A cute and chronic exertional (nontraumatic) compartment syndromes are well-documented in the lower leg. We present a case of acute exertional compartment syndrome of the forearm in a teenager. Decompressive fasciotomy was performed, resulting in full preservation of upper extremity function. We highlight the features of her management and present a literature review of this rare clinical entity.
CASE REPORTA 19-year-old, right hand dominant woman presented to the emergency department in the early morning, complaining of pain and swelling of the right wrist and forearm which had begun the previous night, 9 hours earlier. She was newly employed as a cake decorator, and had been decorating a cake for one and one half hours. She recalled applying substantial, prolonged pressure using her right hand to squeeze icing out of a decorating bag. After completing this activity, she felt pain over her right wrist and forearm, which progressed gradually throughout the evening and night, finally awakening her from sleep. Over-the-counter analgesics did not relieve her pain. On examination in the emergency department, there was marked swelling over her proximal right forearm and tightness to palpation of the dorsal and volar forearm compartments and the mobile wad (Fig. 1A). Pain was elicited on passive extension of the right wrist and fingers. Her two-point discrimination was 4 mm or less in all the digits. Radial and ulnar pulses were palpable at the wrist, and there was brisk capillary refill in all fingertips. Radiographs of the right wrist and forearm did not demonstrate any bony abnormalities.Compartment pressures were measured using a handheld pressure monitoring system (Stryker Instruments, Kalamazoo, Mich.). Volar and dorsal compartment pressures were found to be 22 mm Hg and 35 mm Hg, respectively. Complete blood count and electrolytes were normal, but her serum creatinine kinase was elevated at 15,500 IU/L (normal Ͻ180). Decompressive forearm fasciotomy was scheduled emergently.The compartment pressures were checked again intraoperatively using an arterial line set-up, and were found to have risen to 41 mm Hg in the volar and 43 mm Hg in the dorsal forearm compartments. Surgical decompression of the volar compartment was performed through a standard incision on the volar forearm. Healthy-appearing muscles of the volar forearm ballooned out through the fasciotomy incision (Fig. 1B). The forearm fascia was released completely up to the carpal tunnel. After release, volar forearm pressures decreased to 4 mm Hg. We considered surgical release of the carpal tunnel at that time, as this maneuver is a valid and logical thought while performing volar forearm release in most instances. In our case, however, the carpal tunnel did not seem to be involved, as it did not appear to be tight upon probing with the insertion of an instrument, and thus it was not released. Pressure in the mobile wad compartment decreased after volar compartment release, but remained elevated at 25 mm Hg. Therefore, decompressive fasciotomy of the do...