Fasciotomy: Upper Extremity

Excerpt

1. Early fasciotomy is the standard of care for upper extremity compartment syndrome (UECS) and may prevent the development of irreversible contractures of forearm and hand musculature, a pathology initially described by Volkmann (VOLKMAN Centralblat fur hirurgie 8:801–803, 1881). Compartment syndrome (CS) is a feared orthopedic complication and common cause for permanent functional damage and limb loss as well as one of the most common causes for litigation in orthopedic surgery (DePasse et al. J Am Acad Orthop Surg 25:e109–e113, 2017; Marchesi et al. Injury 45(Suppl 6):S16–S20, 2014).

2. CS of the forearm is the second most common cause of CS in the extremities given the injury proneness of the upper extremity and hand as a prime organ of prehension and grasp (Leversedge et al. J Hand Surg Am 36:544–559, 2011). Given this important physiologic function, one can argue that the functional loss due to an established CS is higher than that of the lower extremity.

3. For UECS, a high level of alertness to clinical symptoms such as pain to passive stretch and increasing pain or analgesic requirements is key to not miss the diagnosis in the alert patient.

4. UECS shares common etiologies for CS seen in other body areas: either an external reduction of CS size such as external pressure from casts, dressings, and gravity or increase in compartmental size as seen in bleeding and fracture displacement, microvascular barrier damage in ischemia, burn injury, and envenomations (Leversedge et al. J Hand Surg Am 36:544–559, 2011). Several additional etiologies are pertinent to UECS such as iatrogenic extravasations of intravenous fluids, upper extremity arterial catheterizations (Omori et al. Orthopedics 36:e121–e125, 2013), and electrical trauma (Lee et al. J Am Acad Orthop Surg, 2018).

5. UECS is most commonly encountered in the forearm, which has three designated compartments (i.e., the lateral (mobile wad), the dorsal extensor, and the volar) of which contains the bulk of muscle mass in the flexor compartment. There are ten designated hand compartments which can be affected in hand compartment syndrome as seen, for instance, in crushing injuries (exploded hand syndrome), fractures and dislocations, as well as extravasations.

When performing fasciotomies for UECS, special emphasis must be placed to decompress the muscles of the deep flexor compartment due to their nonredundant blood supply which makes them especially prone to ischemic damage (Inoue and Taylor Plast Reconstr Surg 98:195–210, 1996).