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COMPARTMENT SYNDROME, HAND

Introduction

Compartment syndrome in the hand is the result of increased interstitial pressure and decreased microvascular circulation to a closed fascial compartment after insult or injury. While the condition is uncommon, when it occurs, it is generally observed in children after a burn or insect or animal bite or after a severe crush injury to the hand in a child or adult. If compartment syndrome of the hand is not promptly diagnosed and treated, tissue ischemia, cell death and functional loss can ensue.1-4

Related Anatomy

  • Carpal tunnel - The carpal tunnel is not a true hand compartment but acute carpal tunnel syndrome often co-exists with compartment syndrome of the hand.
  • 10 compartments in the hand
    • 4 dorsal interossei
    • 3 palmar interossei
    • Hypothenar
    • Thenar
    • Adductor pollicis

Incidence and Related Conditions

  • Distal radius fractures in adults
  • Severe crush injuries of the hand and wrist
  • 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
  • Artery injuries

Work-up

  • History
  • Physical Exam
  • 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
ICD-10 Codes

  • COMPARTMENT SYNDROME, HAND

    Diagnostic Guide Name

    COMPARTMENT SYNDROME, HAND

    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

Symptoms
Pain often severe
Passive stretch of hand intrinsic muscles exacerbating pain with pain refractory to splinting and elevation
Swelling and pallor of the hand. This can occur with blisters, mottling, ecchymosis, shiny skin
Parethesias, paresis: changes in sensation may precede weakness
History of crush injury to the hand
History of excessive anticoagulation with bleeding into the hand intrinsic muscles and compartments
Typical History

A 43 year old male plumber who was trying to install a 300 pound stone lined water heater when the heater fell off the hand cart and crushed his hand against the concrete wall. Two hours later he arrived in the emergency room complaining of severe left hand pain, finger numbness, and severe hand swelling. Flexing his PIP joints with his MP joints extended caused excruciating pain.  X-ray showed three displaced metacarpal fractures. The hand compartment pressures were all elevated (23-29 mmHg). Emergency hand fasciotomies and ORIF of the fractures were performed immediately.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Prevent or minimize tissue loss
  • Preserve hand function
Conservative
  • If a patient, for example, has multiple metacarpal fractures and presents with mild increased pain, swelling and complaints of numbness, then the appropriate treatment may simply be loosening the splint and or hand dressings.  If this procedure immediately relieves or markedly improves the symptoms and signs of impending compartment syndrome, then a compartment syndrome has probably been everted, but careful monitoring of the patient is still mandatory.
  • If the symptoms and signs of compartment syndrome cntinue despite loosening dressings and splints then compartment pressures should be measure and surgery consider. 
  • If compartment syndrome is present or highly likely, surgery is manditory
Operative
  • Fasciotomy: If a hand compartment syndrome is diagnosed then fasciotomies and carpal tunnel release should be performed urgently.
  • If the the compartment syndrome is secondary to a severe burn then escharotomies and fasciotomies should be done.
  • All incisions should be left open with a plan for repeat surgical debridement in 24-72 lhours.
  • Postoperative: if secondary closure is not possible, split-thickness skin grafting is used
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)
  • Incisions for dorsal hand compartment releases
    Incisions for dorsal hand compartment releases
  • Incisions for palmar hand compartment releases
    Incisions for palmar hand compartment releases
Complications
  • Early: tissue damage, functional impairment, intrinsic tightness
  • Late: neurologic deficit, contracture, gangrene, Volkmann ischemic contracture, muscle fibrosis, loss of contractility
Outcomes
  • Sparse reports from the literature with results that vary widely
Video
Pressure monitor set up prior to measuring muscle compartment pressures
Simulation of thenar muscle compartment pressure monitoring
Simulation of hypothenar muscle 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).
  • The "5P's" of acute compartment syndrome :
    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
  • Unfortunately, the predictive value the historical complaints and physical exam  findings is low.3
  • The diagnosis of hand compartment pressure is confirmed with 30mmHg to the mean arterial pressure or 20 mmHg below the diastolic blood pressure.
  • Other surgeons feel surgery is indicated when the compartment pressure is ≥30 mmHg.
  • Ouelette and Kelley accept the diagnosis of hand compartment syndrome if the pressure is 25mmHg without symptoms or at 15-25 mmHg in a tense swollen hand held in a intrinsic minus position.
  • There is no consensus on what pressure readings are absolutely diagnostic of a compartment syndrome.3,4
  • Sometimes the best the examiner can do is compare the pressure in the injured forearm to the same compartment in the uninjured forearm.
References

Cited Articles

  1. Egro FM, Jaring MR, Khan AZ. Compartment syndrome of the hand: beware of innocuous radius fractures.Eplasty 2014 ePub. PMID: 24501620
  2. Ciclamini D, et al. Particularities of hand and wrist complex injuries in polytrauma management. Injury 2014;45(2):448-51. PMID: 24119831
  3. Codding JL, Vosbikian MM, Ilyas AM. Acute compartment syndrome of the hand. J Hand Surg 2015; 40A: 1213-1216. PMID: 25801580
  4. Leversedge FJ, MooreTJ, Peterson BC, Seiler JG. Compartment syndrome of the upper extremity. J Hand Surg 2011; 36A: 544-560. PMID: 21371631
  5. Ouellette EA, Kelly R. Compartment syndrome of the hand. J Bone Joint Surg Am 1996; 78(10):1515-1533. PMID: 8876579

Reviews

  1. Rush RM Jr, Arrington ED, Hsu JR. Management of complex extremity injuries: tourniquets, compartment syndrome detection, fasciotomy, and amputation care. Surg Clin North Am 2012;92(4):987-1007. PMID: 22850158
  2. Ortiz JA Jr, Berger RA. Compartment syndrome of the hand and wrist. Hand Clin 1998;14(3):405-18. PMID: 9742420
  3. Leversedge FJ, MooreTJ, Peterson BC Seiler JG. Compartment syndrome of the upper extremity. J Hand Surg 2011; 36A: 544-560.

Classics

  1. Gardner RC. Impending Volkmann's contracture following minor trauma to the palm of the hand. A theory of pathogenesis. Clin Orthop Relat Res 1970;72:261-4. PMID: 5459794
  2. Abdul-Hamid AK. First dorsal interosseous compartment syndrome. J Hand Surg Br 1987;12(2):269-72. PMID: 3624994
  3. Volkmann R. Die ischaemischen Muskellahmungen and Kontrakturen. Zentralbl Chir 1881;8:801–3.
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