Abstract
Background:
We aimed to describe the demographic, injury-related, and treatment-related characteristics of patients who undergo fasciotomies for acute hand compartment syndrome.
Methods:
A cohort of 53 adult patients with acute hand compartment syndrome treated with fasciotomy at 2 tertiary care referral centers over a 10-year time period from January 1, 2006, to June 30, 2015, were retrospectively identified. We reviewed the electronic medical record for patient-related variables (eg, age, sex, smoking status, diabetes mellitus), injury-related variables (eg, mechanism of injury, presence of fractures), and treatment-related variables (eg, compartments released, number of operations, use of split-thickness skin grafts, and time from injury to surgery).
Results:
The mean age of our cohort was 45 years, and 33 patients (62%) were men. The mechanism of injury varied widely, but the most common causative mechanisms were crush injury (25%), prolonged decubitus (17%), and infection (11%). Associated hand fractures were present in 15 (28%) patients. The surgically released compartments varied; the dorsal interosseous compartments (83%), thenar compartment (75%), and hypothenar compartment (74%) were most frequently released, while the adductor pollicis compartment (43%) and Guyon canal (28%) were least frequently released.
Conclusions:
The demographics of acute hand compartment syndrome have evolved in the last 25 years compared with the prior literature, partly as a result of the opioid epidemic leading to a rise in “found down” compartment syndrome. Treating providers should recognize crush injury, prolonged decubitus, and infection as the most common causes of acute hand compartment syndrome.
Keywords: acute compartment syndrome, carpal tunnel, crush injury, found down, Guyon canal, hand, trauma
Introduction
Acute compartment syndrome is a disorder of elevated pressure within a closed fascial compartment resulting in decreased capillary perfusion pressure and compromised tissue viability. 1 Prolonged tissue hypoperfusion initiates a vicious cycle of increased capillary permeability leading to increased swelling in the closed fascial space and elevation of compartment pressures.2,3 The treatment of acute compartment syndrome is prompt diagnosis and emergent fasciotomy. Delay in treatment is associated with poor outcomes, including neurologic deficits, musculotendinous contractures, or limb amputation.4-6
There are 10 closed fascial compartments of the hand, comprising 4 dorsal interosseous compartments, 3 volar interosseous compartments, the thenar compartment, the hypothenar compartment, and the adductor pollicis compartment.3,4 Some authors additionally include the carpal tunnel and Guyon canal as closed fascial compartments of the hand.7,8 Acute hand compartment syndrome is a rare phenomenon, and current evidence is limited to case reports and small case series. 9 Much of our current understanding of the epidemiology of acute hand compartment syndrome is based on a landmark case series by Ouellette and Kelly of 10 adults and 9 children treated with fasciotomy. 8 Patient, injury, and treatment characteristics for this rare, devastating disorder remain poorly described.
Given this gap in our current understanding, we sought to answer the following question: What are the demographic, injury-related, and treatment-related characteristics of patients who undergo fasciotomies for acute hand compartment syndrome?
Methods
Patient Identification
With institutional review board approval, patients who underwent fasciotomy for acute compartment syndrome of the hand were retrospectively identified by querying upper extremity compartment syndrome diagnosis codes using the institutional Research Patient Data Registry database at 2 level I trauma centers across a 10-year time period from January 1, 2006, to June 30, 2015. The billing records database was queried using the International Classification of Diseases, Ninth Revision (ICD-9) codes 729.71 (nontraumatic compartment syndrome of upper extremity) and 958.91 (traumatic compartment syndrome of upper extremity).
The initial query resulted 438 patients coded with a diagnosis of upper extremity compartment syndrome; the electronic medical records of these patients were screened. Our inclusion criteria were all adult patients with a diagnosis of hand compartment syndrome treated with surgical fasciotomy. The ICD-9 code for compartment syndrome of the upper extremity does not further differentiate by location (hand, forearm, arm, etc.). Because the queried ICD-9 code is inclusive of the entire upper extremity, 347 patients were excluded for a diagnosis other than acute compartment syndrome of the hand, including 120 patients surgically treated for acute forearm compartment syndrome. Moreover, 36 patients were excluded for incomplete document of history, physical examination, or operative report, 1 patient was excluded for prophylactic fasciotomy without clinical suspicion of acute compartment syndrome, and 1 patient was excluded for fasciotomy performed in the setting of a hand replantation. A final cohort of 53 patients with acute hand compartment syndrome treated with fasciotomy were included in the study (Figure 1).
Figure 1.
Study inclusion flow diagram.
In this retrospective study, the diagnosis of acute hand compartment syndrome was made clinically by the treating surgeon. The decision to use compartment pressure measurement as an adjunct to diagnosis was at the discretion of the treating team and nonstandardized.
Outcome Variables
We reviewed the electronic medical record for the characteristics of the 53 patients in our final cohort. The following patient-related variables were recorded: age, sex, self-reported race, smoking status, and comorbid diabetes mellitus. The following injury-related variables were recorded: mechanism of injury, presence of hand fracture(s), presence of additional fracture(s) in the ipsilateral limb, presence of other fracture(s), presence of closed head injury, and presence of chest or abdominal injury. The following treatment-related variables were recorded: use of compartment pressure measurement, compartment(s) released, number of operations, time from injury to surgery (<6, 6-12, 12-24, or >24 hours), and use of split-thickness skin graft for wound closure. Time from injury to surgery for nontraumatic etiologies of acute hand compartment syndrome was calculated from the history from the time of presumed onset of compartment syndrome physiology and broadly categorized (<6, 6-12, 12-24, or >24 hours).
Statistical Analysis
Descriptive statistics for study variables were calculated. There was 100% data completeness for all variables, except 98% data completeness for diabetes mellitus, 96% for current smoking, 96% for time to surgery, and 94% for self-reported race. Parametric continuous variables were expressed as mean (standard deviation), nonparametric continuous variables were expressed as median (interquartile range), and categorical variables were expressed as percentages.
Results
Fifty-three patients who underwent fasciotomy for acute hand compartment syndrome composed our final cohort. The mean age of our cohort was 45 years, and 33 patients (62%) were men. Twenty-five (49%) patients were active smokers, and 8 (15%) patients had diabetes mellitus (Table 1). In 7 of 53 patients (13%), compartment pressure measurement was used as an adjunct to diagnosis; otherwise, the diagnosis was established by history and physical examination. The mechanism of injury varied widely, but the most common causative mechanisms were crush injury (25%), prolonged decubitus (17%), and infection (11%). Twelve of 53 patients (23%) developed hand compartment syndrome secondary to substance abuse; 7 of these 12 patients were “found down,” 2 sustained burn injuries related to substance abuse, 1 developed an intravenous drug use-related infection, 1 developed a toxic injury, and 1 fell from a height. Associated hand fractures were present in 15 (28%) patients (Table 2). The median number of operations per patient was 2 (interquartile range: 1-2, mode 1, range: 1-6), and only 8 (15%) patients required split-thickness skin grafting for wound closure (Figure 2). The surgically released compartments varied; the dorsal interosseous compartments (83%), thenar compartment (75%), and hypothenar compartment (74%) were most frequently released, while the adductor pollicis compartment (43%) and Guyon canal (28%) were least frequently released (Table 3). The time from injury to surgery was variable. Thirty-two percent of patients underwent fasciotomy within 6 hours of injury; however, in 36% of patients, fasciotomy was performed more than 24 hours after injury. Eight of 12 patients (67%) who developed hand compartment syndrome secondary to substance abuse underwent fasciotomy after more than 24 hours, and none of these 12 patients underwent fasciotomy within 12 hours (Table 4).
Table 1.
Patient-Related Characteristics of the Cohort (n = 53). a
| Variable | Mean (SD) |
|---|---|
| Age | 45 (15) |
| n (%) | |
| Male | 33 (62) |
| Race | |
| White | 39 (74) |
| Black | 6 (11) |
| Hispanic | 3 (6) |
| Asian | 2 (4) |
| Unknown | 3 (6) |
| Current smoker | 25 (49) |
| Diabetes mellitus | 8 (15) |
Current smoking was available for 51 patients (96%) and diabetes mellitus for 52 patients (98%).
Table 2.
Injury-Related Characteristics of the Cohort (n = 53).
| Variable | n (%) |
|---|---|
| Mechanism of injury | |
| Crush injury | 13 (25) |
| Prolonged decubitus (“found down”) | 9 (17) |
| Infection (non-IVDU-related) | 6 (11) |
| Burn | 6 (11) |
| IV infiltration | 4 (8) |
| Penetrating trauma | 3 (6) |
| Motor vehicle collision | 2 (4) |
| Pedestrian struck | 2 (4) |
| Toxic or metabolic disorder | 2 (4) |
| Fall from height | 1 (2) |
| Ground-level fall | 1 (2) |
| Vascular injury | 1 (2) |
| Infection (IVDU-related) | 1 (2) |
| Traumatic hematoma | 1 (2) |
| Blunt trauma | 1 (2) |
| Hand fracture | 15 (28) |
| Additional ipsilateral limb fracture | 6 (11) |
| Other fracture | 4 (8) |
| Closed head injury | 2 (4) |
| Chest/abdominal injury | 2 (4) |
Note. IV = intravenous line; IVDU = intravenous drug use.
Figure 2.
Histogram depicting the number of operations for patients treated with fasciotomy for acute hand compartment syndrome.
Table 3.
Treatment-Related Characteristics of the Cohort (n = 53).
| Variable | Median (IQR) |
|---|---|
| No. of operations | 2 (1-2) |
| n (%) | |
| Use of compartment pressure measurement | 7 (13) |
| Compartments released | |
| Dorsal interossei | 44 (83) |
| Thenar | 40 (75) |
| Hypothenar | 39 (74) |
| Carpal tunnel | 34 (64) |
| Volar interossei | 33 (62) |
| Adductor pollicis | 23 (43) |
| Guyon canal | 15 (28) |
| Use of STSG for wound closure | 8 (15) |
| Time to surgery, hours | |
| Unknown | 2 (4) |
| <6 | 17 (32) |
| 6-12 | 8 (15) |
| 12-24 | 7 (13) |
| >24 | 19 (36) |
Note. STSG = split-thickness skin graft; IQR = interquartile range.
Table 4.
Relationship Matrix Between Mechanism of Injury and Time to Fasciotomy. a
| Mechanism of injury | Time to surgery, hours | |||
|---|---|---|---|---|
| <6 | 6-12 | 12-24 | >24 | |
| Crush injury | 3 | 4 | 3 | 3 |
| Prolonged decubitus (“found down”) | 0 | 0 | 1 | 8 |
| Infection (non-IVDU-related) | 1 | 0 | 0 | 5 |
| Burn | 1 | 2 | 2 | 1 |
| IV infiltration | 4 | 0 | 0 | 0 |
| Penetrating trauma | 3 | 0 | 0 | 0 |
| Motor vehicle collision | 2 | 0 | 0 | 0 |
| Pedestrian struck | 0 | 2 | 0 | 0 |
| Toxic or metabolic disorder | 1 | 0 | 0 | 1 |
| Fall from height | 0 | 0 | 1 | 0 |
| Ground-level fall | 1 | 0 | 0 | 0 |
| Infection (IVDU-related) | 0 | 0 | 0 | 1 |
| Traumatic hematoma | 1 | 0 | 0 | 0 |
Note. IV = intravenous line; IVDU = intravenous drug use.
Cells of the relationship matrix denote the number of patients who underwent fasciotomy within each time frame for each mechanism of injury. Time to surgery was unknown for 2 patients (vascular injury and blunt trauma) and they were not included in this relationship matrix.
Discussion
We found that acute hand compartment syndrome most commonly occurs in younger patients with a male predominance. Injury mechanisms varied widely, but crush injury, prolonged decubitus, and infection were the most common. More than 20% of hand compartment syndromes developed secondary to substance abuse. Compartments released varied as well, but the dorsal interosseous compartments, thenar compartment, and hypothenar compartment were most commonly released. Time delay to fasciotomy was bimodal, with the group undergoing fasciotomy more than 24 hours after injury being largely patients there were found down.
This study has several limitations. First, our study was intended as a descriptive study, and we did not correlate patient, injury, or treatment characteristics with surgical outcomes. Second, our study was retrospective in nature and limited by the available documentation. Use of compartment pressure measurements was at the discretion of the treating team and nonstandardized. Variables such as time delay to fasciotomy can be difficult to judge retrospectively. We have mitigated inaccuracies by using 4 broad time ranges (<6, 6-12, 12-24, or >24 hours) that have previously been used in the published literature. 1 Third, our study was susceptible to ascertainment bias. We focused on only surgically treated patients with acute hand compartment syndrome. Our findings are not generalizable to “missed” compartment syndrome or nonoperatively treated compartment syndrome. It may be possible, for instance, that prolonged decubitus injuries are more likely associated with “missed” compartment syndrome treated nonoperatively. We would expect such a sampling bias to underestimate the true prevalence of such an injury mechanism in the development of acute hand compartment syndrome. Moreover, because acute compartment syndrome is understandably thought of as a “can’t miss” diagnosis, using surgical fasciotomy as the reference standard for diagnosis may overestimate the true prevalence of acute hand compartment syndrome and bias-associated demographics. Fourth, this study was performed at 2 level I trauma centers. Our findings may not be generalizable to all practice settings.
In our cohort, acute hand compartment syndrome most commonly occurred in a younger patient population with a mean age of 45 years, with a 62% male predominance. These demographics closely mirrored the demographics of hand fractures in general. In a population-level study, MacDermid et al 10 showed that 93 673 patients with hand fractures in Ontario, Canada, had a mean age of 42 years with a 66% male predominance. Our findings also support prior descriptions in acute compartment syndromes of the hand, forearm, and leg.2,5,11 Nearly 50% of our cohort actively smoked, which is higher than previous reports in the forearm and leg.5,6,11 Smoking may predispose to acute compartment syndrome due to peripheral vascular disease and baseline relative tissue ischemia. 6 The most common injury mechanisms resulting in acute hand compartment syndrome in our series were crush injury, prolonged decubitus, and infection. This finding is in contrast with Ouellette and Kelly 8 1996 case series of 10 adult patients with acute hand compartment syndrome, in which 6 patients developed acute hand compartment syndrome from intravenous infiltrations, 2 from crush injury, 1 from a penetrating injury, and 1 from postsurgical swelling. Possible explanations for these differences include regional differences in trauma and infection, an evolution of trauma demographics over the last 25 years, and the opioid epidemic associated with a rise in “found down” compartment syndrome.4,12 In sharp contrast to Ouellette and Kelly, substance abuse accounted for nearly one-quarter of hand compartment syndrome cases in our series, all with at least 12 hours of delay of presentation for fasciotomy, and 67% with more than 24 hours of delay of presentation for fasciotomy. This suggests that patients with hand compartment syndrome secondary to substance abuse may be at risk for particularly poor outcomes. Similar to Ouellette and Kelly series, 8 dorsal interosseous compartments were most frequently released in our study. The adductor pollicis compartment was released in only 43% of cases and Guyon canal in 28% of cases. While our study was descriptive and not normative, we speculate based on our findings that routine release of all 10 closed fascial compartments of the hand, the carpal tunnel, and Guyon canal may be unnecessary in every case. Rather, there may be a role for selective release of hand compartments. Split-thickness skin graft was only used in 13% of cases for wound closure in the hand, compared with previously reported skin graft rates of 47% in the forearm and 43% in the leg. 1 The low rates of split-thickness skin grafting are likely related to smaller wound surface areas in the hand, amenable to healing by secondary intention.
Acute hand compartment syndrome is seen across varying patient demographics and injury mechanisms. Treating providers should recognize crush injury, prolonged decubitus, and infection as the most common causes of acute hand compartment syndrome. A higher than previously described percentage of hand compartment syndrome can be attributed to substance abuse, which may portend poorer outcomes due to delays to fasciotomy. Further research is required to better understand this disorder and predictors of outcomes. Direction for future research includes which hand compartments necessitate release, factors associated with surgical outcomes, and the effects of delays in treatment.
Footnotes
Ethical Approval: This study was approved by our institutional review board.
Statement of Human and Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.
Statement of Informed Consent: Informed consent was waived in this retrospective study.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs: Derrick W. Williams 
https://orcid.org/0000-0003-0155-8244
Dafang Zhang
https://orcid.org/0000-0003-0155-8244
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