Unusual presentation of acute compartment syndrome of the forearm and hand

Background

It is essential to maintain a multidisciplinary approach to ensuring effective holistic care for complex patients. This case report describes the management of a man with an unusual presentation of compartment syndrome in the forearm and hand, mimicking skin infection and necrotising fasciitis, which prompted urgent multidisciplinary collaboration.

The patient necessitated urgent preoperative planning and teamwork between multiple medical disciplines and theatre staff that allowed timely surgical intervention with satisfactory outcome. This case highlights the importance of teamwork at a hospital setting in achieving effective patient care.

Case presentation

A 49-year-old man with a background of schizoaffective disorder, asthma, hypothyroidism, type 2 diabetes mellitus, right testicular cancer as well as chronic abdominal pain secondary to adhesions and long standing reduced sensation in the fourth and fifth fingers in both hands was referred to the orthopaedic surgeons with an acute onset of left forearm and hand pain and swelling, widespread blisters and skin erythema (figures 1 and 2). He had presented at the accident and emergency department and was unable to extend his fingers that were clawed with loss of sensation in the whole hand after finding himself lying face down on carpet at home for an unknown period of time. The patient could not recall the reason for this and he denied any thermal, biological or chemical exposure. There was no evidence of the patient lying on a radiator or any other thermal source.

Clinical examination presented difficulties due to the pronounced wrist and finger contractures, the extensive blistering in the left forearm and hand, the continuous discharge of broken large blisters and the hypersensitivity of the erythematous skin. The fingers were fixed in a clawed position and any attempt to straighten them was causing severe pain.

The radial pulse was palpable, but palpation of the ulnar artery was not conclusive. Capillary refill in the fingers was under 3 s and remained unchanged for the 2 hours prior to surgery was performed.

The patient was apyrexial, normotensive with a blood pressure of 131/79 mm Hg and heart rate of 99 bpm. Diffuse tender swelling was present over the left forearm and left hand, with diffuse redness and large blisters over dorsal and flexor aspect of the left forearm as well as the dorsal aspect of the hand. The blisters were weeping yellow discharge. There was also some area of marked erythema on his nose.

Pain was severe on any attempt to passively extend the wrist and the fingers; the patient was unable to actively move his fingers at all. The degree of clawing of the fingers deteriorated rapidly within the 2 hours of preoperative assessments. General examination of other systems was unremarkable.

Investigations

The patient denied any chemical ingestion/exposure and there was no clear cause as to why and how he may have found himself face down on the floor; CT of the head was requested, which did not show any obvious focal mass lesion or midline shift; no skull fracture was visible. Radiographs of the left wrist showed soft tissue swelling and some degenerative changes; no acute bony injury was seen. In the chest radiographs, the heart and mediastinum could not be assessed due to projection; the left base was largely obscured due to overlying cardiac shadows, the remainder of the lungs were clear. Bloods on presentation revealed a C reactive protein of 35 mg/L, white cell count of 5.2×10⁹/L, creatinine of 56 µmol/L. Electrolytes and urea were normal; haemoglobin was 92 g/L, platelets were 74×10⁹/L. Skin culture swabs were taken and subsequently showed no significant growth.

Differential diagnosis

Due to the dramatic skin presentation of the forearm and hand and the striking presence of multiple large blisters several diagnoses were considered. A burn injury was ruled out as the patient denied any heat exposure and there was nothing to suggest contact with a caustic substance in the history. Additionally, a dermatological condition such as bullous pemphigoid was possible; however, the presentation was acute and there were no prodromal symptoms or itching reported.

Following further discussions with the consultant microbiologist on call, the accident and emergency staff and the consultant plastic surgeon on call, differential diagnosis narrowed to three likely diagnoses: compartment syndrome; necrotising fasciitis and aggressive infection/cellulitis. Despite the lack of trauma and, no evidence of bony fractures on radiographs of the hand and forearm, compartment syndrome became the most likely diagnosis. It was supported by the progressively worsening disproportionate pain, the tense swelling of the forearm and the severe pain on passive stretch of the fingers. The history of a long lie on the floor was highly suggestive that his arm could have been trapped underneath him.

The multiple blisters and the erythema in the forearm and hand along with an erythema on the patient’s nose substantiated the suspicion of an infective aetiology, although prolonged pressure on the forearm and hand when the patient was lying on the floor was equally considered.

Necrotising fasciitis was also strongly considered because of the dramatic presentation of the symptoms and the diabetic background of the patient, despite the relatively normal blood investigations; the understanding that the presence of a small abrasive trauma to the skin that could have been the entry portal of the bacteria, could not be detected due to the extensive blistering, was worrying. The slight elevation of the inflammatory markers, the lack of fever and the exacerbation of the pain on passive and active movements of the fingers made us believe that compartment syndrome in the presence of infection/cellulitis in the forearm and hand was the most probable diagnosis, although necrotising fasciitis could not be safely excluded. Following discussion with the consultant microbiologist on call, the patient was put on meropenem 1 g three times per day and clindamycin 600 mg four times per day according to the hospital guidelines for necrotising fasciitis.

As per local hospital guidelines for optimal management of complex upper limb cases with skin involvement, the protocol required interdisciplinary team consult between the orthopaedic and plastics team. Following prompt assessments by the on-call consultant anaesthetist and plastic surgeon, the decision to perform fasciotomies in the forearm and hand with/without excision of necrotic muscles, depending on the operative findings, was made. This decision was made based on the presentation and the clinical examination as well as the rapid deterioration; compartment measurements were not undertaken as the erythema in the skin and the discharging blisters were considered infected, and were compromising the recommended entry sites for pressure measurements.

Treatment

The response from all medical colleagues and the theatre staff was rapid and within 2 hours from the time the patient was initially presented to the orthopaedic department, fasciotomies were performed; one extensive along the anterior part of the forearm including release of the carpal tunnel and the canal of Guyon, one over the posterior forearm, one along the radial side of the thenar eminence, and two over the dorsal side of the hand, over the 2/3 and 4/5 metacarpal intervals (figure 3). It was striking that all muscle groups, particularly the forearm flexors and the thenar muscles bulged and grossly protruded following the fasciotomies, confirming the diagnosis of compartment syndrome. There was also significant bulging of the median nerve and even more of the ulnar nerve following the release of the carpal tunnel and the canal of Guyon.

No tourniquet was used and the blood loss was minimal.

There was no evidence of muscle necrosis, and therefore no need for any muscle excision. Multiple subcutaneous and deep muscle culture swabs were taken (six), of which one sample showed skin flora and the rest showed no significant growth. The wounds were left open and dressed with bulky non-adhesive dressings.

The patient recovered uneventfully and his pain significantly reduced immediately postoperatively.

The wounds were inspected a week later (figure 4) (figure 5) and cover with partial-thickness skin grafting from the left thigh was performed for the extensive wound in the volar aspect of the forearm(figure 6) . All other wounds were sutured without tension (Figure 7). Subsequent wound inspections showed satisfactory progress of healing and graft incorporation.

Outcome and follow-up

The patient was subsequently discharged home at 3 weeks postoperatively.

At 4 weeks post fasciotomy, the patient reported reduced, although improving, sensation in the left hand affecting all fingers and the thumb. He can oppose and flex his thumb, but he was not able to make a fist yet.

Three months down the line, the patient was reviewed to see how he is progressing in the community (figure 8) (figure 9). The patient reported marked improvement in his left hand function and participation in activities of daily living; he reported minimal pain and was able to extend his fingers passively. He was undergoing physiotherapy but unfortunately did not complete the course due to the COVID-19 pandemic. The patient continues with hand therapy and follow-up appointments by the plastic surgeons.