Arm Fasciotomy Through Lateral Approach

Abstract

Summary: 

Acute compartment syndrome represents one of the few true orthopaedic emergencies. Timely management is essential to prevent permanent sequelae. This video describes a case of acute compartment syndrome of the arm. Relevant patient history, physical examination, and laboratory findings are discussed, and a presentation of the operative technique for arm fasciotomy through a lateral approach is highlighted. Diagnostic criteria for acute compartment syndrome and indications for fasciotomy are reviewed, with a discussion of published outcomes after fasciotomy.

Video available at:https://links.lww.com/JOT/A792

BACKGROUND

Compartment syndrome is a result of increased pressure within an anatomical compartment and represents a potentially limb- and life-threatening emergency. It is a clinical diagnosis in an awake, alert patient, with the most sensitive examination finding being pain with passive stretch of muscles within the affected compartment.¹ In the case of an obtunded patient or an equivocal examination, compartment pressures may be measured, with a difference between the diastolic blood pressure and compartment pressure (ΔP) less than 30 mm Hg being diagnostic.¹

Fasciotomy for release of elevated compartmental pressure represents the cornerstone of compartment syndrome management, with rapid treatment essential to preserve function of the affected limb. While compartment syndrome may affect any fascial compartment, compartment syndrome of the arm is rarely reported.

CASE REPORT

The patient is a 45-year-old man who presented 2 days after a computer console had fallen on his right arm while he was moving furniture. The patient was impaired with both benzodiazepines and alcohol at the time of the injury and was unconscious for an unknown period after the incident. After the injury, he noted significant motor and sensory loss of his right arm but did not present to the hospital as he believed his symptoms would resolve. The patient sought medical care after 2 days due to concern about his persistent arm numbness. On examination, his right arm was tense, most strikingly in the posterior compartment. He initially had present but decreased sensation in the radial, median, and ulnar nerve distributions, but this rapidly evolved to complete lack of sensation throughout the entire upper extremity with the exception of the axillary nerve distribution. In addition, the patient had no motor function distal to the elbow, and passive range of motion of his elbow produced severe pain, particularly with extension. Furthermore, the patient presented with severe edema of the right arm with overlying cellulitis and blistering on the anteromedial aspect of the brachium. Given a clinical picture consistent with an evolving right arm compartment syndrome, the decision was made to perform a fasciotomy. A lateral approach was chosen given the patient's anteromedial arm blistering/cellulitis.

SURGICAL TECHNIQUE

An incision was made from the deltoid tuberosity to the lateral epicondyle. The subcutaneous tissue was sharply dissected down to the muscular fascia, and a full-thickness flap was raised anterior to the intermuscular septum. An incision was made in the anterior compartment fascia and extended proximally and distally, with visible, viable muscle bulging after this release. The muscles of the anterior compartment were palpated to confirm reduced compartmental pressure. Given suspicion for possible deltoid compartment syndrome, the skin incision was extended proximally, and the fascia overlying the deltoid was incised. A full-thickness flap was then raised posterior to the intermuscular septum to expose the fascia of the posterior compartment. The posterior compartment fascia was then incised, with visible, viable muscle bulging after this release. The posterior compartment musculature was then palpated to confirm reduced compartmental pressure. The wound was copiously irrigated, a vessel loop was used to approximate the skin edges, and a vacuum dressing was applied.

POSTOPERATIVE COURSE

Over the course of the first 4 days postoperatively, the patient continued to have severe motor and sensory deficits, although he did begin to regain axillary nerve function, had normal axillary nerve sensation, and began to regain median nerve function. He returned to the operating room on postoperative day 4 for definitive wound closure. At the time of discharge on postoperative day 12, he had completely regained median nerve sensation, had present but diminished radial nerve sensation, but continued to have no ulnar nerve sensation. His motor examination remained unchanged with only 3/5 median nerve function present. His motor function continued to slowly but steadily improve with aggressive occupational therapy, and when he was last seen 7 months postoperatively, he had fully regained axillary and median nerve motor function, had 4/5 musculocutaneous and radial nerve motor function, but still only 2/5 ulnar nerve function. His sensory examination showed normal axillary and median nerve sensation, slightly decreased radial nerve sensation, and significantly diminished ulnar nerve sensation.

CONCLUSIONS

Compartment syndrome of the arm is a rare occurrence, with deltoid compartment syndrome having been reported only 10 times previously.^2–11 Thus, there is limited information regarding arm compartment syndrome specifically, but in general, outcomes after fasciotomy are variable and depend on the duration of ischemia. In animal models, irreversible injury to nerves and muscles has been observed after 8 hours of ischemia.¹² Delay of fasciotomy beyond 6–24 hours may result in neurologic deficit, as occurred with this patient, ischemic contracture, infection, amputation, or death. Compartment syndrome represents one of the few truly urgent orthopaedic diagnoses.