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| Journal of the New Zealand Medical Association,
11-February-2005, Vol 118 No 1209
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Beware: compartment syndrome of the hand
Warren Leigh, Vasu Pai
Compartment syndrome of the forearm or leg, is a well-known
postoperative complication. However, compartment syndrome of the hand is not
common and is not easy to diagnose. Various aetiologies been
reported1–3—and when diagnosis is
missed, it results in ischaemic contractures and permanent disability.
The occurrence of compartment syndrome in the hand after
radial osteotomy (or any other elective osteotomy of the forearm bones requiring
fasciotomy) has not been described. This article presents a case of interossous
muscle compartment syndrome as a complication of this procedure and highlights
difficulty in diagnosing such a problem.
Case reportA 30-year-old gentleman presented
with a malunited fracture of his left distal radius. He underwent corrective
osteotomy of the distal radius, bone grafting, and Kirschner wire fixation. Two
days after surgery he was complaining of worsening pain in his hand. As he could
fully straighten his fingers, his cast was changed and he was discharged from
the hospital on oral analgesics.
The next day he presented to the emergency department of a
different hospital with worsening pain in his left hand. On examination, there
was gross swelling of the hand. Blisters were present on both the radial and
ulnar borders at the level of the wrist.
The wire
sites were clean and there was no sign of infection at the operation site He
could actively straighten without worsening of pain. The pain was most severe on
trying to make a fist. Finger movements were limited with only 15* to 30*
degrees at metacarpophalangeal and interphalangeal joints. Passive flexing his
interphalangeal joints with metacarpophalangeal joint in extension caused severe
pain. Forearm muscles were soft and non-tender. Sensation was intact in median,
ulnar, and radial nerve distributions; and capillary return as well as radial
and ulnar arterial pulses were normal.
Compartment syndrome of the hand was diagnosed, and the
patient underwent fasciotomy. Through double dorsal incisions along second and
fourth metacarpals, all four dorsal interossei spaces (as well as three palmer
spaces) were released. This was followed by a carpel tunnel, and thenar
compartment release.
Upon fascial release, the interossei muscles were found to
be swollen, but there was no evidence necrosis. A delayed closure of wounds was
carried out. Postoperatively the patient did well. There was dramatic
improvement in his symptoms. At last follow-up, patient regained full motor
control and there was no deformity.
DiscussionThere are 10 compartments in the
hand: the thenar, hypothenar, adductor, 3 palmar, and the 4 dorsal interossei
compartments.8 It has been suggested that the
muscles situated on the radial side of the hand are more prone to compartment
syndrome than those on the ulnar side (as they are supplied by more
end-arteries).1 Decompression should include
fasciotomy of all compartments of the hand.
Compartment syndrome is caused by an increase in pressure
within a closed compartment that increases to a level causing vascular perfusion
to be compromised. This can be secondary to swelling or external
compression.3,4 When this ischaemia is
unrecognised, it can greatly impair normal hand function.
A variety of causes of hand compartment syndrome have been
reported such as fractures, suction injuries, crush injuries, metacarpal
fractures, arterial injuries, and injection of intravenous fluids and contrast
material.2–8 Ouellette and
Kelly2 reviewed 19 patients with compartment
syndrome of the hand and had had only 1 related to surgery following an
arthrodesis of the wrist.
Figure 1. Test for compartment syndrome of the forearm:
extension of finger from flexed position
 Our case illustrates several important points. Compartment
syndrome in the postoperative patient should always be in the differential
diagnosis. Presence of hand sensation, a normal capillary return and ability to
straighten fingers (diagnostic of compartment syndrome of the forearm; Figure
1), may all be normal in compartment syndrome of the hand. It is a diagnosis
that requires a high index of clinical suspicion. The main symptoms are a tense
swollen hand with severe pain that is out of proportion to the clinical
situation.
The definitive test6 for
compartment syndrome of the hand is a positive stretch test for intrinsic
muscles of the hand. This is carried out by flexing the interphalangeal joints
of the fingers while the metacarpal joints are held in neutral (Figure
2).
Figure 2. Test for compartment syndrome of the hand:
flexion of interphalangeal joint with metacarpophalangeal joint in
extension
 Author
information: Warren B Leigh, Registrar, Orthopaedics, Dunedin Hospital,
Dunedin; Vasu S Pai, Senior Registrar, Orthopaedic Department, Wellington
Hospital, Wellington
Acknowledgements:
The authors thank Dr Peter Lloyd for assisting in the preparation of this
manuscript.
Correspondence:
Dr VS Pai, 9 Bennett Grove, Newlands, Wellington. Fax: (04) 477 4633; email: vasu_chitra@slingshot.co.nz
References:
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