Ortho Dx: Soft Tissue Swelling in the Hand - Clinical Advisor

Ortho Dx: Soft Tissue Swelling in the Hand

Slideshow

  • Figure 1. Anteroposterior radiograph of the right hand.

  • Figure 2. Lateral radiograph of the right hand.

A 2-year-old boy is brought to the emergency department of a local hospital by his mother after she accidentally shut his right hand in a car door 2 hours prior. On examination the patient has significant pain and swelling to the right hand. Anteroposterior and lateral radiographs of the right hand (Figures 1 and 2) show significant soft tissue swelling of the dorsal hand without fracture. The patient is inconsolable and appears to be in significant pain. Compartment syndrome of the hand is suspected.

What is the most sensitive sign on physical examination to diagnose acute compartment syndrome?

Compartment syndrome occurs as a result of increased pressure within a space that compromises neurovascular function. If compartment pressures aren’t released in a timely manner, muscle necrosis can occur; this may lead to permanent disability. Muscle death and nerve dysfunction...

Submit your diagnosis to see full explanation.

Compartment syndrome occurs as a result of increased pressure within a space that compromises neurovascular function. If compartment pressures aren’t released in a timely manner, muscle necrosis can occur; this may lead to permanent disability. Muscle death and nerve dysfunction can occur 6 hours after compartment pressures approach 30-mm Hg lower than a patient’s usual diastolic pressure. Diagnosing compartment syndrome in young children can be difficult as they often present obtunded, crying, or nonverbal and may be unable to provide feedback to help make the diagnosis.

The classic symptoms of compartment syndrome include pain out of proportion to the apparent injury, swelling, and compartment tension to palpation. The need for additional analgesic requirements is also a sign of acute compartment syndrome. However, these symptoms are nonspecific and unreliable. Pain with passive motion at the metacarpophalangeal joint corresponding to the affected intrinsic musculature is the most sensitive test to diagnose hand compartment syndrome.1 In general, pain with passive stretch of the fingers is the most sensitive sign on physical examination.

Common causes of compartment syndrome of the hand include trauma, drug use, snake bites, and insect bites. Once the diagnosis of hand compartment syndrome has been established, an emergent fasciotomy is necessary. Continuous frequent monitoring with documentation of intact neurovascular examinations is important when ruling out compartment syndrome. Due to the devastating consequence of missing or delaying prompt treatment, any suspected compartment syndrome should be emergently treated. Following fasciotomy, primary or delayed closure is performed. Full functional recovery is expected within 6 months postoperatively.1,2

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).

References

1. Codding JL, Vosbikian MM, Ilyas AM. Acute compartment syndrome of the hand. J Hand Surg Am. 2015;40(6):1213-1216.

2. Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome.  J Pediatr Orthop. 2001;21(5):680-688.  

Next hm-slideshow in Ortho Dx