Acute Exertional Compartment Syndrome of the Forearm

Abstract

A cute and chronic exertional (nontraumatic) compartment syndromes are well-documented in the lower leg. We present a case of acute exertional compartment syndrome of the forearm in a teenager. Decompressive fasciotomy was performed, resulting in full preservation of upper extremity function. We highlight the features of her management and present a literature review of this rare clinical entity. CASE REPORTA 19-year-old, right hand dominant woman presented to the emergency department in the early morning, complaining of pain and swelling of the right wrist and forearm which had begun the previous night, 9 hours earlier. She was newly employed as a cake decorator, and had been decorating a cake for one and one half hours. She recalled applying substantial, prolonged pressure using her right hand to squeeze icing out of a decorating bag. After completing this activity, she felt pain over her right wrist and forearm, which progressed gradually throughout the evening and night, finally awakening her from sleep. Over-the-counter analgesics did not relieve her pain. On examination in the emergency department, there was marked swelling over her proximal right forearm and tightness to palpation of the dorsal and volar forearm compartments and the mobile wad (Fig. 1A). Pain was elicited on passive extension of the right wrist and fingers. Her two-point discrimination was 4 mm or less in all the digits. Radial and ulnar pulses were palpable at the wrist, and there was brisk capillary refill in all fingertips. Radiographs of the right wrist and forearm did not demonstrate any bony abnormalities.Compartment pressures were measured using a handheld pressure monitoring system (Stryker Instruments, Kalamazoo, Mich.). Volar and dorsal compartment pressures were found to be 22 mm Hg and 35 mm Hg, respectively. Complete blood count and electrolytes were normal, but her serum creatinine kinase was elevated at 15,500 IU/L (normal Ͻ180). Decompressive forearm fasciotomy was scheduled emergently.The compartment pressures were checked again intraoperatively using an arterial line set-up, and were found to have risen to 41 mm Hg in the volar and 43 mm Hg in the dorsal forearm compartments. Surgical decompression of the volar compartment was performed through a standard incision on the volar forearm. Healthy-appearing muscles of the volar forearm ballooned out through the fasciotomy incision (Fig. 1B). The forearm fascia was released completely up to the carpal tunnel. After release, volar forearm pressures decreased to 4 mm Hg. We considered surgical release of the carpal tunnel at that time, as this maneuver is a valid and logical thought while performing volar forearm release in most instances. In our case, however, the carpal tunnel did not seem to be involved, as it did not appear to be tight upon probing with the insertion of an instrument, and thus it was not released. Pressure in the mobile wad compartment decreased after volar compartment release, but remained elevated at 25 mm Hg. Therefore, decompressive fasciotomy of the do...

Acute, Exertional Medial Compartment Syndrome of the Foot in a High-Level Athlete

“…There are, however, a number of reports in the literature of acute exertional compartment syndrome in which unaccustomed exertion leads to abnormal intramuscular pressure. 5,8,18,29,34,41 Acute compartment syndrome may also occur as an acute complication of a pre-existing chronic exertional compartment syndrome. 9,39 Symptoms of chronic exertional compartment syndrome rapidly subside with cessation of exercise, while symptoms of acute exertional compartment syndrome tend to worsen after exercise, and pain is often completely out of proportion to the apparent degree of injury.…”

Acute compartment syndrome of the dorsal forearm following noncontact injury

“…12 A number of case reports exist describing acute compartment syndrome secondary to muscular rupture in the leg, and many conclude that noncontact mechanism as a cause of acute compartment syndromes is rare and easily missed. [8][9][10][11][13][14][15][16] Although we identified 3 case reports of exertional acute compartment syndrome of the dorsal forearm, [17][18][19] to our knowledge, ours is the first such report associated with muscular rupture.…”

Acute Exertional Compartment Syndrome of Bilateral Upper Extremities After a Push-up Contest

“…In fact, there are only a few case reports describing AECS of the forearm. 12345 Dhawan et al detailed a case report of unilateral forearm AECS in a patient who developed symptoms after beginning a new job as a cake decorator. 1 There have also been three case reports describing isolated AECS of the extensor carpi ulnaris after repeated forearm and wrist movements, such as using a hammer.…”

“…More commonly seen in the leg, descriptions of AECS involving the upper extremities are limited to a small number of case reports. 123456 We present a case detailing AECS of bilateral upper arm and forearms to increase the awareness of this rare, highly morbid, but treatable condition. If recognized and managed promptly and appropriately, devastating consequences may be avoided.…”