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CME: Orthopedics

Recognizing and managing upper extremity compartment syndrome

Miranda-Klein, Jacqueline; Howell, Christopher M. DSc, MSc, MPAS, PA-C, MBA; Davis-Cheshire, Michael OTD, MOT, OTR/L, CHT

Author Information
Journal of the American Academy of Physician Assistants: May 2020 - Volume 33 - Issue 5 - p 15-20
doi: 10.1097/01.JAA.0000660124.51074.e5
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Abstract

Box 1
Box 1

Compartment syndrome is defined as an increase in anatomical pressure within a defined myofascial compartment that exceeds the resting pressure of the capillary system.1-3 The rising pressure collapses vascular structures, impairing local perfusion and causing direct compression of the muscles and nerves. This leads to transcellular pump failure and ultimately tissue ischemia.1,3-5 Although any area of the body may be affected by acute compartment syndrome, the upper extremities account for more than 18% of observed cases.6 Sudden compartment pressure increases frequently are caused by high-energy trauma, leading to fractures (which account for 69% of cases), hematomas, or edema that induces direct and indirect volume expansion.1,6,7 Interestingly, common injury patterns have been associated with age demographics; for example, the distal radius in adults and the supracondylar region in children.1,6 Every clinician must be vigilant for compartment syndrome, as low-energy traumas without fractures and iatrogenic causes also have been implicated in similar physiologic patterns, accounting for more than 23% of upper extremity compartment syndrome cases.7,8 Other less common causes include external compression (as from tight casts, bandages, or circumferential burns), tissue infiltration by IV infusions, and rapidly progressive extremity infections (namely Streptococcal species).9-11 Regardless of source or location, complications from the injury and treatment, including contractures and immobility, can be disabling and lead to significant impairments in patient quality of life.12 Despite this risk of permanent injury and the need for prompt recognition and treatment, the diagnosis remains more elusive in practice when high-energy trauma is excluded.2 Classic patient history and symptoms may be lacking even when high-energy trauma is observed, which compounds the risk of delaying essential treatment. One additional obstacle to diagnosis is universal acceptance of diagnostic criteria, with some clinicians advocating for standardized pressure values and others for a delta pressure unique to the patient's underlying physiology.13,14

Box 2
Box 2

ANATOMY

The upper extremity consists of three prominent anatomical regions: the upper arm, forearm, and hand. Each region has multiple compartments with their own complexity and functions. For example, the hand contains 10 compartments: four dorsal interosseous compartments, three volar interosseous compartments, and the hypothenar, thenar, and adductor pollicis compartments (Figure 1).15 The forearm contains only three compartments: dorsal, volar, and mobile wad, located on the dorsolateral forearm.16 The volar compartment can be further broken down into superficial and deep fascial layers.6,17

FIGURE 1.
FIGURE 1.:
Compartments of the handIllustration used with permission of Nicholas Little

The upper arm, or brachium, also is made up of three compartments: anterior, posterior, and deltoid.16 Though the characteristics and complexities of each region differ, with the hand being the most complex, the volar compartment of the forearm is most likely to be affected by rising pressures (Figure 2).5,16

FIGURE 2.
FIGURE 2.:
Compartments of the forearmIllustration used with permission of Nicholas Little

PATHOPHYSIOLOGY

The pathophysiology of acute compartment syndrome is variable, just as causes, location, and host response differ. Chronic cases of compartment syndrome also have been observed, though to a much lesser extent.3,4 Most cases of chronic compartment syndrome occur in the lower extremity. Its classic distinction is marked by a condition of repetitive motion and a rising compartment pressure, manifest as pain and paresthesia, alleviated with rest.2,18,19 Acute injury patterns result from increased interstitial bulk and limited compartmental compliance.4 Most commonly, this is following a direct tissue trauma with local swelling, which causes vascular compression and congestion leading to capillary leak against a noncompliant myofascial compartment.3 Tissue ischemia develops from the direct constriction of the space, which in turn may lead to rhabdomyolysis.3 As rhabdomyolysis develops, it creates what Mehta and colleagues have termed a codependent myofascial tightening, as the muscle breakdown perpetuates an expanding tissue edema and ultimately irreversible myonecrosis.3

CLINICAL PRESENTATION

The presentation of upper extremity compartment syndrome can vary widely from asymptomatic to profoundly painful. The classic symptoms are pain and paresthesias with signs of pallor, paralysis, pulselessness, and poikilothermia.1,3,5,9 Pain is characteristically out of proportion to the injury.9 Although classic and largely specific, these findings have consistently displayed poor predictive value with a limited sensitivity for the condition, particularly with pulselessness, which has been consistently reported as a late-stage finding.6,9 Additionally, more consistent findings of upper extremity compartment syndrome include those of “tense swelling of the muscle structures,” which if permitted to progress may include visible derangements of the skin, such as blistering and necrosis.6 Special patient populations, such as children and those with altered mental status, are particularly vulnerable to missed increased compartment pressures.1,6 In children, traditional findings typically manifest late and only in the presence of irreversible tissue damage.1 More consistent hallmarks of compartmental threats in children are anxiety, restlessness, and increasing pain localized to the affected extremity.1 Obtunded patients, on the other hand, will present with numerous limitations that are a challenge to predict, although they may have some features that are considered cardinal. For example, upper extremity compartment syndrome of the forearm presents a confirmatory physical examination finding that includes the intrinsic-minus position, or claw position, of the hand on the affected extremity.6

Still widely accepted as a clinical diagnosis, upper extremity compartment syndrome requires a high index of suspicion before interventions can be adequately entertained.8 Intracompartmental pressure ultrasound, doppler ultrasound, and spectral doppler ultrasound remain the most useful bedside instruments when the diagnosis is suspected. Other modalities often are used when diagnosis remains elusive or when other possible underlying concerns exist, as seen in polytrauma.

DIAGNOSTIC DETERMINATION

Many diagnostic modalities may be considered during a patient's clinical course. Often these studies are associated with the injury preceding the presentation of upper extremity compartment syndrome, as seen in plain radiographs revealing a fracture that ultimately leads to compartmental complications within hours to days. Other imaging studies may be deemed contributory and clinically appropriate depending on the cause of the condition along with the timing of symptom onset and clinician differential.

Ultrasound

One such modality often used in the acute setting is the Doppler ultrasound, which can identify a vascular occlusion causing swelling and pain, such as deep vein thrombosis (DVT). When used, the Doppler supports or refutes indeterminate arterial flow.5

MRI

Because it provides the grading of muscle involvement and highlights the likelihood of reversible ischemia, MRI is regarded as a superior imaging modality.3 Furthermore, MRI can be used for surgical planning due to its ability to precisely identify the location of the affected muscle groups and facial compartments.3 However, MRI has limitations, including cost, availability, and time for accuracy.

Even when MRI is available, this advanced imaging may be clinically impractical. Additionally, the authors want to emphasize the clinical nature of the diagnosis. Imaging is meant to support equivocal cases of disease, not to be an essential resource to confirm if those cases are deemed certain.3 The gold standard for the diagnostic conclusion of upper extremity compartment syndrome is the direct measurement of elevated interstitial pressures.16,20

Numerous instruments and methods for intracompartmental pressure assessment are available, including pressure catheters and arterial line pressure monitoring, but the practical clinical uses, including benefits and limitations of these devices, are beyond the scope of this article.21 Nonetheless, these tools are particularly important for patients whose presentation may impede examination, such as those with obtundation or with existing central and peripheral neurologic deficits that may impair the reliability of an examination.5,12

Normal compartment pressures

The physiologically normal compartment pressures are about 8 mm Hg in adults and 10 to 15 mm Hg in children.9 Although consensus guidelines almost universally support critical compartment syndrome when pressures are between 30 and 50 mm Hg, the general use of an absolute pressure alone has been questioned; having historically led to nonessential fasciotomies, particularly in patients with a high absolute BP.9,13 Instead, delta pressures, defined as the difference between the compartment pressure and diastolic BP, have been proposed to more accurately reflect rising compartment pressures in the patient's specific physiologic needs.5 Comparing the relationship between the patient's systemic resting BP and the established compartment pressure, the threshold difference of less than 30 mm Hg warrants critical treatment (for example, fasciotomy) and can reduce the incidence of inappropriate treatment in suspected cases of upper extremity compartment syndrome.13,21,22

TREATMENT DIRECTION

Studies have shown evidence that damage is reversible when treatment is provided within 4 hours of onset; irreversible damage is clinically certain if treatment is not provided within 8 hours from onset.3,9,23 Therefore, the acute management for a confirmed upper extremity compartment syndrome is an immediate surgical intervention via fasciotomy.3,9,23

However, reversible ischemia is not synonymous with reversible injury. This is particularly important in the upper extremity where, even with prompt discovery and treatment, rising pressures could risk jeopardizing fine motor movements resulting in large part from neurologic derangements.9,12 Even so, not all surgical techniques are the same. Classically, pressure release of the forearm has required incisions in both the volar and dorsal compartments.6 Yet, some literature suggests that one incision in the volar aspect can provide adequate pressure relief of the dorsal compartment with appropriate pressure monitoring.7,17 Research continues to explore various surgical strategies to reduce morbidity. Regardless of the fasciotomy technique used, alternative methods used in an effort to avoid invasive fascial release have failed to improve morbidity and in some cases have caused more harm.17 In patients with upper extremity compartment syndrome, retaining hand function is of utmost importance, with the consequences of mistreated upper extremity compartment syndrome leading to debilitating outcomes.9 Although prompt surgical intervention is essential, the role of early postoperative rehabilitation could prove to be of equal value in improving long-term functional outcomes.

THE ROLE OF REHABILITATION

Clinicians can take several steps to maximize functional outcomes in patients with upper extremity compartment syndrome. Appropriate positioning can limit adaptive shortening of the collateral ligaments and volar plates of the hand. Edema control through elevation and appropriate compression can reduce fluid volume in the affected upper limb, reducing the amount of granulation tissue formed in the injured compartment(s) and adjacent anatomic regions. Instructing the patient to perform range of motion (ROM) of joints proximal to the level of injury can prevent stiffness and abnormal postures, particularly at the shoulder and elbow. Initiating appropriate ROM can reduce the likelihood of arthrofibrosis of the joints and adherence of the long tendons located in the anterior and posterior forearm. A postsurgical physical therapy regimen is important to ensure a complete recovery.24

Acute position/immobilization

The collateral ligaments of the metacarpal-phalangeal (MCP) joints of the index, middle, ring, and small fingers are elongated when the joint is flexed. Flexion of 60 degrees or greater is considered sufficient to prevent adaptive shortening, which is common following upper extremity compartment syndrome injury and surgery. Conversely, the collateral ligaments of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are elongated when the joints are in extension. For these reasons, it is important to position the index through small fingers with the MCPs in flexion and the PIPs and DIPs in extension.25

Midshaft fractures of the metacarpal

Unfortunately, upper extremity compartment syndrome rarely occurs in isolation. Midshaft fractures of the metacarpal (an injury often associated with acute compartment syndrome in the hand) should be immobilized in a similar position, although for clinically different reasons. MCP flexion of 70 degrees decreases the dorsal angulation forces caused by the intrinsic and extrinsic flexor muscles.26 In patients with midshaft proximal phalanx fractures, MCP flexion of 70 degrees balances the deformation caused by intrinsic insertion's volar force proximally and the extensor expansion pulling the distal fragment dorsally.27

Exceptions

Based on the presence of other injured structures, additional exceptions should be considered on a case-by-case basis. For example, if the patient has an extensor tendon injury, consider placing the MCPs in extension to prevent excess tension on the tendon repairs.28 For a patient with flexor tendon injury, consider placing the PIP and DIP joints in some flexion to decrease potential loading to the repaired flexor tendons.29

The first web space, between the thumb and index finger, is an important component of thumb abduction and opposition, motions that are critical for gross motor grasp and fine motor manipulation. Contraction and scarring of the adductor pollicis and first dorsal interosseous muscles can lead to substantial loss of function, impairing long-term recovery. Positioning the thumb in palmar abduction with the web space as wide as practical can limit loss of this important ability by holding these two muscles in an elongated state. Although joint stiffness is still highly likely to occur, the joints of the thumb will be in positions that permit functional use (versus adduction or radial abduction), reducing morbidity.

Prevention is preferable

Surgical correction of these deformities through capsulotomies, tenolyses, muscle and tendon releases, skin grafts, or flaps may have to be employed at a later time, but are difficult, costly, and have uncertain outcomes. Therefore, prevention is by far the preferable treatment.30

Elevation

Early use of elevation helps with proximal transportation of fluid that causes swelling and can reduce postoperative pain.31 Instruct the patient in correct elevation technique. Ensure that the patient understands that elevation means that the injured extremity must be farther from the floor than the heart and more proximal joints. Educate patients to think of swelling as water running downhill; they should position their arm so that the edema can flow downhill without encountering any uphill runs. Viewed in this way, it becomes obvious that a sling is not an adequate elevation tool. The hand might be at the level of the heart (although often it is not) but the elbow is below the heart, creating an uphill run. Patients should be aware that the ulnar nerve at the cubital tunnel is vulnerable to compression in certain positions, particularly when the patient is resting on a flexed elbow while trying to elevate the hand (Figure 3).

FIGURE 3.
FIGURE 3.:
Hand step anatomyIllustration used with permission of Nicholas Little

ROM of uninvolved joints not directly involved in injury is prone to long-term deficits due to changes in joint structures, muscle, and tendon resulting from postural changes and disuse atrophy. The shoulder is particularly prone to such problems. Patients with injured upper extremities tend to adopt a stereotypical position of comfort: scapular elevation, shoulder adduction and internal rotation, with elbow flexion. Caution patients to avoid keeping the injured upper limb in one posture for prolonged periods of time. Facilitate preservation of normal joint kinematics, muscle balance, and tone by providing patients with specific exercises. Encourage patients to perform shoulder shrugs and move their shoulders through the full ROM by reaching behind their heads, then high overhead, followed by reaching out to the side and down, and finishing the motion by reaching as far up their lower backs as they are able (like reaching for the rear clasp of a bra). This sequence moves the shoulder and elbow through full ROM.

Referral to hand therapy

Hand therapists are uniquely qualified to manage complex injuries of the upper extremity such as compartment syndrome, by balancing the often-contradictory indications of multiple injured structures. Although 85% of certified hand therapists are predominantly occupational therapists, physical therapists can become certified hand therapists as well.32 When a patient with compartment syndrome is referred to hand therapy, treatment will include immobilization, progressive mobilization, edema control, wound care, scar management, adaptive equipment, activity modification, and strengthening. Clinicians should be open to referring patients with upper extremity compartment syndromes early in their clinical course, following surgical correction. Nonetheless, regimens of immobilization, elevation and home exercises may begin while the referral is pending.

CONCLUSION

Upper extremity compartment syndrome accounts for more than 18% of observed cases of compartment syndrome, with adults suffering more radial injuries and children sustaining more distal humerus injuries.6

Several nontraumatic causes have been reported.1,6-11 Consider the clinical diagnosis of upper extremity compartment syndrome after employing necessary imaging modalities. A direct intracompartmental pressure assessment is considered the most clinically beneficial instrument in securing the diagnosis.16,20 Once confirmed, surgical release (fasciotomy) is required.3,9,23 Despite surgical interventions, morbidity remains high, owing in large part to irreversible neurologic injury.17 With prompt occupational therapy, restoration of motor function and improved quality of life may be realized, beginning with techniques used by their primary care provider.24

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Keywords:

upper extremity; compartment syndrome; fasciotomy; fine motor function; occupational therapy; extremity rehabilitation

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