Compartment Syndrome of the Forearm: A Systematic Review

CURRENT CONCEPTS
Compartment Syndrome of the Forearm: A
Systematic Review
Bharati S. Kalyani, MD, Brent E. Fisher, MD, Craig S. Roberts, MD, Peter V. Giannoudis, MD
In this systematic review, we examined the available evidence regarding compartment
syndrome of the forearm. Applying our inclusion criteria, we found 12 articles for a total of
84 cases using the MEDLINE (Ovid) database. All were retrospective studies (level IV
evidence). In this study, papers were analyzed for causes, diagnosis, treatment, methods of
wound closure, functional outcome, and complications. The most common cause of compartment syndrome of the forearm in children was a supracondylar fracture, while in adults
the most common cause was a fracture of the distal radius. The diagnostic criterion used was
clinical assessment alone in 48%, and in 52%, a combination of measurement of intracompartmental pressure and clinical assessment was used. The intracompartmental pressure was
measured using various techniques including a wick catheter, slit catheter, the Whitesides
technique, and the Stryker compartment pressure measuring device. Fasciotomy was the
preferred method of treatment (73%). In cases reporting wound management, postfasciotomy
skin grafting was needed in 61% of the cases, whereas secondary closure was performed in
39% of the cases. Neurological deficit was the most common complication (21%). (J Hand
Surg 2011;36A:535–543. © 2011 Published by Elsevier Inc. on behalf of the American
Society for Surgery of the Hand.)
Key words Compartment syndrome, forearm, fasciotomy, skin grafting.
T
FromtheDepartmentofOrthopaedicSurgery,UniversityofLouisville,Louisville,KY;andtheAcademic
Department of Trauma and Orthopaedics, University of Leeds, Leeds, UK.
Received for publication May 10, 2010; accepted in revised form December 4, 2010.
Institutional support was provided by Synthes to BSK, BEF, and CSR.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: Craig S. Roberts, MD, Department of Orthopaedic Surgery, University of
Louisville,210E.GrayStreet,Suite1003,Louisville,KY40202;e-mail:[email protected]
0363-5023/11/36A03-0032$36.00/0
doi:10.1016/j.jhsa.2010.12.007
study was to systematically review the current evidence
regarding forearm compartment syndrome.
MATERIALS AND METHODS
This was an institutional review board– exempt investigation, which was performed at a level 1 trauma
center using a MEDLINE (Ovid) database search. Using the advanced search engine, the key word terms
used were “compartment syndrome” and “forearm.”
The terms were mapped to “forearm” and “compartment syndromes,” yielding 190 articles. A total of 155
articles remained after limiting for the English language
and human subjects.
The inclusion criteria were original articles that reported 2 or more acute cases of forearm compartment
syndrome. We analyzed the articles that met our criteria
based on the following categories: etiologies, diagnosis,
treatment, methods of fasciotomy wound closure, outcome, and complications.
Single case reports, articles not written in the English
language, and articles based on exercise-induced compartment syndrome were excluded. We included in our
©  Published by Elsevier, Inc. on behalf of the ASSH. 䉬 535
Current Concepts
HE TRUE INCIDENCE of forearm compartment
syndrome is difficult to determine, but fractures
of the forearm and the distal radius are certainly
associated with forearm compartment syndromes.1–3
Elliott and Johnstone4 reported that 23% of forearm
compartment syndromes were caused by soft tissue
injuries not involving fractures, and 18% were caused
by fractures.
To our knowledge, there is limited available evidence regarding the causes, treatment, methods of
wound closure, functional outcome, and complications
of forearm compartment syndrome. The purpose of this
536
COMPARTMENT SYNDROME OF THE FOREARM
study articles involving forearm compartment syndrome in neonates as well as compartment syndrome
associated with vascular injury.
ment syndrome due to radial head or neck fracture in
children. Iatrogenic causes included osteotomies of the
radius and/or ulna.6
RESULTS
Of the 155 articles initially screened, only 12 met our
criteria, yielding 84 cases.5–16 Patients ranged in age from
newborn to 67 years. Of the 35 patients whose gender was
reported, 27 were male and 8 were female (Table 1).
Diagnosis
All 12 articles in this study used physical examination
findings as criteria for diagnosis and 6 articles described
pressure measurements for diagnosis and decision making regarding fasciotomy (Table 4).5–16 To be included
in the studies by Gelberman et al8 and Mubarak et al,11
patients were required to have undergone intracompartmental pressure measurement.
Gelberman et al,8 in a study of 26 cases, noted
diminished sensibility by 2-point discrimination to be a
consistent and reliable finding. Eaton and Green6 also
noticed glove anesthesia in 9 of 19 patients. The most
reliable finding was sensory deficit.6 – 8,11,12,16
Gelberman et al8 measured both volar and dorsal compartmental pressure using a wick catheter. The range of
pressure increase was from 35 to 95 mm Hg in the volar
compartment and from 20 to 70 mm Hg in the dorsal
compartment.
Etiology
The 12 articles included discussed the etiology of compartment syndromes (Table 2).5–16 A total of 26 cases
were attributed to fractures and 4 were bilateral.6 – 8,14,16
Seven cases of neonatal forearm compartment syndrome were reported.5,9 Penetrating trauma (7 gunshot
wounds and 6 stab wounds) accounted for 15.4% of
injuries.6,8,10,11 Eight cases were associated with forearm compression due to drug abuse, 7 with crush injuries, 7 with intravenous infiltration, and 5 with snakebites.6 – 8,11,13,15 Other etiologies included tourniquet
use, hemophilia, phlebitis, burns, and postsurgical issues.6,8 Arterial injury occurred in approximately
10.7% of cases.6,8,10
Compartment syndrome resulting from fractures occurred most often in closed fractures. The most common
cause of compartment syndrome in adults was a fracture of
the distal radius, whereas in children the most common
cause was a supracondylar fracture of the humerus (Table
3).6,14,16 Peters and Scott12 reported 3 cases of compart-
TABLE 1.
Treatment
All 12 articles with 84 patients described the treatment
of forearm compartment syndrome (Tables 5, 6). The
time interval between injury and treatment ranged from
3 hours to 16 weeks.6,8,11–13,16 A total of 61 of the 84
patients were treated surgically.5–16 Of the 59 patients
treated with fasciotomy, 57 incisions were described,
Demographics
Author
Caouette-Laberge et al5
Eaton and Green
6
Geary7
8
Patients (n)
Extremities (n)
Male
Female
5
5
3
2
19
19
NA
2
3
1
NA
Case report
NA
3–53
Case series
1
42–62
Case report
26
26
NA
2
2
2
Morin et al10
5
5
5
Mubarak et al11
4
4
2
2
3
3
1
2
2
2
2
5
8
4
2
2
2
Current Concepts
Peters and Scott
12
Seiler et al13
Simpson and Jupiter
14
Sneyd et al15
Stockley et al
16
Total
Percentage
Study Type
NA
Kline and Moore9
Gelberman et al
Age
1
5
5
5
80
84
27
8
77%
23%
NA, information not available.
JHS 䉬 Vol A, March 
NA
Case series
NA
Case report
23–39
Retrospective case report
20–51
Cohort
6–8
Case report
46–57
Case report
23–45
Retrospective case series
63–67
Case report
15–49
Case report
Birth through 67
COMPARTMENT SYNDROME OF THE FOREARM
Fasciotomy wound management
Seven articles described fasciotomy wound management in 30 patients with 34 injuries (Table
7).7,8,11–14,16 In 13 patients the wound was managed by secondary closure, and 20 patients required skin grafting.7,8,11–14,16
COMPLICATIONS
Seven articles described complications in 18 of 43
extremities, for those 7 studies (Table 8).5–9,11,16 Various contractures were reported in 4 cases and neurological deficits in 9.6 –9 Eaton and Green6 reported gangrene of the fingers in 1 case. Stockley et al16 reported
chronic regional pain syndrome in 1 of 5 patients in
their study. Mubarak et al11 reported 1 complication of
Volkmann’s ischemic contracture in a patient with drug
overdose–related limb compression who sought medical assistance more than a day and a half after injury.
Geary7 reported an adduction deformity of the thumb
owing to contracture of the first interosseous muscle
and variable loss of all sensation in the fingers. Eaton
and Green6 reported a wrist contracture in 1 patient, and
1 patient who developed progressive gangrene of the
fingers subsequent to segmental resection of the brachial artery.
Outcome
Only Eaton and Green6 provided a method to stratify
the results for treatment of forearm compartment syndrome. In patients treated with a fasciotomy, excellent
results were reported in 12, fair results in 1, and poor
results in 3. The authors noted poor results (Volkmann’s ischemic contracture) within 4 months of onset
in the 3 patients who did not have fasciotomies, despite
dynamic splinting and surgery.
DISCUSSION
Forearm compartment syndrome has been associated
with several etiologies, one of the most common causes
of which is fracture. Distal radius fractures were the
most prevalent cause of forearm compartment syndrome in the articles we reviewed, accounting for
37.5% of fractures associated with compartment syndromes of the forearm and 14.3% of overall causes.
McQueen et al3 reported similar numbers in a study of
164 cases of acute compartment syndrome covering all
extremities.
Supracondylar fractures caused 8 of the 12 pediatric
cases, in line with classical data.1,17 It appears, however, that supracondylar fractures might not be the
predominant. Cause of forearm compartment syndrome
in children, as they were in the past.2,18 Grottkau et al,2
in a study of the National Pediatric Trauma Registry,
assessed 131 pediatric cases of compartment syndrome
and noted that 74% of upper extremity fracture cases
were of the forearm, and only 15% were due to supracondylar fractures. Bae et al18 studied 33 consecutive
pediatric patients with 36 cases of acute compartment
syndrome. They reported 18 upper extremity cases with
10 cases after fracture; however, only 2 resulted from
supracondylar fractures. Bae et al.18 suggested that a
possible reason for this decrease in supracondylar fracture-related compartment syndrome was changes in the
fracture management, with the wide acceptance of percutaneous pin fixation and cast immobilization with the
elbow at no greater than 90° of flexion. A cause of
JHS 䉬 Vol A, March 
Current Concepts
and the modified anterior approach of Henry was most
commonly used.6 –9,11–16
Overall, in 45 patients, a compartment release was
done using a volar incision, in 1 patient with a dorsal
incision, and in 11 both volar and dorsal compartment
releases were performed.5–16 In 4 patients either the
fasciotomy was not discussed or the patients had another procedure.5,8 A carpal tunnel release was performed at the time of volar compartment decompression in 30 cases. Gelberman et al8 described release of
lacertus fibrosis, pronator teres, and flexor digitorum
superficialis, although the number of patients receiving
this treatment was not specified. Eaton and Green6
performed arterial surgery in 8 patients. Simpson and
Jupiter14 performed release of the ulnar nerve and artery
in Guyon’s canal in 1 patient.
A total of 23 patients were treated nonsurgically
(Table 5).5,6,8,9,11,15 Gelberman et al8 elected not
to perform fasciotomy on 14 patients because the
pressure in both volar and dorsal compartments
was less than 30 mm Hg. Kline and Moore9 reported a case of a neonate who was evaluated
several hours after delivery for full-thickness skin
loss with peripheral healing and flexion contracture of the wrist and fingers. The neonate was
treated without a fasciotomy because it had adequate circulation to the hand. The authors reported
that nerve function gradually improved and the
flexion contracture resolved with passive stretching. Eaton and Green6 used a stellate ganglion
block for 3 patients and found that none of the
patients were improved by this procedure. Sneyd et
al15 managed 1 patient by limb elevation to 45°.
Mubarak et al11 elected not to treat one patient
with burns covering over 95% of the body; the
patient subsequently died 12 hours after injury.
537
538
COMPARTMENT SYNDROME OF THE FOREARM
TABLE 2.
Primary Mechanism of Injury
Patients (n)
Extremities
(n)
5
5
19
19
2
3
Gelberman et al8†
26
26
Kline and Moore9
2
2
Morin et al10‡
5
5
Mubarak et al11
4
4
Peters and Scott12
3
3
Seiler et al13
2
2
Simpson and Jupiter14
5
8
Sneyd et al15
2
2
Author
Caouette-Laberge et al5
6
Eaton and Green *
Geary7
Stockley et al16
Total
5
5
80
84
Percentage
Bilateral
Crush Injury
Fracture
Tourniquet
8
Stab Wound
1
3
1
7
2
2
1
3
3
8
5
4
7
26
1
6
4.8
8.3
31.0
1.2
7.1
There might be more than 1 associated possible cause of development of compartment syndrome.
GSW, gunshot wound.
*Three were not mentioned, 1 owing to arterial injury.
†Two other fractures were associated with crush injuries.
‡Two fractures were related to gunshot wounds.
TABLE 3.
Fracture Breakdown
Author
6
Eaton and Green *
8
Patients (n)
Extremities (n)
8
8
Adult
8
Gelberman et al †
4
4
4
Morin et al10‡
2
2
2
Peters and Scott12
3
3
Simpson and Jupiter14
5
8
Stockley et al16
Total
Pediatric
3
5
5
5
4
1
27
30
15
12
55.6
44.4
Percentage
% Overall cases
Only surgical patients were reported.
*Two radioulnar injuries were associated with supracondylar fractures.
†Of the 14 surgical patients, 2 were not included in analysis owing to third-degree burns that influenced outcomes.
‡Two fractures were associated with gunshot wounds.
Current Concepts
forearm compartment syndrome rarely discussed is
neuroleptic malignant syndrome.19
Patients younger than 35 years of age and involved
in high-energy injuries and polytrauma are at higher
risk for developing a forearm compartment syndrome.2,3,14,15 In addition, Hwang et al20 noted that
patients sustaining a distal radius fracture with concomitant ipsilateral elbow injury developed compartment
syndrome 15% of the time, well above the 0.25% risk
of compartment syndrome development after a distal
radius fracture alone.
Compartment syndrome is generally diagnosed by
clinical examination based on a keen index of suspicion, but it can be supplemented by additional testing.
Removal of any constrictive dressings is a critical step
to allow for accurate assessment of the limb.21 Regard-
JHS 䉬 Vol A, March 
539
COMPARTMENT SYNDROME OF THE FOREARM
TABLE 2.
Gunshot
Wound
Continued
Narcotic
Overdose
Hemophilia
Snakebite
Phlebitis
IV
Infiltration
Burns
Neonatal
Postsurgery
Unspecified
Arterial
Injury
5
2
1
4
3
3
2
3
1
5
1
1
2
1
2
4
5
1
2
1
2
2
7
8
1
5
1
7
3
7
1
4
8.3
9.5
1.2
6.0
1.2
8.3
3.6
8.3
1.2
4.8
Continued
Fractures (n)
Supracondylar
Fracture
10
8
Proximal Radius
Radius-Ulna
Radial Shaft
Distal Radius
Not
Specified
2
4
3
2
1
2
3
3
8
8
5
32
10.7
1
8
3
6
4
2
12
1
25.0
9.4
18.8
6.2
37.5
3.1
9.5
3.6
7.1
2.4
14.3
1.2
ing the use of compartment pressures, there was nearly
an equal distribution between the number of patients
diagnosed by clinical examination and those supplemented by intracompartmental pressures.5–16 Although
many authors considered intracompartmental pressures
unnecessary for diagnosis, many recommend its use in
obtunded patients, polytrauma, and patients with equivocal clinical findings.8,15
Various skin incisions were used for volar compart-
ment forearm fasciotomy. The typical volar incision
begins 1 cm proximal and 2 cm lateral to the medial
epicondyle and crosses obliquely across the antecubital
fossa and over the volar aspect of the mobile wad.8,12
The incision curves in a medial direction, reaching the
midline at the junction of the middle and distal third of
the forearm. The incision is continued just ulnar to the
palmaris longus tendon to avoid the palmar cutaneous
branch of the median nerve. The incision crosses the
JHS 䉬 Vol A, March 
Current Concepts
TABLE 3.
9
540
COMPARTMENT SYNDROME OF THE FOREARM
Method of Diagnosis
TABLE 4.
Author
Caouette-Laberge et al5
Eaton and Green
6
Geary7
8
Patients (n)
Extremities (n)
Clinical Findings
5
5
5
19
19
19
2
3
3
Clinical Plus
Intracompartmental Pressure
26
26
Kline and Moore9
2
2
Morin et al10
5
5
5
Stryker
4
4
4
Wick
3
3
1
2
Slit
2
2
1
1
Whitesides
5
8
2
6
Stryker
2
2
2
Gelberman et al
Mubarak et al
11
Peters and Scott
12
Seiler et al13
Simpson and Jupiter
14
Sneyd et al15
Stockley et al16
Total
Wick
2
5
5
5
80
84
40
44
47.6
52.4
Percentage
TABLE 5.
26
Technique
Method of Treatment
Patients
(n)
Extremities
(n)
Surgical
Nonsurgical
5
5
2
3
19
19
16
3
2
3
3
Gelberman et al8
26
26
12
14
Kline and Moore9
2
2
1
1
5
5
5
4
4
3
3
3
3
2
2
2
5
8
8
2
2
1
Author
Caouette-Laberge et al
Eaton and Green
6
Geary7
Morin et al
10
Mubarak et al11
Peters and Scott
12
Seiler et al13
Simpson and Jupiter
Sneyd et al15
Stockley et al
Total
16
14
5
1
1
5
5
5
80
84
61
23
73
27
Percentage
Current Concepts
wrist crease at an angle and extends into the midpalm
for concomitant carpal tunnel release. Other, less common incisions are the volar ulnar incision that starts radial
to the flexor carpi ulnaris and extends to the medial epicondyle of the humerus, and the zigzag incision.22,23
When there is a forearm compartment involving both
the volar and the dorsal compartments, it is preferable
first to release the volar compartment. Volar compartment release often decompresses the dorsal compart-
ment.23 Therefore, a compartment pressure measuring
device should be available to allow dorsal compartment
pressure measurement after volar fasciotomy. If there is
no improvement in pressure measurement, dorsal fasciotomy is necessary.
We found the overall complication rate of forearm
compartment syndrome to be 42%, with studies reporting
neurological deficits as the most common complication.
Earlier decompression will minimize these sequelae.
JHS 䉬 Vol A, March 
Method of Decompression
TABLE 6.
Author
Patients (n)
Eaton and Green6
7
5
5
2
19
19
16
Volar
Incision
Dorsal
Incision
Combined Volar/
Dorsal Incision
JHS 䉬 Vol A, March 
3
3
26
12
7
Kline and Moore9
2
2
1
1
Morin et al10
5
5
5
2
3
Mubarak et al11
4
4
3
2
1
Peters and Scott12
3
3
3
3
2
2
2
2
5
8
8
7
2
2
1
5
5
5
80
84
61
Simpson and Jupiter14
Sneyd et al
15
Stockley et al16
Total
Percentage, surgical
patients
Arterial
Surgery
8
2
Seiler et al
Lacertus
Fibrosis
Release
2
26
13
Carpal
Tunnel
Release
16
Gelberman et al8*
Geary
Not Specified/
No Fasciotomy
3
1
2
2
3
3
10
10
1
3
1
3
8
1
5
5
45
1
11
4
30
16
8
74
2
18
7
49
26
13
COMPARTMENT SYNDROME OF THE FOREARM
Caouette-Laberge et al5
Extremities (n)
Surgical
Treatment
*Two surgical patients were not discussed because third-degree burns affected the outcome.
541
Current Concepts
542
COMPARTMENT SYNDROME OF THE FOREARM
TABLE 7.
Fasciotomy Wound Management
Author
Patients—Surgical
Management (n)
Extremities
(n)
Delayed Primary Closure
2
3
1
Geary7
8
Postfasciotomy
Skin Grafting
2
10
10
3
6
Mubarak et al16
3
3
2
1
Peters and Scott17
3
3
1
2
Seiler et al20
2
2
1
1
5
8
5
3
5
5
30
34
Gelberman et al
Simpson and Jupiter
Stockley et al
21
23
Total
5
Percentage
13
20
39
61
Caouette-Laberge et al5 performed debridements, not fasciotomies (2 patients). Eaton and Green,6 Morin et al,10 and Sneyd et al15 did not mention
management of wound (22 patients). Gelberman et al8 discussed only 9 of 12 fasciotomies and 9 of 10 cases mentioned in the study.
TABLE 8.
Complications
Patients
(n)
Extremities
(n)
Caouette-Laberge
et al5
5
5
Eaton and Green6
19
19
1
2
3
1
Gelberman et al8*
10
10
Kline and Moore9
2
2
Mubarak et al11
4
4
Stockley et al16
5
5
42
43
Author
Geary7
Total
Studies reporting
complications
(%)
Contracture
Neurological
Deficit
Gangrene
Volkmann’s
Ischemic
Contracture
Crush
Syndrome
Sudeck’s
Algodystrophy
1
1
8
2
2
1
1
4
9
9.3
20.9
1
1
2
1
2.3
2.3
4.7
2.3
*Only complications for surgical patients were recorded.
Current Concepts
The strengths of our study include the number
and diversity of the cases analyzed. Weaknesses
were that all of the studies were retrospective case
series or case reports (level IV evidence), and
several studies are greater than 20 years old. This
highlights the need for a prospective, multicenter
study regarding the treatment and outcome of forearm compartment syndrome.
Acute compartment syndrome of the forearm has
multiple etiologies affecting patients of all ages. If untreated, it will result in contractures, neurological deficits, and complete loss of forearm and hand function.
Emergent treatment is necessary to prevent sequelae
and vigilance in diagnosis is mandatory. Patients under
35 years of age with forearm fractures and polytrauma
are at high risk for forearm compartment syndrome and
require careful monitoring. In obtunded patients and
those with equivocal physical examination findings,
objective diagnostic measurements are beneficial. The
diagnosis of forearm compartment syndrome requires
immediate fasciotomy. The most common surgical approach is a volar curvilinear incision that often decompresses the dorsal compartment. After fasciotomy, repeat debridement of any nonviable tissue may be
required and secondary procedures are necessary for
wound closure.
JHS 䉬 Vol A, March 
COMPARTMENT SYNDROME OF THE FOREARM
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Current Concepts
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