Orthopedic Teaching Cases 2023, Jan, 17 | 12:00 am

Hand CASE 31

CASE                               31                               

A 17-year-old patient presents for evaluation. He reports that after racing his motocross bike for approximately 20 minutes, he reports pain, weakness of grip, forearm swelling and numbness and tingling of all five digits. On physical examination, he has normal sensation, normal strength of all major muscle groups. It resolves with rest.

What is the most likely diagnosis?

  1. Carpal tunnel syndrome

  2. Chronic exertional compartment syndrome

  3. Cervical spinal stenosis

  4. Anterior interosseous compressive neuropathy

  5. Parsonage–Turner syndrome

Discussion

The correct answer is (B). Chronic exertional compartment syndrome would cause weakness and numbness at times of extreme muscle use. At times of rest, as in the clinic setting, the physical examination is expected to be normal. Treatment is forearm fasciotomy done on a scheduled basis. Carpal tunnel syndrome would involve the radial three and one half digits and would not be expected to cause forearm swelling or grip weakness. Cervical spinal stenosis would not be exertional in nature. Anterior interosseous compressive neuropathy would have weakness without sensation changes. A weakness of thumb, index, and middle pinch and grip is expected. Parsonage–Turner syndrome is an idiopathic brachial plexopathy that presents with usually unilateral shoulder pain followed by numbness and weakness in the upper extremity. It is often posttraumatic, postinfectious, or postvaccination.

Additional Questions

The orthopaedic service is consulted on a 32-year-old patient with severe hand pain. The patient underwent an 8 hour operative procedure in which his hands were tucked during positioning and his hips abducted. After extubation, he began complaining of pain in the left hand. His heart rate is 108 and his blood pressure is 92/54.

Which of the following is most consistent with a diagnosis of compartment syndrome?

  1. Compartment pressure of 28

  2. Dorsal swelling greater than volar swelling

  3. Hand held with MPs flexed and IPs extended

  4. Pain with passive flexion greater than extension of the thumb

  5. Painless adduction and abduction of the thumb

 

Discussion

The correct answer is (A). Compartment pressures of 30 to 45 mm Hg or within 30 mm Hg of the diastolic pressure are consistent with a diagnosis of compartment syndrome. The swelling is generally diffuse. The hand is held in intrinsic minus position in compartment syndrome with IPs flexed and MPs extended. Pain with digit extension causes pain as a first sign as well as pain with abduction.

Which of the following is the correct number of compartments in the hand and incisions necessary to release the hand compartments?

  1. Eight compartments, four incisions

  2. Eight compartments, eight incisions

  3. Eight compartments, five incisions

  4. 10 compartments, 4 incisions

  5. 10 compartments, 10 incisions

 

Discussion

The correct answer is (D). There are 10 compartments in the hand: thenar, hypothenar, adductor, volar interosseous (3) and dorsal interosseous (4). They can be accessed via two longitudinal incisions centered over the second and fourth metacarpals dorsally to decompress the volar and dorsal interossei as well as the adductor compartment. A longitudinal incision on the radial side of the first metacarpal decompresses the thenar compartment. A longitudinal incision over the ulnar side of the fifth metacarpal decompresses the hypothenar compartment. This is a total of 20 compartments and 4 incisions.

The patient undergoes hand compartment releases and a carpal tunnel release. Herniation of muscle is noted with necrosis of the superficial muscle. The median nerve is exposed within the wound.

Which is indicated?

  1. Debridement of muscle and closure of skin to prevent desiccation of tissues

  2. Defer excision of necrotic muscle until necrosis is completely demarcated

  3. Application of a moist dressing after debridement of necrotic tissue

  4. Compressive dressing to prevent hemorrhage and further blood loss

  5. Debridement and placement of wound vac sponge within the wounds

 

Discussion

The correct answer is (D). Wounds should be left open and dressed with a moist dressing in this situation. Early closure of the skin can increase compartment pressures and cause further tissue damage. A second look procedure is indicated and therefore the wounds are left open. Any necrotic tissue should be excised. Delaying excision of necrotic tissue can cause further inflammation and swelling. A compressive dressing can increase compartment pressures and worsen compartment syndrome. A wound vac sponge should not be placed directly on vessels or nerves. This is a contraindication to negative pressure wound therapy. The sponge can erode vessel walls and cause severe bleeding, often occurring at the time of sponge removal.

Objectives: Did you learn...?

 

Recognize chronic exertional as well as acute compartment syndrome of the hand including the presentation and diagnosis?

 

 

Describe the anatomy of the hand compartments and how to release each of them? Manage compartment syndrome after release?