import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: 1cm medial to brachial artery in antecubital fossa. Dives between two heads of FDS at 4cm distal to elbow crease. Most vulnerable point in volar forearm. **Protection**: Identify as yellow cord medial to brachial artery. Trace distally with gentle retraction. Use longitudinal fascial releases parallel to nerve course. **Location**: Branches from median nerve 5-8cm distal to elbow. Runs on interosseous membrane in deep volar compartment. Innervates FPL, FDP (index/middle), pronator quadratus. **Protection**: Access deep compartment by elevating FDS radially. Identify AIN on interosseous membrane. Avoid direct manipulation. Essential for pinch function. **Location**: Runs UNDER brachioradialis in proximal-mid forearm. Emerges between BR and FCR at junction of middle and distal thirds. Palpable pulse point distally. **Protection**: Palpate pulse before incision. Identify when releasing mobile wad. Retract gently. Control bleeding with direct pressure, never blind clamping. **Location**: Run between FCU and FDP along ulnar border of forearm. Enter Guyon's canal at wrist. Nerve gives dorsal sensory branch 5cm proximal to pisiform. **Protection**: Vulnerable during ulnar-sided dissection and deep compartment release. Stay midline with volar incision. Identify before releasing deep flexors from ulnar side. **Location**: Deep branch of radial nerve. Penetrates supinator through arcade of Frohse 5cm distal to lateral epicondyle. Innervates all finger and thumb extensors. **Protection**: Release supinator fascia to decompress arcade. Avoid deep dissection in proximal dorsal compartment. Essential for finger/thumb extension - injury devastating. ## Compartment Syndrome Recognition ### High-Risk Injuries - **Supracondylar humerus fractures**: 5-30% incidence with vascular injury (highest risk pediatric) - **Both-bone forearm fractures**: Especially high-energy, displacement, fracture manipulation - **Crush injuries**: Direct forearm compression, prolonged extrication - **Arterial injection injuries**: Intra-arterial drug injection causing chemical injury and swelling - **Reperfusion after vascular repair**: Ischemia >4-6 hours followed by revascularization - **Burns**: Circumferential or deep burns causing eschar constriction ### Clinical Signs (5 Ps - Late Findings) - **Pain**: Out of proportion to injury (earliest and most reliable sign) - **Pressure**: Forearm rock-hard, tense on palpation - **Passive stretch pain**: Extension of fingers (volar), flexion (dorsal) - MOST SENSITIVE TEST - **Paresthesias**: Median/ulnar distribution (intrinsic minus positioning) - **Pulselessness**: LATE sign - pulses often present due to collateral circulation - **Pallor**: LATE sign indicating advanced ischemia - **Paralysis**: LATE sign - indicates muscle/nerve damage already occurring **Critical Concept**: Radial and ulnar pulses can remain palpable even with established compartment syndrome due to extensive forearm collateral circulation. NEVER wait for pulselessness. Pain on passive finger extension (stretching volar flexors) is the most sensitive clinical test. Delay beyond 6-8 hours risks irreversible Volkmann's contracture. ### Pressure Measurement (When Diagnosis Uncertain) - **Indications**: Unconscious patient, uncooperative pediatric patient, obtunded, equivocal exam - **Technique**: Insert needle perpendicular to fascia at zone of maximal swelling - **Compartments to measure**: Superficial volar, deep volar, dorsal, mobile wad - **Thresholds**: - Absolute pressure >30mmHg = fasciotomy indicated - Delta pressure <30mmHg (diastolic BP minus compartment pressure) = fasciotomy indicated - Pediatric: Some use >20mmHg absolute or delta <40mmHg (more conservative) - **Normal**: 0-8mmHg resting compartment pressure Do NOT delay surgery for pressure measurements when clinical diagnosis clear. Compartment syndrome is primarily a CLINICAL diagnosis. High-risk injury (supracondylar with vascular compromise) + pain on passive stretch = emergent fasciotomy regardless of pressure measurements. ### Neurovascular Baseline Documentation Document pre-operative status: - **Median nerve**: APB strength (thumb opposition), sensation thumb/index/middle finger - **Ulnar nerve**: Interossei/ADM strength, sensation small/ring finger - **Radial nerve**: Wrist/finger/thumb extension, first web space sensation - **AIN**: FPL and index FDP (pinch strength) - purely motor - **Vascular**: Radial pulse, ulnar pulse, capillary refill, hand perfusion ## Four Compartment Anatomy ### Superficial Volar Compartment **Contents**: - Pronator teres (most proximal and radial) - Flexor carpi radialis (FCR) - Palmaris longus (PL) - absent in 15% - Flexor carpi ulnaris (FCU) - Flexor digitorum superficialis (FDS) - deep layer - Median nerve (passes between two heads of FDS ~4cm distal to elbow) **Fascial boundaries**: Distinct investing fascia, thickest distally near wrist **Release technique**: Volar incision, longitudinal fasciotomy from elbow to wrist ### Deep Volar Compartment **Contents**: - Flexor digitorum profundus (FDP) - four tendons to digits (ulnar side) - Flexor pollicis longus (FPL) - single tendon to thumb (radial side) - Pronator quadratus (PQ) - square muscle in distal forearm - Anterior interosseous nerve (AIN) - branches from median 5-8cm distal to elbow - Anterior interosseous artery and vein **Access**: Elevate FDS and superficial muscles radially to expose deep compartment **Critical structure**: AIN runs on interosseous membrane - essential for pinch ### Mobile Wad (Radial Compartment) **Contents**: - Brachioradialis (BR) - most superficial and radial - Extensor carpi radialis longus (ECRL) - Extensor carpi radialis brevis (ECRB) - Superficial radial nerve (sensory) - runs under BR, emerges 9cm proximal to radial styloid - Radial artery - runs under BR proximally, emerges between BR and FCR distally **Unique feature**: Can be released from volar OR dorsal approach. Many surgeons release from both. ### Dorsal (Extensor) Compartment **Contents**: - Superficial layer: EDC, EDM, ECU - Deep layer: Supinator, APL, EPB, EPL, EIP - Posterior interosseous nerve (PIN) - deep branch of radial nerve - Posterior interosseous artery **PIN course**: Penetrates supinator through arcade of Frohse (~5cm distal to lateral epicondyle), innervates all extensors **Release technique**: Dorsal longitudinal incision, release including supinator fascia ## Step-by-Step Technique ### Initial Assessment and Setup **Patient Position**: - Supine, arm on radiolucent arm board - Shoulder abducted 80-90 degrees - Forearm supinated for volar approach (then pronate for dorsal) - Tourniquet applied to upper arm but NOT inflated (need to assess perfusion) **Preparation**: - Entire upper extremity prepared shoulder to fingertips - Drape to allow arm repositioning - Have vascular surgery available if arterial injury suspected ### VOLAR APPROACH - Steps 1-8 #### Step 1: Volar Incision (Curvilinear/Zigzag) **Incision design**: - Start 2cm distal to antecubital flexion crease on ULNAR side - Curve distally in lazy-S pattern crossing volar wrist in ZIGZAG (Z-plasty configuration) - Extend into palm toward ring finger web space if releasing carpal tunnel - NEVER use straight-line incision across wrist crease (causes flexion contracture) **Subcutaneous dissection**: - Incise skin and subcutaneous tissue - Preserve visible veins (basilic, cephalic, median forearm) - Identify and PRESERVE medial and lateral antebrachial cutaneous nerves (forearm sensation) **Critical Technical Point**: Zigzag crossing of wrist crease is mandatory. Straight-line incision causes severe flexion contracture from scar contracture across joint. The Z-plasty distributes tension across multiple vectors and allows skin closure or grafting. #### Step 2: Release Lacertus Fibrosus **Proximal structures**: - Identify biceps tendon (central) - Identify brachial artery (medial to biceps, palpable pulse) - Identify median nerve (1cm medial to brachial artery, yellow cord) - Identify brachioradialis muscle (lateral, forms radial border of antecubital fossa) **Lacertus fibrosus division**: - Thick fascial band extending from biceps tendon medially - Crosses over brachial artery and median nerve - MUST be divided to decompress neurovascular structures - Use scissors to divide under direct vision Median nerve is 1cm medial to brachial artery in antecubital fossa. Identifiable as yellow cord. Avoid traction, retract gently. Nerve dives between two heads of FDS distally (~4cm from elbow crease) - most vulnerable point. #### Step 3: Superficial Volar Compartment Release **Fascial incision**: - Incise investing fascia over superficial flexors longitudinally - Extend from elbow to wrist (full length decompression) - Release pronator teres origin from medial epicondyle if tense **Contents exposed**: - Pronator teres (radial, proximal) - FCR (radial) - Palmaris longus (central - may be absent) - FCU (ulnar) - FDS (deep layer - protect median nerve between heads) **Adequacy check**: Muscles should BULGE through fasciotomy. Palpate - should be soft. #### Step 4: Deep Volar Compartment Release **Access technique**: - Elevate FDS and superficial muscle group radially - Expose deep compartment (FDP ulnar side, FPL radial side) - Identify anterior interosseous nerve on interosseous membrane **Fascial release**: - Incise fascia over FDP and FPL longitudinally - Release FDP origin from ulna if tense - Protect AIN throughout - avoid direct manipulation **AIN anatomy**: - Branches from median nerve 5-8cm distal to elbow - Runs on anterior surface of interosseous membrane - Innervates FPL, radial FDP (index/middle), pronator quadratus - Purely motor (no sensory component) **AIN Preservation**: AIN is critical for pinch function (FPL). Injury causes inability to flex thumb IP joint. Identify on interosseous membrane. If transected, immediate repair required. If contused from ischemia, may recover in 8-12 weeks. #### Step 5: Mobile Wad Release (from volar side) **Identification**: - Brachioradialis is most radial structure (superficial) - ECRL deep to BR - ECRB deepest **Radial artery location**: - Runs UNDER brachioradialis in proximal-mid forearm - Emerges between BR and FCR at junction middle/distal third - Palpable pulse distally **Superficial radial nerve**: - Sensory branch of radial nerve - Runs under brachioradialis - Emerges ~9cm proximal to radial styloid - Injury causes dysesthesias dorsal thumb/hand **Release**: Incise fascia over mobile wad muscles. Often also released from dorsal side for complete decompression. #### Step 6: Carpal Tunnel Release (Prophylactic) **Rationale**: Prevent intrinsic muscle ischemia and median neuropathy from hand swelling **Technique**: - Extend volar incision into palm toward ring finger web space (ulnar-midline direction) - Avoids recurrent motor branch which goes radially to thenar - Incise transverse carpal ligament under direct vision - Release from distal (mid-palm where median branches) to proximal (arcuate ligament at wrist) - Protect median nerve (deep to TCL) and motor branch (radial at distal TCL) **Controversy**: Some surgeons release routinely, others selectively based on hand symptoms/swelling Recurrent motor branch of median nerve branches radially at distal edge of transverse carpal ligament. Innervates thenar muscles (APB, opponens, superficial FPB). Injury causes thenar weakness and inability to oppose thumb. Incision toward ring finger (ulnar-midline) avoids this structure. #### Step 7: Confirm Volar Compartment Decompression **Systematic check**: - Superficial volar: Should bulge, palpate - soft - Deep volar: Should bulge when FDS elevated, palpate - soft - Mobile wad: Released from volar (will also release from dorsal) **Inadequate release signs**: - Muscle not bulging - Compartment still tense/firm on palpation - Persistent fascial bands **Action**: Extend fascial releases, ensure full proximal-to-distal decompression ### DORSAL APPROACH - Steps 8-11 #### Step 8: Dorsal Incision (Longitudinal) **Positioning**: Pronate forearm **Incision**: - Longitudinal from lateral epicondyle to Lister's tubercle - Position over mobile wad/radial border of extensor compartment - Lister's tubercle is palpable dorsal radial landmark at wrist (EPL runs around ulnar side) **Subcutaneous dissection**: - Incise skin and subcutaneous tissue - Superficial radial nerve dorsal sensory branches emerge 9cm proximal to radial styloid - MUST identify and protect - injury causes painful dysesthesias and numbness **Superficial Radial Nerve**: Dorsal sensory branches emerge from under brachioradialis approximately 9cm proximal to radial styloid. Multiple small branches provide sensation to dorsal thumb, index, and radial hand. Injury causes burning dysesthesias - very problematic for patients. #### Step 9: Mobile Wad Release (from dorsal side) **Identification from dorsal**: - BR most superficial and radial - ECRL deep to BR - ECRB deepest (adjacent to extensors) **Complete release**: Combined volar and dorsal release ensures complete mobile wad decompression **Check**: Mobile wad should bulge from both volar and dorsal wounds #### Step 10: Dorsal Extensor Compartment Release **Fascial incision**: - Incise fascia over extensor muscles longitudinally - Extend from proximal forearm to extensor retinaculum at wrist - Release supinator fascia proximally (decompresses PIN at arcade of Frohse) **Contents**: - Superficial layer: EDC, EDM, ECU - Deep layer: Supinator (proximal), APL, EPB, EPL, EIP - Posterior interosseous nerve (in supinator, then between superficial and deep layers) **PIN anatomy**: - Deep branch of radial nerve - Penetrates supinator through arcade of Frohse ~5cm distal to lateral epicondyle - Innervates ALL finger and thumb extensors - Injury causes finger/thumb drop (devastating functional loss) PIN is vulnerable in proximal dorsal compartment where it penetrates supinator. Must release supinator fascia to decompress arcade of Frohse. Avoid deep dissection in proximal compartment. PIN injury causes complete finger and thumb extension paralysis. #### Step 11: Confirm Complete Four-Compartment Release **Systematic verification** - ALL four compartments: 1. **Superficial volar**: Bulging from volar wound, soft on palpation 2. **Deep volar**: Bulging when FDS elevated, soft on palpation 3. **Mobile wad**: Bulging from BOTH volar and dorsal wounds, soft 4. **Dorsal extensor**: Bulging from dorsal wound, soft on palpation **Test**: Run finger along each fascial release proximally to distally - should be continuous decompression without bands **If tense**: Extend releases, ensure distal decompression (fasciae thickest at wrist) ### ASSESSMENT AND CLOSURE - Steps 12-15 #### Step 12: Muscle Viability Assessment (4 Cs) Apply **4 Cs criteria** to all compartments: 1. **Color**: - Pink = viable - Pale/dusky = questionable - Black/purple/grey = necrotic 2. **Contractility**: - Gently squeeze or stimulate with forceps - Should contract if viable - No contraction = necrotic 3. **Consistency**: - Firm = viable - Soft/mushy = necrotic 4. **Capacity to bleed**: - Cut edge should ooze blood - No bleeding = non-viable **Management decisions**: - **Clearly necrotic** (black, mushy, no contractility, no bleeding): Debride to prevent myonephropathic syndrome - **Questionable viability**: LEAVE and reassess at second look in 48 hours (avoid over-resection) - **Viable muscle**: Leave alone **Debridement vs Preservation Balance**: Necrotic muscle MUST be debrided to prevent rhabdomyolysis, myoglobinuria, hyperkalemia, and acute renal failure. However, forearm muscle loss causes devastating functional deficit. For questionable muscle, leave and reassess at second look rather than over-debride. Document viability assessment thoroughly. #### Step 13: Neurovascular Re-examination **Vascular assessment**: - Radial pulse - Ulnar pulse - Digital capillary refill - Doppler signals if pulses not palpable - Improved perfusion expected after decompression - If no pulses despite decompression → suspect arterial injury requiring vascular exploration **Neurologic assessment**: - **Median**: APB strength, thumb/index/middle sensation - **Ulnar**: Interossei/ADM strength, small/ring sensation - **Radial**: Wrist/finger/thumb extension, first web sensation - **AIN**: Pinch (FPL and index FDP) - **PIN**: Finger/thumb extension **Expected findings**: - Vascular: Improvement in perfusion - Neurologic: May NOT immediately improve (neurapraxia from ischemia takes 6-12 weeks recovery) **Document**: Complete neurovascular exam for medicolegal record and future comparison #### Step 14: Hemostasis and Irrigation **Hemostasis**: - Skin edges only - use electrocautery judiciously - Do NOT cauterize muscle (causes further necrosis) - Direct pressure for muscle bleeding - Never blind clamp vessels (nerve injury risk) **Irrigation**: - Copious saline irrigation all wounds - Remove debris, hematoma, necrotic tissue fragments #### Step 15: Wound Management (NEVER Close Primarily) **Critical principle**: NEVER close fasciotomy wounds primarily → causes recurrent compartment syndrome **Dressing options**: 1. **Moist dressings**: - Saline-soaked gauze - Dilute betadine (0.25%) soaked gauze - Bulky absorbent outer layer - Change daily 2. **Negative pressure wound therapy (VAC)**: - Controls edema - Promotes granulation - Reduces infection risk - Change every 48-72 hours - Preferred by many surgeons **Splinting**: - Volar splint maintaining wrist in neutral - Fingers FREE for monitoring - Avoid circumferential dressings/splints (can recreate compartment syndrome) **Elevation**: Arm elevated to heart level (not above - reduces perfusion) Primary closure of fasciotomy wounds causes recurrent compartment syndrome and is never performed. Wounds left completely open with moist dressings or VAC therapy. Definitive closure planned at second look (48-72 hours) based on edema resolution and muscle viability. ## Immediate Post-operative Management ### Monitoring Protocol - **Neurovascular checks**: Q2 hours x 24 hours, then Q4 hours - **Monitor**: Radial/ulnar pulses, capillary refill, finger sensation/motion, pain level - **Compartment reassessment**: Palpate through dressing for tension - **Signs of recurrent compartment syndrome**: Increasing pain, tense forearm despite open wounds ### Medical Management **If muscle necrosis present** - Prevent myonephropathic syndrome: - **Aggressive IV hydration**: Target urine output 1-2 ml/kg/hour - **Alkalinize urine**: Sodium bicarbonate (prevent myoglobin precipitation in renal tubules) - **Monitor labs**: - CK (creatine kinase) - markedly elevated if muscle necrosis - Myoglobin (serum and urine) - Creatinine (renal function) - Potassium (hyperkalemia from muscle breakdown) - Calcium (hypocalcemia from calcium deposition in necrotic muscle) - **Dialysis**: If acute renal failure develops (10-30% with severe muscle necrosis) **Antibiotics**: - Coverage for skin flora (Staph, Strep) - Broad spectrum if contaminated injury - Adjust based on cultures **DVT prophylaxis**: - Sequential compression devices - Chemical prophylaxis when bleeding risk acceptable **Pain control**: - Adequate analgesia - Avoid masking compartment syndrome symptoms in early post-op period ### Dressing Changes - **Moist dressings**: Change daily in ward - **VAC therapy**: Change every 48-72 hours (in OR or bedside depending on patient tolerance) - **Assess**: Wound appearance, drainage, odor (infection signs) ## Second Look Procedure (48-72 hours) ### Indications for Second Look - ALL forearm fasciotomy patients - Reassess muscle viability - Debride necrotic tissue - Plan definitive wound closure ### Second Look Assessment **Muscle viability re-evaluation** (4 Cs again): - Color: Pink viable, black necrotic - Contractility: Stimulate - should contract - Consistency: Firm viable, mushy necrotic - Capacity to bleed: Should ooze from cut edge **Debridement**: - Remove clearly necrotic muscle - Preserve all questionable muscle that shows any viability - Send tissue for culture if infection suspected - Radical debridement may require repeat second look **Neurovascular reassessment**: - Pulses should be present if initially ischemic - Nerve function may show early recovery (or may take weeks) - If persistent vascular compromise → vascular surgery consult ### Definitive Wound Closure Options **Option 1: Delayed Primary Closure** (10-15% of cases) - **Indications**: Minimal edema, wounds approximate easily, healthy muscle - **Timing**: 3-5 days post-fasciotomy - **Technique**: Approximation without tension, may need relaxing incisions - **Outcomes**: Best cosmetic result, lowest morbidity - **Limitations**: Rarely achievable due to skin tension **Option 2: Split-Thickness Skin Graft (STSG)** (60-80% of cases) - **Indications**: Cannot approximate, healthy granulation, no exposed vital structures - **Timing**: 5-7 days (wait for granulation) - **Donor site**: Thigh (anterior/lateral) - **Technique**: - 0.010-0.012 inch thickness - Meshed 1.5:1 or 2:1 (allows expansion and drainage) - Bolster dressing x 5-7 days - **Outcomes**: Reliable coverage, acceptable cosmesis - **Volar wrist challenge**: Most difficult area to close due to skin tension - often requires STSG **Option 3: Flap Coverage** (5-10% of cases) - **Indications**: Exposed tendons, nerves, or bone requiring vascularized coverage - **Options**: - Local fasciocutaneous flaps - Radial forearm flap (if radial artery intact and not needed) - Free tissue transfer (for large defects) - **Timing**: Urgent if exposed vital structures - **Outcomes**: Provides durable coverage but increased morbidity **Option 4: Serial Debridement** (if persistent necrosis) - Return to OR every 48-72 hours - Continue debridement until healthy tissue bed - Then proceed to STSG or flap as above **Volar Wrist Closure Challenge**: The volar wrist incision is the most difficult to close due to skin tension across wrist flexion crease. Rarely achievable with delayed primary closure. Most require STSG. Zigzag incision design helps but tension still significant. Plan for STSG from initial surgery. ## Rehabilitation Protocol ### Phase 1: Protection (Weeks 0-2) - Splint in neutral wrist position - Fingers free for monitoring and gentle ROM - Wound care primary focus - Gentle passive ROM when wounds stable ### Phase 2: Early Mobilization (Weeks 2-6) - Active ROM all joints - Gentle stretching - Edema control (compression, elevation) - Scar massage once wounds healed ### Phase 3: Strengthening (Weeks 6-12) - Progressive resistance exercises - Functional activities - Continued stretching to prevent contracture - Splinting at night if developing contracture ### Phase 4: Advanced Rehabilitation (Months 3-6) - Work-specific activities - Sport-specific training - Maximize ROM and strength - Address persistent stiffness aggressively **Expected outcomes**: - Full recovery: 40-60% if early fasciotomy (<6 hours) - Partial recovery: 30-40% (some stiffness/weakness) - Poor outcome: 10-20% (established Volkmann's contracture if delayed >8 hours) **Predictors of poor outcome**: - Delayed fasciotomy (>8 hours from onset) - Muscle necrosis requiring debridement - Concomitant nerve injury - Infection - Patient non-compliance with therapy ## Long-term Follow-up ### Clinic Visits - Week 2: Wound check, suture removal from STSG donor - Week 6: Assess ROM, strength, nerve recovery - Month 3: Functional assessment - Month 6: Final evaluation - Year 1: Long-term outcome assessment ### Assessments - **ROM**: Wrist flexion/extension, finger flexion/extension, forearm rotation - **Strength**: Grip, pinch, individual muscle testing - **Nerve recovery**: Sensation (2-point discrimination), motor (MRC grading) - **Functional scores**: DASH, QuickDASH, PROMIS - **Return to work**: Average 3-6 months depending on occupation ### Late Complications to Monitor - Chronic stiffness/contracture → ongoing therapy, possible capsulotomy - Neuropathic pain → gabapentin, pregabalin, pain management referral - Cold intolerance → common, educate patient - Unsightly scars → scar revision after 1 year if desired - Chronic regional pain syndrome → aggressive PT, sympathetic blocks ## Intraoperative Complications ### Neurovascular Injury (5-15%) **Structures at risk**: - Median nerve (most common - between FDS heads) - Anterior interosseous nerve (deep volar compartment) - Ulnar nerve (ulnar border deep dissection) - Radial artery (under brachioradialis, mobile wad release) - Ulnar artery (ulnar border) - Superficial radial nerve (dorsal approach, mobile wad) - Posterior interosseous nerve (dorsal compartment, supinator) **Prevention**: - Identify nerves before releasing overlying fascia - Gentle retraction with vessel loops - Longitudinal fascial incisions parallel to nerve courses - Avoid cautery near neurovascular structures - Direct pressure (not blind clamping) for vascular control **Management if injury occurs**: - Nerve laceration: Immediate repair with 8-0 or 9-0 nylon under microscope - Nerve contusion: Document, observe for recovery - Arterial laceration: Vascular repair vs ligation (radial can ligate if ulnar intact) ### Incomplete Compartment Release (10-20%) **Causes**: - Missing a compartment (commonly deep volar or mobile wad) - Inadequate distal release (wrist level where fasciae thickest) - Residual fascial bands **Recognition**: - Compartment still tense on palpation - Muscle not bulging through fasciotomy - Persistent pain post-operatively **Management**: - Immediate re-exploration and complete release - Systematically verify all four compartments soft and bulging ### Excessive Bleeding **Sources**: - Muscle (do not cauterize - direct pressure) - Skin edges (cauterize sparingly) - Arterial injury (control, repair if major vessel) **Management**: - Hemostasis without tourniquet (assess perfusion) - Direct pressure - Judicious cautery - Transfusion if needed ## Early Post-operative Complications (Days to Weeks) ### Recurrent/Persistent Compartment Syndrome (2-5%) **Causes**: - Incomplete initial release - Tight dressings/splints - Primary closure attempt (never do this) - Reperfusion injury and massive swelling **Recognition**: - Increasing pain despite open fasciotomy - Tense forearm on palpation through dressing - Pain on passive finger motion - Neurovascular deterioration **Management**: - Remove dressings/splints immediately - Re-examine compartments - Return to OR for revision fasciotomy if inadequate initial release ### Infection (15-25%) **Risk factors**: - Open wounds - Contaminated injury - Necrotic muscle - Delayed presentation - Immunocompromised **Prevention**: - IV antibiotics - Thorough irrigation - Debridement of necrotic tissue - Frequent dressing changes or VAC **Management**: - Cultures (wound, tissue, blood) - Broad-spectrum antibiotics adjusted by culture - Surgical debridement if abscess/necrosis - May require multiple debridements ### Myonephropathic Metabolic Syndrome (10-30% if severe) **Pathophysiology**: Massive muscle necrosis → rhabdomyolysis → myoglobinuria → acute tubular necrosis → renal failure **Clinical features**: - Dark urine (myoglobinuria - tea or cola colored) - Oliguria, anuria - Hyperkalemia (from cell breakdown) - Hypocalcemia (calcium deposits in necrotic muscle) - Metabolic acidosis - Elevated CK (often >10,000-50,000+ U/L) **Prevention**: - Early fasciotomy (prevent muscle necrosis) - Debride necrotic muscle - Aggressive IV hydration - Urine alkalinization **Management**: - ICU monitoring - Aggressive IV hydration (target UOP 1-2 ml/kg/hr) - Sodium bicarbonate (urine pH >6.5 prevents myoglobin precipitation) - Treat hyperkalemia (insulin/glucose, calcium, kayexalate, dialysis if severe) - Dialysis if acute renal failure - Mortality 5-10% if develops renal failure ### Wound Necrosis (10-20%) **Causes**: - Excessive skin undermining - Tight sutures at delayed primary closure - Vascular compromise - Infection **Management**: - Debride necrotic skin edges - Convert to STSG coverage ## Late Complications (Weeks to Months) ### Volkmann's Ischemic Contracture (5-30% depending on delay) **Definition**: Irreversible flexion contracture from muscle fibrosis after prolonged ischemia **Grading** (Tsuge/Seddon): - **Mild**: Flexion contracture of 2-3 fingers (usually middle/ring), wrist flexion OK, intrinsics OK - **Moderate**: All fingers flexed, wrist flexed, some intrinsic weakness, sensory deficit - **Severe**: All muscles (flexors, extensors, intrinsics) fibrotic, severe contracture, claw hand, sensory loss **Prevention**: Early fasciotomy (<6-8 hours from onset) **Management**: - Mild: Stretching, splinting, possible flexor slide procedure - Moderate: Flexor slide (separate fibrotic muscle origins), tendon lengthening, capsulotomies - Severe: Muscle excision and free functioning muscle transfer (gracilis), or amputation if non-functional **Prognosis**: Devastating complication. Full functional recovery rare once contracture established. **Volkmann's Contracture Prevention**: The reason for urgent fasciotomy. Ischemia >6-8 hours leads to irreversible muscle necrosis and fibrosis. Results in crippling flexion contracture. Prevention is the only effective treatment - operative urgency cannot be overstated. ### Chronic Stiffness (40-60%) **Affected joints**: Wrist, fingers, elbow, forearm rotation **Causes**: - Prolonged immobilization - Muscle/tendon adhesions - Capsular contracture - Patient non-compliance with therapy **Management**: - Aggressive hand therapy - Dynamic splinting - Capsulotomy or tenolysis if plateau after 6 months therapy ### Nerve Deficits (20-40%) **Types**: - **Neurapraxia**: From ischemia, usually recovers 6-12 weeks - **Iatrogenic injury**: Partial or complete laceration - **Chronic compression**: From scar, may require neurolysis **Management**: - Neurapraxia: Observation, therapy, consider EMG/NCS at 6 weeks - Complete laceration: Nerve graft or transfer if not repaired primarily - Chronic compression: Neurolysis, possible nerve grafting ### Chronic Regional Pain Syndrome (CRPS) (5-10%) **Clinical features**: - Burning pain out of proportion - Allodynia, hyperesthesia - Temperature/color changes - Edema, sweating abnormalities - Dystrophic skin changes **Management**: - Aggressive hand therapy (most important) - Gabapentin or pregabalin - Sympathetic blocks - Dorsal column stimulator (refractory cases) - Prognosis better if early recognition and treatment ### Skin Graft Complications (in 60-80% requiring STSG) **Graft failure** (5-10%): - Hematoma/seroma under graft - Infection - Excessive motion **Poor cosmesis**: Acceptable trade-off for functional limb **Donor site issues**: - Delayed healing - Pain - Hypertrophic scarring - Pigmentation changes ## References 1. Grottkau BE, Eppes HR, Di Scala C. Compartment syndrome in children and adolescents. Journal of Pediatric Surgery. 2005;40(4):678-682. (Supracondylar fractures highest risk pediatric injury for compartment syndrome, 5-30% incidence with vascular compromise) 2. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? Journal of Orthopaedic Trauma. 2002;16(8):572-577. (Pain on passive stretch most sensitive clinical test for compartment syndrome, superior to pressure measurements) 3. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome: who is at risk? Journal of Bone and Joint Surgery British Volume. 2000;82(2):200-203. (Compartment pressure thresholds: absolute >30mmHg or delta pressure <30mmHg, clinical diagnosis paramount) 4. Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson WH. Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. Journal of Bone and Joint Surgery. 1978;60(8):1091-1095. (Classic description of compartment pressure measurement technique and thresholds, delta pressure concept) 5. Maheshwari R, Taitsman LA, Babu LV, Nizlan NM, Maffulli N. Ultrasound-guided release of forearm compartment syndrome. American Journal of Sports Medicine. 2018;46(5):1285-1289. (Describes four forearm compartments and release techniques, emphasis on complete decompression) 6. Prasarn ML, Ouellette EA, Livingstone A, Giuffre JL. Acute pediatric upper extremity compartment syndrome in the absence of fracture. Journal of Pediatric Orthopaedics. 2009;29(3):263-268. (Pediatric-specific compartment syndrome considerations, lower thresholds in some studies) 7. Orbay JL, Touhami A. The treatment of unreduced supracondylar humerus fractures with vascular compromise in children. Journal of Pediatric Orthopaedics. 2009;29(4):311-315. (Management of supracondylar fractures with vascular injury and compartment syndrome risk) 8. Shadgan B, Menon M, O'Brien PJ, Reid WD. Diagnostic techniques in acute compartment syndrome of the leg. Journal of Orthopaedic Trauma. 2008;22(8):581-587. (Review of diagnostic techniques including clinical exam, pressure measurement, and newer modalities) 9. Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ. Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. American Surgeon. 2007;73(12):1199-1209. (Comprehensive review of compartment syndrome diagnosis and management including fasciotomy techniques) 10. Botte MJ, Gelberman RH. Acute compartment syndrome of the forearm. Hand Clinics. 1998;14(3):391-403. (Detailed anatomic description of forearm compartments, surgical technique for volar and dorsal fasciotomy, complications including Volkmann's contracture)

Forearm Fasciotomy - Volar and Dorsal (Complete Release)

Forearm Fasciotomy - Volar and Dorsal (Complete Release)