Compartment syndrome of upper limb following snake bite, a case report

Abstract

Introduction:

Snakebites, recognized as a neglected tropical disease by the WHO, cause significant morbidity and mortality globally. Although antivenom is the primary treatment, managing complications like compartment syndrome (CS) and soft tissue necrosis remains challenging. This case report describes a 39-year-old woman who developed CS following a green pit viper bite and subsequent antivenom administration, necessitating a fasciotomy.

Case:

The patient sustained a bite to her right middle finger, receiving 10 vials of polyvalent anti-snake venom. The next day, she developed symptoms suggestive of CS, prompting an emergency fasciotomy. The procedure included volar and dorsal forearm releases, finger incisions, and compartment releases. She was discharged on day 20 with optimal hand function and instructed to continue physiotherapy.

Discussion:

Snake venom contains toxic peptides and proteases that cause local and systemic effects, with severity influenced by venom quantity, bite location, and timely intervention. Upper extremity bites, particularly to the hand, are prone to CS due to the region’s vascularity and anatomy. Although CS after snakebites is rare, its symptoms can mimic local envenomation, requiring careful differentiation and urgent management to prevent permanent damage. Fasciotomy may be necessary if CS persists despite antivenom therapy, as demonstrated in our case.

Conclusion:

Snakebites, particularly to the upper extremities, require careful monitoring for complications like CS. Timely diagnosis and fasciotomy are crucial to prevent limb loss and preserve function.

Introduction

Snake bite has been enlisted as a neglected tropical disease by WHO in June 2017. With 1.8 to 2.7 million incidents of envenomations annually, an estimated 5.4 million individuals worldwide are bitten by snakes. Snake bites cause between 81 410 and 137 880 deaths annually, as well as around three times as many amputations and other permanent impairments^[1]. Depending on the species of snake, a bite can result in a wide range of clinical symptoms, from a localized tissue reaction to multiple organ failure. Antivenom is useful in preventing or lessening the systemic effects, but managing local symptoms is difficult, particularly in cases of soft tissue necrosis and CS^[2]. In our case, despite timely administration of anti-snake venom (ASV), the patient showed no clinical improvement, swelling persisted, and in the absence of compartment pressure monitoring, a clinical diagnosis of ACS was made—prompting urgent fasciotomy to prevent permanent tissue damage. This case report has been reported in line with SCARE checklist 2025^[3].

HIGHLIGHTS

• Upper extremity snakebites, particularly to the hand, are prone to complications like CS due to the area’s vascularity and anatomical complexity.

• Early recognition of CS and prompt fasciotomy are critical to prevent limb loss and preserve function.

• Immediate surgical decompression through fasciotomy is critical in managing CS, helping to restore perfusion, prevent necrosis, and maintain optimal limb function.

Case presentation

A 39-year-old female with a documented history of a green pit viper bite on the dorsum of the middle finger of her right hand initially received treatment at a local facility, where she was given 10 vials of polyvalent ASV diluted in 500 mL of normal saline over 1 hour. Her condition remained stable, and she was discharged following a 24-hour period of observation. However, the following day, she developed significant swelling of the right upper limb, accompanied by progressively worsening pain, numbness, paresthesia, and an inability to move her fingers. She subsequently presented to the emergency department at our institution with these symptoms. On arrival, her vitals were stable. Examination revealed diffuse swelling of the right hand and forearm extending to the mid-arm, with fang marks visible on the dorsum of the middle phalanx of the middle finger. Multiple blisters were present on her fingers, forearm, and elbow (Fig. 1). The passive stretch test was positive, indicating significant pain out of proportion to the injury, raising clinical suspicion of compartment syndrome.

Figure 1.

A: tense swelling of whole forearm and hand with multiples blisters and bite marks. B: volar incision to release anterior compartment of forearm which shows reddish muscle which bleed to touch. C: release of posterior compartment of forearm and compartment of hand. D: apposition of margins of surgical wounds on subsequent debridement.

Initial laboratory findings showed an elevated white blood cell count (10,900/mm³), prolonged prothrombin time (31.1s) with an elevated INR of 2.7, and elevated markers of inflammation and muscle damage, including CRP (63.4 mg/L), CPK (768 IU/L), CK-MB (56 IU/L), and LDH (228 U/L). Additionally, the patient was anemic with a hemoglobin level of 8.0 g/dL and a packed cell volume (PCV) of 23%. Her renal function was slightly impaired, with blood urea at 54 mg/dL and creatinine at 1.4 mg/dL.

Given the clinical diagnosis of compartment syndrome, an emergency fasciotomy was performed. A volar and dorsal release of the forearm was achieved through incisions on both aspects, while additional incisions over the second and fourth fingers addressed hand compartmental pressure. Medial and lateral incisions were made to release the thenar and hypothenar compartments. The wounds were left open to allow for swelling reduction, with plans for delayed primary closure. Postoperatively, strict hand elevation and early physiotherapy were initiated.

A second-look debridement was performed after 48 hours, revealing healthy wound margins and viable muscle tissue. The wounds were progressively closed using shoelace sutures to ensure optimal tension reduction. Multiple debridements and further appositions of the shoelace suture technique resulted in full closure of the dorsal and volar incisions on the 7th and 12th postoperative days, respectively. Overall timeline of management has been shown in Table 1.

Table 1.

Timeline of case management

Day	Events
0	Snakebite (green pit viper) on the dorsum of middle finger of right hand
	Initial treatment with ASV (10 vials) in local health care center and discharged
2	Development of generalized swelling, severe pain, numbness, and limited finger movement
	Presentation to our center, diagnosis of compartment syndrome, emergency fasciotomy performed
4	Second look debridement with healthy wound margin
7	Wound closure of the dorsal incisions
12	Complete closure of the volar incisions
20	Discharge with optimal hand function

During her hospital stay, the patient received two units of packed red blood cells (PRP), two units of fresh frozen plasma (FFP), and three units of whole blood transfusion to address her anemia and coagulopathy. She was discharged on postoperative day 20 with optimal hand function, instructed to continue physiotherapy for full recovery. The patient has optimal hand function as evidenced by her follow up visit after 1 month of discharge.

Discussion

Snake venom is composed of various toxic components, such as peptides, hyaluronidases, and proteases, which induce both local and systemic effects post-envenomation^[4]. The clinical manifestations of a venomous snakebite depend on several factors, including the bite’s depth and location, the volume of venom injected, and the victim’s overall health and age. Additionally, the timeliness of treatment plays a critical role in determining outcomes. Locally, venom can increase vascular permeability, causing edema and elevated tissue pressure, which compromises blood flow and risks ischemic injury. If untreated, this can lead to severe complications, such as tissue necrosis or even amputation^[2].

Snake Bites commonly occur on the extremities, with two-thirds of bites affecting the upper extremities, as was the case in our patient^[2]. Bites on the hand can lead to rapid systemic effects due to the hand’s rich vascular supply and the thin skin on the dorsum^[5]. Additionally, critical structures such as joints, nerves, and tendons are located superficially in this region. In the hand and forearm, there is an increased risk of compartment syndrome, as venom can be delivered into deeper compartments. Therefore, early intervention in cases of snakebite to the hand is crucial, as it poses a greater urgency compared to bites in other areas^[6].

CS, although rare, is a serious complication of snakebite. Its symptoms, including severe pain, swollen and immobile extremities, can mimic local cytotoxic envenomation. CS has been reported in approximately 1.4% of viper bite cases in Switzerland and 1.36% in Greece, highlighting its low incidence but critical nature^[7]. Several factors, such as leukocytosis, high INR and elevated aspartate aminotransferase (AST) levels, have been associated with a higher risk of developing CS^[8].

The pathophysiology of compartment syndrome involves a cycle of edema that exacerbates capillary permeability and fluid leakage, resulting in hypoxia and acidosis within the affected compartment. This leads to increased intracompartmental pressure, impairing circulation and causing irreversible damage to muscles and nerves^[9]. Early identification and management of CS are crucial, as decompression, typically via fasciotomy, is needed to restore muscle perfusion to prevent permanent damage. However, the role of fasciotomy in snakebite-related CS is controversial. Current literature emphasizes that fasciotomy should be reserved for cases unresponsive to antivenom therapy, as early antivenom administration can effectively control elevated compartment pressures in many cases^[7,10].

Antivenom therapy remains the cornerstone of managing severe snakebite envenomations, with clinical and animal studies indicating that early administration can often prevent the need for surgical intervention. However, when CS persists despite appropriate antivenom treatment, fasciotomy becomes necessary to prevent long-term complications, including limb loss^[11]. In our case, despite timely antivenom administration, signs of CS remained, warranting an urgent fasciotomy. The rapid intervention resulted in a favorable outcome, with the patient eventually regaining full upper limb function.

This case aligns with previous studies, such as that by Kim et al^[12], where fasciotomies were frequently performed for snake bites to the hand, further supporting the idea that bites in the upper extremities pose a higher risk of CS. The higher rate of fasciotomy in such cases likely reflects the increased risk of CS in the upper extremities due to their anatomical structure.

Conclusion

In summary, snakebites, particularly those affecting the upper extremities, necessitate close monitoring to promptly identify both systemic and local complications, with a special focus on early indicators of CS. Timely recognition of CS and prompt intervention with fasciotomy are crucial to prevent limb loss and maintain optimal limb function. This case contributes to the growing body of evidence supporting the role of early fasciotomy in snakebite-related compartment syndrome based on clinical suspicion, even in the absence of intracompartmental pressure measurements. Given the variability in clinical presentation and the absence of standardized diagnostic thresholds, future studies are needed to establish clear guidelines for the timing and criteria of fasciotomy in snakebite-associated compartment syndrome.

Ethical approval

This case was approved as not human research by Institutional Review Board.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal on request.

Sources of funding

The study did not receive any grant from funding agencies in the public, commercial or not-for-profit sectors.

Author contributions

N.B., P.D.: conceptualization, writing – original draft, writing – review and editing. D.B., S.K.: writing – original draft, writing – review and editing, project administration. S.B.: writing - original draft, writing – review and editing. S.S.: conceptualization, supervision, writing – review and editing. All the authors read and approved the final manuscript.

Conflicts of interest disclosure

The authors report no conflicts of interest in this work.

Guarantor

Navin Bhattarai.

Research registration unique identifying number (UIN)

Not applicable.

Provenance and peer review

Not commissioned, not peer-reviewed.

Data availability statement

Not applicable.