17 Limb-Threatening Emergencies


17 Limb-Threatening Emergencies

Dariush Nikkhah, Wojtech Konczalik

17.1 Fasciotomy for Acute Compartment Syndrome

Compartment syndrome is an emergency that if not dealt in time can lead to limb dysfunction and loss. The surgeon should be guided clinically and should not waste time on investigations particularly when signs of compartment syndrome are present. The warm ischemia time for muscle is 6 hours and therefore emergent forearm fasciotomy should be rapidly performed.

The limb in these patients is often tense; there is severe unrelenting pain which cannot be controlled with opiates. Pain is worsened by passive extension. Late signs include diminished pulses.

Surgery involves a long curvilinear incision over the flexor forearm and a straight line incision over dorsal extensor compartment. The carpal tunnel is first released, a U-shaped flap is placed over the wrist and this is to protect the median nerve from exposure. The incision should release the deep and superficial compartments of the arm. The flexor pollicis longus (FPL) compartment is often the most affected. The mobile wad (brachioradialis, extensor carpi radialis brevis [ECRB], and extensor carpi radialis longus [ECRL]) should also be released. Once the patient is stabilized, the wound can be skin grafted with vacuum-assisted closure (VAC). If caught in time, patients can make a full recovery with good long-term outcome (Fig. 17‑1, Fig. 17‑2, Fig. 17‑3).

Fig. 17.1 (a,b) Volar and dorsal markings for forearm compartment release.
Fig. 17.2 (a–d) Forearm fasciotomies, releasing three compartments in forearm and dorsal compartment with final result and limb salvage in 3 months.
Fig. 17.3 (a,b) Preoperative markings for forearm and upper arm fasciotomies in a patient who had sustained multiple shotgun blast injuries. (c,d) After forearm and upper arm fasciotomy release.

17.2 Hand Compartment Release

This may be necessary in severe crush injuries to the hand: high-pressure injection injuries, reperfusion injuries after replantation, and in circumferential hand burns. The hand has 10 compartments in total and all must be released to prevent muscle necrosis.

The compartments include hypothenar, thenar, adductor pollicis, the four dorsal interosseous muscles, and three volar interosseous muscles. The carpal tunnel must also be released (Fig. 17‑4, Fig. 17‑5, Fig. 17‑6, Fig. 17‑7, Fig. 17‑8, Fig. 17‑9).

Fig. 17.4 (a,b) Preoperative markings for hand compartment release in patient with crush injury.
Fig. 17.5 Carpal tunnel release, median nerve contused. Distal extent marked by Kaplan’s line and identified by superficial palmar fat pad.
Fig. 17.6 Releasing dorsal and volar interossei through dorsal incisions. Make sure incisions are orientated away from extensors to prevent their exposure.
Fig. 17.7 Two longitudinal incisions over the second and fourth metacarpal to release volar/dorsal interossei and adductor compartments.
Fig. 17.8 Release hypothenar compartment via incision over ulnar aspect of the fifth metacarpal.
Fig. 17.9 Longitudinal incision over radial aspect of the first metacarpal to decompress thenar compartment.

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May 21, 2020 | Posted by in Hand surgery | Comments Off on 17 Limb-Threatening Emergencies
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