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
Incidence and Related Conditions
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
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:
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.
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.
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.