Hand Compartment Syndrome

Algorithm Steps

1. ▶

   Start

   Suspected Hand Compartment Syndrome

   Tight, swollen hand after injury

   1. ●

      Action

      Common Etiologies

      What causes hand compartment syndrome?

      • TRAUMA:
      • - Crush injury
      • - Fractures (metacarpal, carpal)
      • - High-pressure injection
      • - Burns (circumferential)
      • VASCULAR:
      • - Arterial injury/ligation
      • - Reperfusion after ischemia
      • OTHER:
      • - Snake bite (venom edema)
      • - IV infiltration
      • - Tight cast/dressing
      • - Bleeding (coagulopathy)
      1. ●

         Action

         Hand Compartments (10 total)

         Anatomic spaces

         • THENAR (1): Thumb intrinsics
         • HYPOTHENAR (1): Small finger intrinsics
         • ADDUCTOR POLLICIS (1): Deep to thenar
         • INTEROSSEI (4): Between metacarpals
         • - 3 palmar + 1 dorsal per web space
         • - Often counted as 4 or 7
         • CARPAL TUNNEL (1): Median nerve, flexors
         • GUYON'S CANAL (1): Ulnar nerve/artery
         • FINGER COMPARTMENTS: Each digit
         1. ⚠

            Warning

            Clinical Diagnosis (6 Ps)

            PAIN is most reliable early sign

            • PAIN: Out of proportion to injury
            • - Pain with PASSIVE STRETCH (key finding)
            • - Stretch intrinsics (extend MPs + flex PIPs)
            • PRESSURE: Tense compartments
            • PARALYSIS: Late sign - motor weakness
            • PARESTHESIAS: Nerve compression
            • PALLOR: Late, indicates ischemia
            • PULSELESSNESS: Very late (unreliable)
            • NOTE: Pulses often present with CS
            1. ●

               Action

               Compartment Pressure Measurement

               Objective confirmation

               • INDICATIONS:
               • - Unconscious/unreliable patient
               • - Equivocal exam
               • - Regional/spinal anesthesia
               • TECHNIQUE:
               • - Stryker needle or arterial line setup
               • - Measure ALL compartments
               • - Interossei: Dorsal approach
               • THRESHOLDS:
               • - Absolute: >30 mmHg concerning
               • - Delta P: DBP - compartment <30 mmHg
               • - Either indicates release
               1. ◆

                  Decision

                  Compartment Syndrome Confirmed?

                  Clinical diagnosis OR pressure confirmation

                  1. ●

                     Action

                     Urgent Hand Fasciotomy

                     Surgical decompression

                     • TIMING: Within 6 hours optimal
                     • INCISIONS:
                     • - Thenar: Radial border of thumb metacarpal
                     • - Hypothenar: Ulnar border of hand
                     • - Interossei: 2 DORSAL incisions
                     • - 2nd/4th metacarpal intervals
                     • - Release all 4 interossei
                     • - Carpal tunnel: Palmar incision
                     • TECHNIQUE:
                     • - Incise skin AND fascia
                     • - Visualize muscle (should bulge)
                     • - Leave wounds OPEN
                     • - Delayed closure at 3-5 days
                     1. ●

                        Action

                        Postoperative Care

                        After fasciotomy

                        • WOUND CARE:
                        • - Moist dressings
                        • - VAC therapy option
                        • - Return to OR in 48-72h
                        • DELAYED CLOSURE:
                        • - Primary if <5 days
                        • - Skin graft if needed
                        • THERAPY:
                        • - Early passive motion
                        • - Edema control
                        • - Splinting in intrinsic plus
                        1. ✓

                           Outcome

                           Outcomes

                           Prognosis

                           • Early release (<6h): Good outcomes
                           • Delayed release: Permanent damage
                           • COMPLICATIONS of missed CS:
                           • - Intrinsic contracture (claw hand)
                           • - Volkmann's ischemic contracture
                           • - Permanent nerve damage
                           • - Loss of function
                           • LEGAL: High medicolegal risk
                  2. ●

                     Action

                     Close Monitoring

                     If not immediately surgical

                     • ONLY if diagnosis uncertain AND:
                     • - Pressures normal
                     • - No pain with passive stretch
                     • - Good perfusion
                     • MONITORING:
                     • - Serial exams q2h
                     • - Elevate hand (not above heart)
                     • - Remove all constricting items
                     • - Keep patient warm
                     • - Low threshold for surgery