Hand Compartment Syndrome

Compartment syndrome in all extremities is an orthopedic emergency. The hand muscles are covered and divided by groups into compartments by a well defined, unyielding envelope called the deep fascia.

Pathology

Compartment syndrome in all extremities is an orthopedic emergency. The hand muscles are covered and divided by groups into compartments by a well defined, unyielding envelope called the deep fascia. Hand compartment syndrome can occur as a result of a major crush injury, burn or injection injury to the hand causing the pressure within the compartments to rise above levels, sufficient to interrupt the blood supply to the tissues within the compartment. This can also occur after a limb has loss blood supply and the flow is re-established like in an arterial injury and repair, prolonged use of tourniquets and replantation of an extremity. When this occurs, the muscles and nerves within the compartment are at risk of dying with little or no chance of recovery. A fracture may or may not accompany a hand compartment syndrome but it is most likely to occur without a wound present which would indirectly decompress the hand compartments. Patients complain of increasing pain that is out of proportion to the injury and continues to increase requiring increase demand for pain medication which is dangerous since it does not address the problem. Other symptoms include numbness, tingling, or no symptoms at all if the compartment syndrome has gone too long and the nerves protective functions have been suppressed. Tissue death then follows. Signs of compartment syndrome include a tense hand, the patient may have pain with stretching of the fingers which affect the muscles of the forearm or there may be a loss of sensation in the hand with a cool sensation of the skin. Rarely, loss of pulses in the wrist ending in loss of function of the hand. Because the signs and symptoms can be variable, physicians must have a high index of suspicion with the patient recognizing that more pain medication is not the answer. This is why increasing pain after an injury requires direct clinical evaluation.

Treatment

If a compartment syndrome is diagnosed, it must be treated promptly, considering 6 hours as a critical time limit with which treatment must be instituted. The treatment consists of a trip to the operating room where the fascia that surrounds and separates each involved compartment must be surgically released. This procedure relieves the pressure within the compartment and allows the muscles and nerves within the compartment to receive their required blood supply. The surgical wounds are often not sutured back immediately to allow for the skin and soft tissue to accommodate any swelling that has occurred during the course of the surgery. The surgical wounds are then sutured back at a later a date. If they cannot be sutured back because of skin tightness, the use of a vacuum-assisted wound closure device may be used. Skin grafts may sometimes be needed to ultimately close the surgical wounds.