Suspected Hand Compartment Syndrome
Tense, swollen hand with pain out of proportion to the injury. Adult or child.
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Plastic SurgeryEmergency
Hand Compartment Syndrome
Hand Compartment Syndrome: Suspected Hand Compartment Syndrome → Immediate measures for every patient → Snake bite, burn or coagulopathy: different firs...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action Immediate measures for every patient
Do these now, then reassess within 30 min
- Remove rings, casts, splints and dressings down to the skin
- Keep the hand at heart level, not raised above it: raising it lowers perfusion pressure
- Treat hypotension; give oxygen
- Call the senior hand, plastic or orthopaedic surgeon now
- Record the time, the findings and every analgesic dose
03Warning Snake bite, burn or coagulopathy: different first step
Check these before any incision
- Snake bite: antivenom first if indicated, with toxicology advice (Poisons 13 11 26). True compartment syndrome is rare. Measure pressures before any fasciotomy.
- Circumferential full-thickness burn: escharotomy first, after burns service advice. Fasciotomy only if signs persist (for example electrical injury).
- Anticoagulant or coagulopathy: start correction now. Do not delay release of a confirmed compartment syndrome for it.
04Action Causes to look for
Keep a high index of suspicion in sedated patients and children
- Crush injury; metacarpal, carpal or distal radius fracture
- IV or arterial line infiltration: highest risk in sedated patients and children
- High-pressure injection injury: urgent hand surgery review, even if the wound looks small
- Prolonged pressure on the limb (overdose, long surgery); tight cast or dressing
- Arterial injury or reperfusion after ischaemia; bleeding on anticoagulants
- Burns, snake bite, severe infection
05Action Test each of the 10 muscle compartments
Pain on passive stretch of the compartment is the key sign
- Interossei (4 dorsal, 3 palmar): passively abduct and adduct the fingers with MCP joints extended and PIP joints flexed
- Adductor pollicis: passive palmar abduction of the thumb
- Thenar: passive abduction and extension of the thumb
- Hypothenar: passive abduction and extension of the little finger
- Also check the carpal tunnel (median nerve), each finger and the forearm
06Action Clinical signs
Pain out of proportion and pain on passive stretch are the earliest signs
- Tense, swollen compartments; paraesthesia
- Weakness, pallor and absent pulses are late signs. Pulses are often present.
- Children: anxiety, agitation and a rising need for analgesia
- Exam unreliable if sedated, ventilated, head injured, after a regional nerve block, or a young child: measure pressures
07Decision Clinical diagnosis clear?
Clear signs in an awake patient who can be examined. Sedated, ventilated, after a nerve block, or a young child: answer No and measure pressures.
- If Yes
08Action Confirmed or clinically clear: urgent hand fasciotomy
Go to theatre now. Late or missed case with established muscle death: two consultants decide first; fasciotomy may cause harm.
- Two dorsal incisions over the 2nd and 4th metacarpals: release all 4 dorsal and 3 palmar interossei and the adductor pollicis
- Thenar incision on the radial side of the 1st metacarpal; hypothenar incision on the ulnar side of the 5th metacarpal
- Carpal tunnel release if median nerve signs; release the forearm if it is also involved
- Tense fingers: mid-axial release on the non-contact side (ulnar side of index, middle and ring; radial side of thumb and little finger)
- Open skin and fascia; debride dead muscle; record each compartment; leave wounds open
09Action After fasciotomy
Plan the re-look and wound closure
- Re-look in theatre within 72 h, earlier if needed; debride dead tissue
- Discuss with plastic surgery within 24 h if they did not operate
- Moist or negative-pressure dressings; delayed primary closure or skin graft
- Splint in the safe position (intrinsic plus); elevate; start hand therapy early
- Crush or late cases: check CK, creatinine and urine output for rhabdomyolysis
10Outcome Outcome depends on time to release
Muscle tolerates about 4 h of ischaemia; damage is irreversible by about 8 h. Late release: intrinsic or Volkmann contracture, nerve damage, loss of hand function.
If No11Action Not clear or exam unreliable: measure compartment pressures
Measure each suspect compartment and record the diastolic BP at the same time
- Delta P = diastolic BP minus compartment pressure. Under 30 mmHg on repeated readings supports compartment syndrome.
- Absolute pressure over 40 mmHg: consider urgent decompression
- Under general anaesthesia the diastolic BP falls (mean 18 mmHg), so delta P can be falsely low. Compare with the pre-operative diastolic BP.
- No threshold is validated for the hand or for children. The consultant surgeon decides with the clinical signs.
- Delta P over 30 mmHg on repeated readings helps rule it out
- Commercial pressure monitor, or arterial-line transducer with a needle. Interossei from the dorsum; thenar and hypothenar if suspect.
12Decision Pressures or repeat exam support compartment syndrome?
Yes: delta P under 30 mmHg on repeated readings, absolute pressure over 40 mmHg, or clinical signs now clear. The consultant surgeon decides.
- If Yes
- Path rejoins step 08Shared downstream outcome
If No13Action Not confirmed: hourly review
Only while the diagnosis is uncertain
- Examine and record every hour: pain, stretch pain, tension, sensation, analgesic use
- Repeat or continuous pressure measurement if the exam is unreliable
- Keep the hand at heart level; nothing tight around the hand or wrist
- Senior surgeon reviews; low threshold for fasciotomy
14Decision Signs worse, or delta P under 30 mmHg on repeat readings?
At each hourly review. Yes: consultant decides on fasciotomy now.
- If Yes
- Path rejoins step 08Shared downstream outcome
If No15End Not worse: continue hourly review until signs resolve
Any new rise in pain or tension: repeat pressures and call the senior surgeon
Guideline Source
BOASt Diagnosis and Management of Compartment Syndrome of the Extremities (British Orthopaedic Association, published July 2014, updated July 2025)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- No hand-specific guideline exists. Pressure thresholds come from leg and forearm studies and are not validated for the hand; they support, not replace, senior clinical judgement.
- Children: signs differ (anxiety, agitation, rising analgesic need); get paediatric hand or orthopaedic advice early.
- Snake bite, burns and coagulopathy need specialist input (toxicology, burns service) before any incision.
- Does not cover chronic exertional compartment syndrome.
Applicable Regions
USEUUKAUGlobal
AU: No national Australian guideline; BOASt and AAOS standards are used. Snake bite: Poisons Information Centre 13 11 26. Remote sites: early retrieval to a centre with hand surgery.
UK: BOASt 2025: hourly assessment, immediate decompression, plastics discussion within 24 h, re-look within 72 h.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Hand Compartment Syndrome?
The Hand Compartment Syndrome is a emergency clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on BOASt Diagnosis and Management of Compartment Syndrome of the Extremities (British Orthopaedic Association, published July 2014, updated July 2025).
What guideline is the Hand Compartment Syndrome based on?
This algorithm is based on BOASt Diagnosis and Management of Compartment Syndrome of the Extremities (British Orthopaedic Association, published July 2014, updated July 2025).
What are the limitations of the Hand Compartment Syndrome?
Known limitations include: No hand-specific guideline exists. Pressure thresholds come from leg and forearm studies and are not validated for the hand; they support, not replace, senior clinical judgement.; Children: signs differ (anxiety, agitation, rising analgesic need); get paediatric hand or orthopaedic advice early.; Snake bite, burns and coagulopathy need specialist input (toxicology, burns service) before any incision.; Does not cover chronic exertional compartment syndrome.. Individual patient factors may require deviation from these recommendations.
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