Compartment syndrome was suspected immediately due to a hard, noncompressible anterior compartment of the forearm. However, Mr. J did not present as one would expect a person with compartment syndrome to present. He was able to tolerate the pain associated with passive extension of his right fingers. He was also able to actively flex and extend his wrist with only moderate pain. In addition, he had intact sensation and intact radial and ulnar pulses.
To confirm the suspected diagnosis of compartment syndrome, a Stryker quick-pressure monitor (a side-port needle) was inserted and revealed an anterior compartment pressure of 87 mm Hg. It was suspected that Mr. J had torn his flexor carpi radialis and that his anticoagulant therapy led to a bleed in the forearm, causing compartment syndrome.
4. Treatment and Outcome
In the ED, Mr. J consented to an emergency fasciotomy and carpal tunnel release. In surgery, a long incision was made from the medial aspect of the proximal forearm, extending distally over the transverse carpal ligament into the proximal palm (Figure 2).
Once the overlying fascia was incised, there was an immediate softening and decompression of the compartment proximally. Distally, the muscle showed evidence of extreme edema and it immediately herniated through the initial fasciotomy. All compartments were decompressed, and all muscle in the proximal and distal forearm appeared to be viable and healthy. No evidence of a muscle or ligament tear was found in the forearm. Sutures were placed to close the carpal tunnel, and one loose suture was placed proximally to cover the median nerve. A sterile bandage and a splint were placed, and Mr. J was admitted to hospital.
On postoperative day one, Mr. J had no pain and had regained the ability to actively flex his fingers on the right side. He was also able to cross his fingers, make an “OK” sign, and abduct fingers, showing that his ulnar, median, and radial nerves were intact. He was not able to actively extend fingers, but had no pain with passive extension.
Once the edema recedes, presumably in a five-day period, Mr. J will go back to the operating room for delayed primary closure of fasciotomy wounds. Our anticipation is that he will make a full recovery, since the compartment syndrome was found and decompressed before muscle necrosis occurred.