Acute onset of pain and a noncompressible area in the anterior forearm
Figure 1. Ecchymosis and moderate edema on ulnar side of the elbow.
A 42-year-old, right-handed man presented to the emergency department (ED) with increasing pain and weakness in his dominant forearm. Six days earlier, Mr. J, a firefighter, had fallen through a window, landing on his outstretched right arm while on the job.
Mr. J reported hearing a pop when he fell, but did not think it was anything serious; he reported no sustained lacerations. Mr. J continued to work after the accident, but pain in his right arm increased over the next few days. He came to the ED when he began to find it hard to make a fist with his right hand.
1. Physical Examination
Initial survey showed significant ecchymosis and moderate edema on the volar and ulnar sides of the right wrist and the ulnar side of the elbow (Figure 1). Mr. J. reported pain with palpation over right distal radius and distal ulna on the volar side. This area was hard to the touch and not compressible. Beginning mid-forearm and extending proximally, the volar and dorsal sides of the forearm were soft and compressible.
Mr. J reported pain with active and passive supination, extension and flexion of his right wrist. Fingers on his right hand were fixed in flexion and Mr. J was unable to actively extend them. When passively extended, he reported increased but tolerable pain. When we tested nerve function in the right hand, Mr. J could not make the "OK" sign, cross his fingers or abduct fingers. He reported normal feeling to light touch in the right upper extremity.
Radial and ulnar pulses were intact: capillary refill time was normal. Mr. J had full active and passive range of motion in the right elbow, without pain. X-rays of the forearm, wrist, and hand were unremarkable.
Mr. J has a history of primary antiphospholipid antibody syndrome, a condition characterized by vascular thromboses.1 He is currently taking aspirin and fondaparinux sodium (Arixtra) daily for anticoagulation.
Mr. J's history reveals that he has been treated for several deep vein thromboses and a pulmonary embolism. In addition, since becoming a firefighter, Mr. J has had bleeding in the thigh, which was treated nonoperatively. He is under the supervision of a hematologist, and reports that his syndrome is well managed with current protocol.
3. Differential Diagnosis
Differential diagnoses for Mr. J included fracture, muscle contusion, torn ligament and compartment syndrome. Fracture was ruled out with negative films. Muscle contusion did not explain the severe pain and inability to actively range fingers. It was thought a muscle or ligament tear could cause hemorrhaging leading to noncompressible compartment syndrome. However, this did not explain the hard forearm compartment.