CURRENT CONCEPTS

Compartment Syndrome of the Forearm: A

Systematic Review
Bharati S. Kalyani, MD, Brent E. Fisher, MD, Craig S. Roberts, MD, Peter V. Giannoudis, MD

In this systematic review, we examined the available evidence regarding compartment

syndrome of the forearm. Applying our inclusion criteria, we found 12 articles for a total of
84 cases using the MEDLINE (Ovid) database. All were retrospective studies (level IV
evidence). In this study, papers were analyzed for causes, diagnosis, treatment, methods of
wound closure, functional outcome, and complications. The most common cause of com-
partment syndrome of the forearm in children was a supracondylar fracture, while in adults
the most common cause was a fracture of the distal radius. The diagnostic criterion used was
clinical assessment alone in 48%, and in 52%, a combination of measurement of intracom-
partmental pressure and clinical assessment was used. The intracompartmental pressure was
measured using various techniques including a wick catheter, slit catheter, the Whitesides
technique, and the Stryker compartment pressure measuring device. Fasciotomy was the
preferred method of treatment (73%). In cases reporting wound management, postfasciotomy
skin grafting was needed in 61% of the cases, whereas secondary closure was performed in
39% of the cases. Neurological deficit was the most common complication (21%). (J Hand
Surg 2011;36A:535–543. © 2011 Published by Elsevier Inc. on behalf of the American
Society for Surgery of the Hand.)
Key words Compartment syndrome, forearm, fasciotomy, skin grafting.

HE TRUE INCIDENCE of forearm compartment study was to systematically review the current evidence

T syndrome is difficult to determine, but fractures

of the forearm and the distal radius are certainly
associated with forearm compartment syndromes.1–3
regarding forearm compartment syndrome.

MATERIALS AND METHODS

Elliott and Johnstone4 reported that 23% of forearm
This was an institutional review board– exempt inves-
compartment syndromes were caused by soft tissue
tigation, which was performed at a level 1 trauma
injuries not involving fractures, and 18% were caused
center using a MEDLINE (Ovid) database search. Us-
by fractures.
ing the advanced search engine, the key word terms
To our knowledge, there is limited available evi-
used were “compartment syndrome” and “forearm.”
dence regarding the causes, treatment, methods of
The terms were mapped to “forearm” and “compart-
wound closure, functional outcome, and complications
ment syndromes,” yielding 190 articles. A total of 155
of forearm compartment syndrome. The purpose of this
articles remained after limiting for the English language
FromtheDepartmentofOrthopaedicSurgery,UniversityofLouisville,Louisville,KY;andtheAcademic and human subjects.
Department of Trauma and Orthopaedics, University of Leeds, Leeds, UK. The inclusion criteria were original articles that re-
Received for publication May 10, 2010; accepted in revised form December 4, 2010. ported 2 or more acute cases of forearm compartment
Current Concepts

Institutional support was provided by Synthes to BSK, BEF, and CSR.
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.
Corresponding author: Craig S. Roberts, MD, Department of Orthopaedic Surgery, University of
Louisville,210E.GrayStreet,Suite1003,Louisville,KY40202;e-mail:craig.roberts@louisville.edu.
0363-5023/11/36A03-0032$36.00/0
doi:10.1016/j.jhsa.2010.12.007
syndrome. We analyzed the articles that met our criteria
based on the following categories: etiologies, diagnosis,
treatment, methods of fasciotomy wound closure, out-
come, and complications.
Single case reports, articles not written in the English
language, and articles based on exercise-induced com-
partment syndrome were excluded. We included in our

©  Published by Elsevier, Inc. on behalf of the ASSH. 䉬 535

 536 COMPARTMENT SYNDROME OF THE FOREARM

study articles involving forearm compartment syn- ment syndrome due to radial head or neck fracture in
drome in neonates as well as compartment syndrome children. Iatrogenic causes included osteotomies of the
associated with vascular injury. radius and/or ulna.6

RESULTS
Of the 155 articles initially screened, only 12 met our
criteria, yielding 84 cases.5–16 Patients ranged in age from
newborn to 67 years. Of the 35 patients whose gender was
reported, 27 were male and 8 were female (Table 1).
Etiology
The 12 articles included discussed the etiology of com-
partment syndromes (Table 2).5–16 A total of 26 cases
were attributed to fractures and 4 were bilateral.6 – 8,14,16
Seven cases of neonatal forearm compartment syn-
drome were reported.5,9 Penetrating trauma (7 gunshot
wounds and 6 stab wounds) accounted for 15.4% of
injuries.6,8,10,11 Eight cases were associated with fore-
arm compression due to drug abuse, 7 with crush inju-
ries, 7 with intravenous infiltration, and 5 with snake-
bites.6 – 8,11,13,15 Other etiologies included tourniquet
use, hemophilia, phlebitis, burns, and postsurgical is-
sues.6,8 Arterial injury occurred in approximately
10.7% of cases.6,8,10
Compartment syndrome resulting from fractures oc-
curred most often in closed fractures. The most common
cause of compartment syndrome in adults was a fracture of
the distal radius, whereas in children the most common
cause was a supracondylar fracture of the humerus (Table
3).6,14,16 Peters and Scott12 reported 3 cases of compart-
Diagnosis
All 12 articles in this study used physical examination
findings as criteria for diagnosis and 6 articles described
pressure measurements for diagnosis and decision mak-
ing regarding fasciotomy (Table 4).5–16 To be included
in the studies by Gelberman et al8 and Mubarak et al,11
patients were required to have undergone intracompart-
mental pressure measurement.
Gelberman et al,8 in a study of 26 cases, noted
diminished sensibility by 2-point discrimination to be a
consistent and reliable finding. Eaton and Green6 also
noticed glove anesthesia in 9 of 19 patients. The most
reliable finding was sensory deficit.6 – 8,11,12,16
Gelberman et al8 measured both volar and dorsal com-
partmental pressure using a wick catheter. The range of
pressure increase was from 35 to 95 mm Hg in the volar
compartment and from 20 to 70 mm Hg in the dorsal
compartment.
Treatment
All 12 articles with 84 patients described the treatment
of forearm compartment syndrome (Tables 5, 6). The
time interval between injury and treatment ranged from
3 hours to 16 weeks.6,8,11–13,16 A total of 61 of the 84
patients were treated surgically.5–16 Of the 59 patients
treated with fasciotomy, 57 incisions were described,

TABLE 1. Demographics
Author Patients (n) Extremities (n) Male Female Age Study Type

Caouette-Laberge et al5 5 5 3 2 NA Case report

6
Eaton and Green 19 19 NA NA 3–53 Case series
Geary7 2 3 1 1 42–62 Case report
8
Gelberman et al 26 26 NA NA NA Case series
Kline and Moore9 2 2 2 NA Case report
Morin et al10 5 5 5 23–39 Retrospective case report
Mubarak et al11 4 4 2 2 20–51 Cohort
12
Peters and Scott 3 3 1 2 6–8 Case report
Current Concepts

Seiler et al13 2 2 2 46–57 Case report

14
Simpson and Jupiter 5 8 4 1 23–45 Retrospective case series
Sneyd et al15 2 2 2 63–67 Case report
16
Stockley et al 5 5 5 15–49 Case report
Total 80 84 27 8 Birth through 67
Percentage 77% 23%

NA, information not available.

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 COMPARTMENT SYNDROME OF THE FOREARM
and the modified anterior approach of Henry was most
commonly used.6 –9,11–16
Overall, in 45 patients, a compartment release was
done using a volar incision, in 1 patient with a dorsal
incision, and in 11 both volar and dorsal compartment
releases were performed.5–16 In 4 patients either the
fasciotomy was not discussed or the patients had an-
other procedure.5,8 A carpal tunnel release was per-
formed at the time of volar compartment decompres-
sion in 30 cases. Gelberman et al8 described release of
lacertus fibrosis, pronator teres, and flexor digitorum
superficialis, although the number of patients receiving
this treatment was not specified. Eaton and Green6
performed arterial surgery in 8 patients. Simpson and
Jupiter14 performed release of the ulnar nerve and artery
in Guyon’s canal in 1 patient.
A total of 23 patients were treated nonsurgically
(Table 5).5,6,8,9,11,15 Gelberman et al8 elected not
to perform fasciotomy on 14 patients because the
pressure in both volar and dorsal compartments
was less than 30 mm Hg. Kline and Moore9 re-
ported a case of a neonate who was evaluated
several hours after delivery for full-thickness skin
loss with peripheral healing and flexion contrac-
ture of the wrist and fingers. The neonate was
treated without a fasciotomy because it had ade-
quate circulation to the hand. The authors reported
that nerve function gradually improved and the
flexion contracture resolved with passive stretch-
ing. Eaton and Green6 used a stellate ganglion
block for 3 patients and found that none of the
patients were improved by this procedure. Sneyd et
al15 managed 1 patient by limb elevation to 45°.
Mubarak et al11 elected not to treat one patient
with burns covering over 95% of the body; the
patient subsequently died 12 hours after injury.
Fasciotomy wound management
Seven articles described fasciotomy wound man-
agement in 30 patients with 34 injuries (Table
7).7,8,11–14,16 In 13 patients the wound was man-
aged by secondary closure, and 20 patients re-
quired skin grafting.7,8,11–14,16
COMPLICATIONS
Seven articles described complications in 18 of 43
extremities, for those 7 studies (Table 8).5–9,11,16 Vari-
ous contractures were reported in 4 cases and neuro-
logical deficits in 9.6 –9 Eaton and Green6 reported gan-
grene of the fingers in 1 case. Stockley et al16 reported
chronic regional pain syndrome in 1 of 5 patients in
JHS 䉬 Vol A, March 
537
their study. Mubarak et al11 reported 1 complication of
Volkmann’s ischemic contracture in a patient with drug
overdose–related limb compression who sought medi-
cal assistance more than a day and a half after injury.
Geary7 reported an adduction deformity of the thumb
owing to contracture of the first interosseous muscle
and variable loss of all sensation in the fingers. Eaton
and Green6 reported a wrist contracture in 1 patient, and
1 patient who developed progressive gangrene of the
fingers subsequent to segmental resection of the bra-
chial artery.
Outcome
Only Eaton and Green6 provided a method to stratify
the results for treatment of forearm compartment syn-
drome. In patients treated with a fasciotomy, excellent
results were reported in 12, fair results in 1, and poor
results in 3. The authors noted poor results (Volk-
mann’s ischemic contracture) within 4 months of onset
in the 3 patients who did not have fasciotomies, despite
dynamic splinting and surgery.
DISCUSSION
Forearm compartment syndrome has been associated
with several etiologies, one of the most common causes
of which is fracture. Distal radius fractures were the
most prevalent cause of forearm compartment syn-
drome in the articles we reviewed, accounting for
37.5% of fractures associated with compartment syn-
dromes of the forearm and 14.3% of overall causes.
McQueen et al3 reported similar numbers in a study of
164 cases of acute compartment syndrome covering all
extremities.
Supracondylar fractures caused 8 of the 12 pediatric
cases, in line with classical data.1,17 It appears, how-
ever, that supracondylar fractures might not be the
predominant. Cause of forearm compartment syndrome
in children, as they were in the past.2,18 Grottkau et al,2
in a study of the National Pediatric Trauma Registry,
assessed 131 pediatric cases of compartment syndrome
and noted that 74% of upper extremity fracture cases
were of the forearm, and only 15% were due to supra-
condylar fractures. Bae et al18 studied 33 consecutive
Current Concepts
pediatric patients with 36 cases of acute compartment
syndrome. They reported 18 upper extremity cases with
10 cases after fracture; however, only 2 resulted from
supracondylar fractures. Bae et al.18 suggested that a
possible reason for this decrease in supracondylar frac-
ture-related compartment syndrome was changes in the
fracture management, with the wide acceptance of per-
cutaneous pin fixation and cast immobilization with the
elbow at no greater than 90° of flexion. A cause of
 538 COMPARTMENT SYNDROME OF THE FOREARM

TABLE 2. Primary Mechanism of Injury

Extremities
Author Patients (n) (n) Bilateral Crush Injury Fracture Tourniquet Stab Wound

Caouette-Laberge et al5 5 5
6
Eaton and Green * 19 19 8 1 3
Geary7 2 3 1
Gelberman et al8† 26 26 7 2 2
Kline and Moore9 2 2
Morin et al10‡ 5 5 1
Mubarak et al11 4 4
Peters and Scott12 3 3 3
Seiler et al13 2 2
Simpson and Jupiter14 5 8 3 8
Sneyd et al15 2 2
Stockley et al16 5 5 5
Total 80 84 4 7 26 1 6
Percentage 4.8 8.3 31.0 1.2 7.1

There might be more than 1 associated possible cause of development of compartment syndrome.
GSW, gunshot wound.
*Three were not mentioned, 1 owing to arterial injury.
†Two other fractures were associated with crush injuries.
‡Two fractures were related to gunshot wounds.

TABLE 3. Fracture Breakdown

Author Patients (n) Extremities (n) Adult Pediatric
6
Eaton and Green * 8 8 8
8
Gelberman et al † 4 4 4
Morin et al10‡ 2 2 2
Peters and Scott12 3 3 3
Simpson and Jupiter14 5 8 5
Stockley et al16 5 5 4 1
Total 27 30 15 12
Percentage 55.6 44.4
% Overall cases

Only surgical patients were reported.

*Two radioulnar injuries were associated with supracondylar fractures.
†Of the 14 surgical patients, 2 were not included in analysis owing to third-degree burns that influenced outcomes.
‡Two fractures were associated with gunshot wounds.
Current Concepts

forearm compartment syndrome rarely discussed is
neuroleptic malignant syndrome.19
Patients younger than 35 years of age and involved
in high-energy injuries and polytrauma are at higher
risk for developing a forearm compartment syn-
drome.2,3,14,15 In addition, Hwang et al20 noted that
patients sustaining a distal radius fracture with concom-
itant ipsilateral elbow injury developed compartment
syndrome 15% of the time, well above the 0.25% risk
of compartment syndrome development after a distal
radius fracture alone.
Compartment syndrome is generally diagnosed by
clinical examination based on a keen index of suspi-
cion, but it can be supplemented by additional testing.
Removal of any constrictive dressings is a critical step
to allow for accurate assessment of the limb.21 Regard-

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 COMPARTMENT SYNDROME OF THE FOREARM 539

TABLE 2. Continued
Gunshot Narcotic IV Arterial
Wound Overdose Hemophilia Snakebite Phlebitis Infiltration Burns Neonatal Postsurgery Unspecified Injury

5
2 1 4 3
3
2 3 1 5 1 1 2 1
2
4 5
1 2 1

7 8 1 5 1 7 3 7 1 4 9
8.3 9.5 1.2 6.0 1.2 8.3 3.6 8.3 1.2 4.8 10.7

TABLE 3. Continued
Supracondylar Not
Fractures (n) Fracture Proximal Radius Radius-Ulna Radial Shaft Distal Radius Specified

10 8 2
4 3 1
2 2
3 3
8 8
5 1 4
32 8 3 6 2 12 1
25.0 9.4 18.8 6.2 37.5 3.1
9.5 3.6 7.1 2.4 14.3 1.2

Current Concepts

ing the use of compartment pressures, there was nearly
an equal distribution between the number of patients
diagnosed by clinical examination and those supple-
mented by intracompartmental pressures.5–16 Although
many authors considered intracompartmental pressures
unnecessary for diagnosis, many recommend its use in
obtunded patients, polytrauma, and patients with equiv-
ocal clinical findings.8,15
Various skin incisions were used for volar compart-
ment forearm fasciotomy. The typical volar incision
begins 1 cm proximal and 2 cm lateral to the medial
epicondyle and crosses obliquely across the antecubital
fossa and over the volar aspect of the mobile wad.8,12
The incision curves in a medial direction, reaching the
midline at the junction of the middle and distal third of
the forearm. The incision is continued just ulnar to the
palmaris longus tendon to avoid the palmar cutaneous
branch of the median nerve. The incision crosses the

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 540 COMPARTMENT SYNDROME OF THE FOREARM

TABLE 4. Method of Diagnosis

Clinical Plus
Author Patients (n) Extremities (n) Clinical Findings Intracompartmental Pressure Technique

Caouette-Laberge et al5 5 5 5
6
Eaton and Green 19 19 19
Geary7 2 3 3
8
Gelberman et al 26 26 26 Wick
Kline and Moore9 2 2 2
Morin et al10 5 5 5 Stryker
11
Mubarak et al 4 4 4 Wick
12
Peters and Scott 3 3 1 2 Slit
Seiler et al13 2 2 1 1 Whitesides
14
Simpson and Jupiter 5 8 2 6 Stryker
Sneyd et al15 2 2 2
Stockley et al16 5 5 5
Total 80 84 40 44
Percentage 47.6 52.4

TABLE 5. Method of Treatment

Patients Extremities
Author (n) (n) Surgical Nonsurgical
5
Caouette-Laberge et al 5 5 2 3
6
Eaton and Green 19 19 16 3
Geary7 2 3 3
Gelberman et al8 26 26 12 14
Kline and Moore9 2 2 1 1
10
Morin et al 5 5 5
Mubarak et al11 4 4 3 1
12
Peters and Scott 3 3 3
Seiler et al13 2 2 2
14
Simpson and Jupiter 5 8 8
Sneyd et al15 2 2 1 1
16
Stockley et al 5 5 5
Total 80 84 61 23
Percentage 73 27
Current Concepts

wrist crease at an angle and extends into the midpalm
for concomitant carpal tunnel release. Other, less com-
mon incisions are the volar ulnar incision that starts radial
to the flexor carpi ulnaris and extends to the medial epi-
condyle of the humerus, and the zigzag incision.22,23
When there is a forearm compartment involving both
the volar and the dorsal compartments, it is preferable
first to release the volar compartment. Volar compart-
ment release often decompresses the dorsal compart-
ment.23 Therefore, a compartment pressure measuring
device should be available to allow dorsal compartment
pressure measurement after volar fasciotomy. If there is
no improvement in pressure measurement, dorsal fas-
ciotomy is necessary.
We found the overall complication rate of forearm
compartment syndrome to be 42%, with studies reporting
neurological deficits as the most common complication.
Earlier decompression will minimize these sequelae.

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 TABLE 6. Method of Decompression
Carpal Lacertus
Surgical Volar Dorsal Combined Volar/ Not Specified/ Tunnel Fibrosis Arterial
Author Patients (n) Extremities (n) Treatment Incision Incision Dorsal Incision No Fasciotomy Release Release Surgery

Caouette-Laberge et al5 5 5 2 2

COMPARTMENT SYNDROME OF THE FOREARM

Eaton and Green6 19 19 16 16 8
7
Geary 2 3 3 3 3 3
JHS 䉬 Vol A, March 

Gelberman et al8* 26 26 12 7 1 2 2 10 10
Kline and Moore9 2 2 1 1 1
Morin et al10 5 5 5 2 3
Mubarak et al11 4 4 3 2 1
Peters and Scott12 3 3 3 3 3 3
13
Seiler et al 2 2 2 2
Simpson and Jupiter14 5 8 8 7 1 8
15
Sneyd et al 2 2 1 1
Stockley et al16 5 5 5 5 5
Total 80 84 61 45 1 11 4 30 16 8
Percentage, surgical 74 2 18 7 49 26 13
patients

*Two surgical patients were not discussed because third-degree burns affected the outcome.

541
Current Concepts
 542 COMPARTMENT SYNDROME OF THE FOREARM

TABLE 7. Fasciotomy Wound Management

Patients—Surgical Extremities Postfasciotomy
Author Management (n) (n) Delayed Primary Closure Skin Grafting

Geary7 2 3 1 2
8
Gelberman et al 10 10 3 6
Mubarak et al16 3 3 2 1
Peters and Scott17 3 3 1 2
Seiler et al20 2 2 1 1
21
Simpson and Jupiter 5 8 5 3
23
Stockley et al 5 5 5
Total 30 34 13 20
Percentage 39 61

Caouette-Laberge et al5 performed debridements, not fasciotomies (2 patients). Eaton and Green,6 Morin et al,10 and Sneyd et al15 did not mention
management of wound (22 patients). Gelberman et al8 discussed only 9 of 12 fasciotomies and 9 of 10 cases mentioned in the study.

TABLE 8. Complications
Volkmann’s
Patients Extremities Neurological Ischemic Crush Sudeck’s
Author (n) (n) Contracture Deficit Gangrene Contracture Syndrome Algodystrophy

Caouette-Laberge 5 5
et al5
Eaton and Green6 19 19 1 1
Geary7 2 3 1 1
Gelberman et al8* 10 10 8 2
Kline and Moore9 2 2 2
Mubarak et al11 4 4 1
Stockley et al16 5 5 1
Total 42 43 4 9 1 1 2 1
Studies reporting 9.3 20.9 2.3 2.3 4.7 2.3
complications
(%)

*Only complications for surgical patients were recorded.

The strengths of our study include the number
and diversity of the cases analyzed. Weaknesses
were that all of the studies were retrospective case
series or case reports (level IV evidence), and
Current Concepts
and vigilance in diagnosis is mandatory. Patients under
35 years of age with forearm fractures and polytrauma
are at high risk for forearm compartment syndrome and
require careful monitoring. In obtunded patients and

several studies are greater than 20 years old. This
highlights the need for a prospective, multicenter
study regarding the treatment and outcome of fore-
arm compartment syndrome.
Acute compartment syndrome of the forearm has
multiple etiologies affecting patients of all ages. If un-
treated, it will result in contractures, neurological defi-
cits, and complete loss of forearm and hand function.
Emergent treatment is necessary to prevent sequelae
those with equivocal physical examination findings,
objective diagnostic measurements are beneficial. The
diagnosis of forearm compartment syndrome requires
immediate fasciotomy. The most common surgical ap-
proach is a volar curvilinear incision that often decom-
presses the dorsal compartment. After fasciotomy, re-
peat debridement of any nonviable tissue may be
required and secondary procedures are necessary for
wound closure.

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 COMPARTMENT SYNDROME OF THE FOREARM
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Current Concepts