartment is the most commonly affected.  This compartment has a superficial and deep layer.3  Within the deep layer the pronator quadratus may have a separate compartment that requires a surgical release of the epimysial fascia. 
    • Dorsal compartment -  This compartment also has a superficial and deep layer.  In addition, the ECU muscle and/or the EPL muscle sometimes have separate myofascial compartements.
    • Mobile wad, rarely involved

Incidence and Related Conditions

  • Supracondylar fractures in children
  • Distal radius fractures in adults, 1% of distal radial fractures have associated compartment syndromes.
  • Severe crush injuries
  • Severe burns
  • Insect and animal bites
  • Extravasation injuries
  • Constrictive casts or splints
  • Hematomas especially in patients on anticoagulants.
  • Infections
  • Reperfusion injury
  • High voltage electric shock

Differential Diagnosis

  • Nerve injuries - The median nerve can be injured or entrapped during distal radius fractures and create pain levels consistent with a compartment syndrome.
  • Arterial injuries, for example a partial laceration of the ulnar artery that do not retract and clot and cause severe swelling.
ICD-10 Codes

  • COMPARTMENT SYNDROME, FOREARM

    Diagnostic Guide Name

    COMPARTMENT SYNDROME, FOREARM

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    COMPARTMENT SYNDROME, UPPER EXTREMITY (FOREARM,WRIST,HAND)    
    - TRAUMATIC T79.A12T79.A11 
    - NONTRAUMATIC M79.A12M79.A11 

    Instructions (ICD 10 CM 2020, U.S. Version)

    CODE FIRST, IF APPLICABLE, ASSOCIATED POSTPROCEDURAL COMPLICATION

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
  • Compartment Syndrome with DBFFx
    Compartment Syndrome with DBFFx
Symptoms
Pain, often severe
Swelling of the forearm
Numbness or paresthesias in the hand
Partial or complete paralysis
History of significant trauma
Typical History

A typical patient is often a young male who has sustained a high energy injury which frequently is an open injury.  Depending on the length of time between injury and presentation to the emergency room, the patient may be complaining of one or more of the "5 P's".  The "5P's" include:

  1. Pain: exacerbated by passive stretch of the ischemic muscles;  pain is refractory to splinting and elevation and appears out of proportion to the mechanism and type of injury.
  2. Pallor: can be seen with blisters, mottling, ecchymosis, shiny skin
  3. Parethesias, paresis: changes in sensation may precede weakness
  4. Paralysis or in the early stages muscle weakness
  5. Pulselessness

Early diagnosis and urgent surgical treatment is mandatory for this patient.

If a diagnosis of compartment syndrome can not be made clinically, for example an intoxicated patient who can not cooperate with a physical examination, then measuring the compartment pressure with a compartment pressure monitor is indicated to confirm or eliminate the diagnosis. When the examiner uses the Whitesides method, a compartment syndrome diagnosis is confirmed when the compartment pressure is with 30mmHg to the mean arterial pressure or 20 mmHg below the diastolic blood pressure. Some surgeons feel surgery is indicated when the compartment pressure is ≥30 mmHg. There is no consensus on what pressure readings are absolutely diagnostic of a compartment syndrome. Sometimes the best the examiner can do is compare the pressure in the injured forearm to the same compartment in the uninjured forearm.3,4.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Imaging Studies in Forearm Compartment Syndrome
  • Diabetic patient presenting with swollen, tense and painful proximal forearm. Note increased thickness of soft tissue shadow (arrow) on X-ray. Blood glucose marked elevated.
    Diabetic patient presenting with swollen, tense and painful proximal forearm. Note increased thickness of soft tissue shadow (arrow) on X-ray. Blood glucose marked elevated.
  • ultrasound consistent with abscess in proximal volar forearm
    ultrasound consistent with abscess in proximal volar forearm
  • MRI consistent with abscess in proximal volar forearm with secondary compartment syndrome
    MRI consistent with abscess in proximal volar forearm with secondary compartment syndrome
Treatment Options
Treatment Goals
  • Prevent or minimize tissue loss
  • Preserve hand and upper extremity function
Conservative

A definite compartment syndrome requires immediate surgery.  

If a patient with a distal radius fracture presents with mild increased pain and complaints of numbness, then the appropriate treatment may simply be loosening the splint or bivalving the cast.  If this procedure immediately relieves or markedly improves the symptoms, then a compartment syndrome has probably been everted, but careful monitoring of the patient is mandatory.

Operative

A definite compartment syndrome requires urgent fasciotomies.

Surgical treatment includes a volar forearm fasciotomy through a lazy-S incision with release of the skin and the fascia; intraoperative assessment of muscle viability and appropriate debridement is also indicated.  Postoperatively, the incisions must be left open with reconstruction late by skin grafting or secondary closure.

If a diagnosis of compartment syndrome can not be made clinically, for example an intoxicated patient who can not cooperate with a physical examination, then measuring the compartment pressure with a compartment pressure monitor is indicated to confirm or eliminate the diagnosis. When the examiner uses the Whitesides method, a compartment syndrome diagnosis is confirmed when the compartment pressure is with 30mmHg to the mean arterial pressure or 20 mmHg below the diastolic blood pressure. Some surgeons feel surgery is indicated when the compartment pressure is ≥30 mmHg. There is no consensus on what pressure readings are absolutely diagnostic of a compartment syndrome. Sometimes the best the examiner can do is compare the pressure in the injured forearm to the same compartment in the uninjured forearm.3,4.

Treatment Photos and Diagrams
Diagnostic Tools and Treatment
  • Monitor for measuring compartment pressure
    Monitor for measuring compartment pressure
  • Monitor for measuring compartment pressure with sterile components- needle (A); Pressure chamber B); & Syringe with sterile normal saline (C)
    Monitor for measuring compartment pressure with sterile components- needle (A); Pressure chamber B); & Syringe with sterile normal saline (C)
  • Volar Incision plan for volar forearm fasciotomies
    Volar Incision plan for volar forearm fasciotomies
  • Compartment Syndrome after Fasciotomy and External Fixation
    Compartment Syndrome after Fasciotomy and External Fixation
  • Dorsal Incision plan for dorsal forearm fasciotomies
    Dorsal Incision plan for dorsal forearm fasciotomies
Complications
  • Early: tissue damage, functional impairment, intrinsic tightness
  • Late: neurologic deficit, contracture, gangrene, Volkmann ischemic contracture, muscle fibrosis, loss of contractility
Outcomes
  • In a systematic review of 12 studies3, only 1 study provided results to stratify by outcome: excellent in 63% (12/19), fair in 5% (1/19) and poor results in 16% (3/19)
Video
Pressure monitor set up prior to measuring muscle compartment pressures
Simulation of volar forearm compartment pressure monitoring
Key Educational Points
  • A perfectly accurate and 100% reliable method for diagnosing a compartment syndrome DOES NOT EXIST!
  • A definite diagnosis of a compartment syndrome requires urgent surgery (fasciotomies).
  • Compartment Syndromes always present as emergencies and rarely at an opportune time. 
  • Medical co-morbitiies and multiple injuries make diagnosing and managing compartment syndrome even more complicated. 
  • DO NOT close the skin at the time of emergency fasciotomies. 
  • Endoscopic fasciotomies may not completely decompress the myofascial compartments.
  • Pressure monitor readings alone ARE NOT a substitute for a carefully done history, physical examination and good clinical judgement.
  • Severe burns require escharotomies and fasciotomies.
References

Cited Articles

  1. Pozzi A, Pivato G, Kask K, et al. Single portal endoscopic treatment for chronic exertional compartment syndrome of the forearm. Tech Hand Up Extrem Surg 2014;18(3):153-6. PMID: 24977494
  2. Cha J, York B, Tawfik J. Forearm compartment syndrome. Eplasty 2014 ePub. PMID: 24917895
  3. Leversedge FJ, MooreTJ, Peterson BC Seiler JG. Compartment syndrome of the upper extremity. J Hand Surg 2011; 36A: 544-560.
  4. Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV. Compartment syndrome of the forearm: a systematic review. J Hand Surg Am 2011;36(3):535-43. PMID: 21371630

Reviews

  1. Donaldson J, Haddad B, Khan WS. The pathophysiology, diagnosis and current management of acute compartment syndrome. Open Orthop J 2014;8:185-93. PMID: 25067973
  2. Garner MR, Taylor SA, Gausden E, Lyden JP. Compartment syndrome: diagnosis, management, and unique concerns in the twenty-first century. Hosp Spec Surg J 2014;10(2):143-52. PMID: 25050098
  3. Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV. Compartment syndrome of the forearm: a systematic review. J Hand Surg Am 2011;36(3):535-43. PMID: 21371630

Classics

  1. Matsen FA III. Compartment syndrome: a unified concept. Clin Orthop Rel Res 1975;113:8-14. PMID: 1192678
  2. Gelberman RH,et al. Decompression of forearm compartment syndromes. Clin Orthop Relat Res 1978;(134):225-9. PMID: 729250
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