e63(1)

C OPYRIGHT Ó 2012 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Acute Compartment Syndrome of the Forearm

Andrew D. Duckworth, MSc, MRCSEd, Sarah E. Mitchell, MRCSEd, Samuel G. Molyneux, MSc, MRCSEd,
Timothy O. White, MD, FRCSEd(Tr&Orth), Charles M. Court-Brown, MD, FRCSEd(Orth),
and Margaret M. McQueen, MD, FRCSEd(Orth)

Investigation performed at the Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

Background: The aims of this study were to document our experience with acute forearm compartment syndrome and
to determine the risk factors for the need for split-thickness skin-grafting and the development of complications after
fasciotomy.
Methods: We identified from our trauma database all patients who underwent fasciotomy for an acute forearm com-
partment syndrome over a twenty-two-year period. Diagnosis was made with use of clinical signs in all patients, with
compartment pressure monitoring used as a diagnostic adjunct in some patients. Outcome measures were the use of
split-thickness skin grafts and the identification of complications following forearm fasciotomy.
Results: There were ninety patients in the study cohort, with a mean age of thirty-three years (range, thirteen to eighty-one
years) and a significant male predominance (eighty-two patients; p < 0.001). A fracture of the radius or ulna, or both, was
seen in sixty-two patients (69%), with soft-tissue injuries as the causative factor in twenty-eight (31%). The median time to
fasciotomy was twelve hours (range, two to seventy-two hours). Risk factors for requiring split-thickness skin-grafting were
younger age and a crush injury (p < 0.05 for both). Risk factors for the development of complications were a delay in
fasciotomy of more than six hours (p = 0.018) and preoperative motor symptoms, which approached significance (p =
0.068).
Conclusions: Forearm compartment syndrome requiring fasciotomy predominantly affects males and can occur following
either a fracture or soft-tissue injury. Age is an important predictor of undergoing split-thickness skin-grafting for wound
closure. Complications occur in a third of patients and are associated with an increasing time from injury to fasciotomy.
Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A
lthough the forearm is the site most frequently affected
by compartment syndrome in the upper limb1-3, the low
prevalence of forearm compartment syndrome makes
it difficult to draw meaningful conclusions regarding etiology,
optimal management, and outcome. The most common cause
of forearm compartment syndrome in adults reported in the
literature is a fracture of the distal end of the radius, although
a substantial number of cases are associated with soft-tissue in-
juries1,4. Diagnosis often combines clinical signs with compart-
ment pressure monitoring of the flexor forearm compartment1,2,4.
Standard treatment includes early fasciotomy of the volar com-
partment, with concomitant decompression of the dorsal com-
partment and carpal tunnel as indicated2,5.
There is substantial morbidity associated with forearm
compartment syndrome and subsequent fasciotomy6, with
one recent systematic review noting a split-thickness skin-
grafting rate of 61% and a complication rate of 42%4. Split-
thickness skin-grafting of the forearm has notable cosmetic
consequences for the patient6. Complications of forearm
compartment syndrome include forearm contracture, loss
of function, neurological deficits, delayed fracture union, and
chronic pain2,4,7,8.
The aim of this study was to document the etiology, man-
agement, and outcome of acute forearm compartment syndrome
treated with fasciotomy. We also aimed to determine the risk
factors associated with the need for split-thickness skin-grafting

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this
work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what
is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the
article.

J Bone Joint Surg Am. 2012;94:e63(1-6) d http://dx.doi.org/10.2106/JBJS.K.00837

 e63(2)
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
A C U T E C O M PA R T M E N T S Y N D R O M E OF THE FOREARM
V O L U M E 94-A N U M B E R 10 M AY 16, 2 012
d d

for wound closure after fasciotomy, as well as the predictors as-

sociated with the development of complications. TABLE I Mechanism of Injury, Fracture Pattern, Signs, and
Compartments Released for All Ninety Patients
Diagnosed with Acute Compartment Syndrome
Materials and Methods
Demographic Characteristic No (%) of Patients
F rom our trauma database, we identified all patients who were thirteen years or
older with forearm fasciotomy over a twenty-two-year period from May 1988
to June 2010. This was classified as an audit under regional guidelines and did not Mechanism of injury
require formal ethical board approval. Patients with a forearm fasciotomy for an Motor vehicle collision 24 (27)
acute compartment syndrome and patients with an associated crush syndrome Fall from a height 13 (14)
were included. Patients who were seen with a missed or chronic compartment Sport 11 (12)
syndrome were excluded, as were patients who developed acute compartment Crush syndrome 9 (10)
syndrome after a primary vascular occlusion. With use of these criteria, 110
Crush injury 9 (10)
patients were identified. One patient had a concomitant compartment syndrome
of the hand involving the interosseous compartments. All other patients had a Fall from a standing position 7 (8)
compartment syndrome of only the forearm compartment. Injection 6 (7)
Sufficient follow-up was defined as documentation in the medical Warfarin-related hematoma 5 (6)
records of a review at a minimum of three months after the fasciotomy to detect Stab wound in forearm 2 (2)
complications. Of the original 110 patients identified, twenty patients were Other 4 (4)
excluded because of inadequate data and/or follow-up, leaving ninety patients
(82%) who made up our study cohort for analysis. Of the twenty patients ex- Fracture
cluded, thirteen had inadequate follow-up, four lived outside our local catchment Distal end of the radius 31 (34)
area and had inadequate data, and three died while in the hospital. No difference Both bones in forearm (diaphyseal) 27 (30)
was detected between patients included in the cohort and the excluded group with Single bone—radius or ulna 4 (4)
regard to age (p = 0.06), sex (p = 0.66), or the number of those in whom the No fracture 28 (31)
syndrome was associated with a fracture (p = 0.08), with open injuries (p = 0.35),
or with the use of warfarin (p = 1.0). Fewer high-energy injuries were seen in the Signs
excluded cohort (p = 0.03). Swelling 90 (100)
We retrospectively reviewed medical records and recorded demographic Pain (pain out of proportion or pain 71 (79)
data, including age, sex, and mechanism of injury. Crush injuries were cate- on passive stretch)
gorized as either a crush syndrome with a prolonged ischemic time and an Sensory abnormality 47 (52)
elevated serum creatinine kinase level or a high-energy crush injury of the Motor abnormality 8 (9)
forearm. High-energy injuries included a fall from a height, a motor vehicle
collision, and a sports or crush injury. Causative fractures were recorded as a Compartments decompressed
fracture of one or both bones in the forearm, with polytrauma defined as two or at fasciotomy
more fractures affecting multiple anatomical sites. The presence of an open Volar and carpal tunnel 37 (41)
fracture was also recorded. Volar only 29 (32)
Volar, dorsal, and carpal tunnel 12 (13)
Diagnosis Volar and dorsal 11 (12)
A clinical diagnosis of compartment syndrome was made if one or more signs Dorsal 1 (1)
8
were objectively present . Signs included pain out of proportion to injury, pain
on passive muscle stretch, excessive swelling, sensory disturbance, or motor
abnormalities. Compartment pressure monitoring was used as a diagnostic biceps tendon to the palm of the hand, with or without decompression of the
adjunct in thirty-one patients (34%). Our method of monitoring used the carpal tunnel as indicated. Carpal tunnel decompression was performed when
continuous indwelling slit catheter (14-gauge, central venous catheter) tech- clinical symptoms and signs indicative of median nerve compression were
nique, with placement in the affected compartment under an aseptic tech- present and/or persistent severe swelling of the distal end of the forearm and
9
nique . The volar compartment was the preferred location for monitoring. In wrist were noted intraoperatively. A fascial incision allowed a thorough in-
the presence of an associated fracture, the tip of the catheter was placed at the spection of the flexor compartment muscles. If this did not provide adequate
2,10
level of the fracture . Once in position, the catheter was flushed with use of decompression, an extensor compartment release was also performed through
normal saline solution and was attached to a blood pressure transducer with use a direct dorsal incision. Inadequate decompression was defined as persistent
9
of standard pressure manometry tubing . A pressure difference (Dp = diastolic swelling in the dorsal compartment despite release of the volar compartment
pressure – intracompartmental pressure) of £30 mm Hg for more than two and/or persistently raised intracompartmental pressures when measured in-
1,2,11
hours was considered diagnostic of a compartment syndrome . traoperatively. Muscle bulge at the time of fasciotomy was used to confirm the
diagnosis. A thorough inspection of all muscle groups was performed, and an
Fasciotomy and Wound Closure: Technique adequate debridement of all devitalized tissue was carried out. Discoloration,
Time to fasciotomy was defined as the time period from admission to surgery. absence of bleeding, and absence of contractility on stimulation were used to
Crush syndrome injuries were not included in these analyses as it is difficult to determine muscle necrosis.
define the onset of the diagnosis in these patients and muscle ischemia is usually Fasciotomy wounds were covered with a sterile dressing, the forearm
established at the time of presentation. A satisfactory cutoff time to fasciotomy was immobilized in a splint in a position of function, and the wound was left
of less than or equal to six hours was chosen because of the evidence in pre- open for forty-eight hours postoperatively. At this point, a second inspection
2,12-14
viously published data on lower limb fasciotomy and outcome . was performed in the operating room to determine the viability of all tissues,
All patients diagnosed as having an acute forearm compartment syn- with a further debridement of nonviable tissues performed as necessary. At-
drome were treated with decompression of the affected forearm compart- tempted direct skin closure was performed if all muscle groups were satisfac-
ment(s). We used a standard technique with an incision extending from the tory, with skin tension on closure avoided. If this was not possible, the patient
 e63(3)
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
A C U T E C O M PA R T M E N T S Y N D R O M E OF THE FOREARM
V O L U M E 94-A N U M B E R 10 M AY 16, 2 012
d d

TABLE II The Demographics and Risk Factors for Patients Categorized by the Use of Skin-Grafting to Close Fasciotomy Wounds

Delayed Closure Skin-Grafting

Total no. (%) of patients 38 (42) 52 (58)

Male patients* 34 (90; 75-96) 48 (92; 81-97)
Age† (yr) 39.0 (14-81; 19.3; 33-45) 28.9 (13-64; 13.7; 25-33)
Fracture* 24 (63; 47-77) 38 (73; 60-83)
Both bones of forearm* 11 (29; 17-45) 16 (31; 20-44)
Open fracture* 2 (5; 5-18) 7 (13; 6.4-26)
Polytrauma* 12 (32; 19-48) 16 (31; 20-44)
Compartments released*
Volar, dorsal, and carpal tunnel 6 (16; 7-31) 6 (12; 5.0-23)
Volar and dorsal 4 (11; 3.5-25) 7 (13; 6.3-26)
Volar and carpal tunnel 16 (42; 28-58) 21 (40; 28-54)
Volar only 11 (29; 17-45) 18 (35; 23-48)
Dorsal only 1 (3; 0-15) 0 (0; 0-8.2)

*The values are given as the number, with the percentage and 95% confidence interval in parentheses. †The values are given as the mean, with
the range, standard deviation, and 95% confidence interval given in parentheses.

underwent split-thickness skin-grafting. The decision regarding delayed wound Results

closure or skin-grafting was determined on an individual patient basis.

Follow-up
Patients returned for follow-up examinations at our institution, which is the
solitary provider of orthopaedic trauma care in the region. The mean follow-up
period was eleven months (range, three to sixty months). Details on wound
closure, complications, and subsequent surgical procedures were recorded at
each visit.
Our main outcome measures were the use of split-thickness skin-
grafting for fasciotomy wound closure and the development of long-term
complications associated with forearm fasciotomy. Complications included the
development of contracture; persistent neurological abnormalities, including
motor and sensory disturbance of the forearm and hand; chronic pain; muscle
2,4,7,8
necrosis; or delayed fracture union . Delayed union was defined as a per-
sistent absence of clinical and radiographic signs of union at the fracture site
three months postoperatively. Radiographic union was defined as the bridging
of three of the four cortices at the fracture site, as determined by anteroposterior
and lateral radiographs. Complications that were associated solely with an
underlying fracture or concomitant injury were excluded.
Statistical Methods
SPSS software (version 17.0; SPSS, Chicago, Illinois) was used for statistical
analysis. Age was normally distributed. Time to fasciotomy had a skewed dis-
tribution. A Student unpaired t test was used to analyze parametric continuous
data, with the Mann-Whitney U test used for nonparametric continuous data.
Categorical binary data were analyzed with use of either the chi-square test or
with the Fisher exact test when the observed frequency of cases in a cell of the
contingency table was less than five. The Spearman correlation was used to
determine the changing rate of complications in relation to time to fasciotomy.
Two-tailed p values were reported, and significance was set at p = 0.05, with
95% confidence intervals (95% CI) presented with use of the modified Wald
method for categorical data.
Source of Funding
No external funding source was received for this study.
T he ninety patients in the study cohort had a mean age of
thirty-three years (range, thirteen to eighty-one years), and
there was a significant male predominance (eighty-two pa-
tients; 91%; 95% CI, 83% to 96%; p < 0.001). The mean age of
the female patients was thirty-nine years (range, twenty-five
to sixty-four years; 95% CI, twenty-seven to fifty-one years),
which was not significantly different (p = 0.309) from the mean
age of the male patients (thirty-three years; range, thirteen to
eight-one years; 95% CI, twenty-nine to thirty-seven years) at
the time of injury.
The most frequently seen mechanism of injury was a
motor vehicle collision, followed by a fall from a height and
sports injuries (Table I). Crush injuries (nine patients) and
crush syndromes (nine patients) each accounted for 10% of
all patients. High-energy injuries were more frequently seen,
accounting for 63% (fifty-seven patients). The mean age of
the patients who sustained a high-energy injury (twenty-
nine years; 95% CI, twenty-five to thirty-three years) was
significantly younger (p < 0.001) than those who sustained a
low-energy injury (forty-one years, 95% CI, thirty-four to
forty-eight years).
A fracture of one or both of the forearm bones had
occurred in sixty-two patients (69%), with soft-tissue in-
juries only in twenty-eight (31%). The mean age of the
patients who sustained a fracture (twenty-nine years; 95%
CI, twenty-six to thirty-two years) was significantly younger
(p < 0.001) than that of the patients who sustained a soft-
tissue injury (forty-four years; 95% CI, thirty-seven to fifty-
one years). An isolated distal radial fracture was the most
frequent fracture (thirty-one patients; 34%), followed by
radial and ulnar diaphyseal fractures (twenty-seven pa-
tients; 30%) (Table I).
 e63(4)
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
A C U T E C O M PA R T M E N T S Y N D R O M E OF THE FOREARM
V O L U M E 94-A N U M B E R 10 M AY 16, 2 012
d d

hours) than in patients with an isolated fracture or soft-tissue

TABLE III The Details of the Twenty-nine Patients Who Had injury (20.2 hours; range, two to seventy-two hours; 95% CI,
Complications After Forearm Fasciotomy
sixteen to twenty-five hours) (p = 0.033). A volar compartment
Complication No (%) of All Patients decompression was performed most frequently (eighty-nine
patients; 99%), with only one patient undergoing an isolated
Neurological deficit 16 (18) dorsal decompression because of a hematoma (Table I). An
Contracture 4 (4) associated carpal tunnel decompression was performed in
Delayed union 4 (4) forty-nine patients (54%).
Muscle necrosis with 3 (3)
associated weakness Split-Thickness Skin-Grafting
Skin graft tethered to tendon, 2 (2) Fifty-two patients (58%) underwent split-thickness skin-grafting
limiting motion to achieve wound closure (Table II). The mean age of those
undergoing grafting was significantly younger than those who
achieved direct closure (p = 0.005). No difference in sex pre-
A diagnosis of compartment syndrome was made with dominance was seen between either group. The mechanism of
use of clinical signs alone in fifty-nine patients (66%). Swelling injury was predictive (p = 0.035), with eight of nine patients
was present in all of our patients. Pain was documented in 79% who sustained crush injuries requiring grafting. None of the
of the patients (Table I) because of a decision made at the time five patients who sustained the injury in relation to warfarin
of definitive fixation to proceed to fasciotomy. Sensory distur- therapy underwent grafting. Fractures, polytrauma, time to
bance was present in 52% of the patients, with motor symptoms fasciotomy, and compartments released had no influence
seen in only 9% of the patients. Compartment pressure moni- on the necessity for split-thickness skin-grafting for wound
toring was used in combination with clinical signs in thirty-one closure.
patients (34%).
The median time to fasciotomy in eighty-one patients Complications
was twelve hours (two to seventy-two hours). The time to Twenty-nine patients (32%) developed complications asso-
fasciotomy was significantly lower in polytrauma patients (13.3 ciated with acute forearm compartment syndrome (Table III).
hours; range, two to forty-six hours; 95% CI, 8.8 to eighteen A neurological deficit was the most common complication

TABLE IV The Demographics and Risk Factors for Patients Categorized by the Development of Complications

No Complications Complications

Total no. (%) of patients 61 (68) 29 (32)

Male patients* 56 (92; 82-97) 26 (90; 73-97)
Age† (yr) 34.1 (13-76; 18.4; 29-39) 31.1 (14-81; 13.4; 26-36)
Fracture* 42 (69; 56-79) 20 (69; 51-83)
Both bones of forearm 17 (28; 18-40) 10 (34; 20-53)
Open fracture 6 (10; 4.2-20) 3 (10; 2.8-27)
Polytrauma 16 (26; 17-39) 12 (41; 25-59)
Prior neurological symptoms*
Sensory 30 (49; 37-61) 17 (59; 41-75)
Motor 3 (5; 1.1-14) 5 (17; 7.1-35)
Compartments released*
Volar, dorsal, and carpal tunnel 8 (13; 6.5-24) 1 (3; 0-19)
Volar and dorsal 7 (11; 5.4-22) 9 (31; 17-49)
Volar and carpal tunnel 26 (43; 31-55) 11 (38; 23-56)
Volar only 20 (33; 22-45) 4 (14; 4.9-31)
Dorsal only 0 (0; 0-7.0) 4 (14; 4.9-31)
Closure*
Delayed closure 27 (44; 33-57) 11 (38; 23-56)
Skin-grafting 34 (56; 43-68) 18 (62; 44-77)

*The values are given as the number, with the percentage and 95% confidence interval in parentheses. †The values are given as the mean, with
the range, standard deviation, and 95% confidence interval given in parentheses.
 e63(5)
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 94-A N U M B E R 10 M AY 16, 2 012
d d
TABLE V The Effect of Time to Fasciotomy on the Development of Complications in Eighty-one Patients
No Complications
Total no. (%) of patients 56 (69)
Time to fasciotomy† (hr) 15.8 (2-72; 14.7; 12-20)
Time to fasciotomy of >6 hr§ 34 (61; 48-72)
*NA = not applicable. †The values are given as the mean, with the range, standard deviation, and 95% confidence interval in parentheses. ‡Mann-
Whitney U test. §The values are given as the number of patients, with the percentage and 95% confidence interval in parentheses.
(sixteen patients; 18%), followed by contracture, delayed frac-
ture union, and muscle necrosis. No association with age, sex,
or mechanism of injury was found (Table IV). The mean time
to fasciotomy was significantly greater in those who sustained
complications (p = 0.044), with patients undergoing fasciot-
omy at greater than six hours after presentation (twenty-two of
twenty-five patients; 88%) significantly more likely to develop
complications (p = 0.018) (Table V). As the time to fasciotomy
increased, the rate of complications increased (r = 0.23, p =
0.044). The presence of impaired neurological motor function
prior to fasciotomy was approaching significance (p = 0.068)
in predicting complications. Fracture, polytrauma, compart-
ments released, and method of wound closure had no influence
on the development of complications.
Discussion
T o our knowledge, this is the largest series in the literature
on acute forearm compartment syndrome, with the eti-
ology, diagnosis, management, and complications reported for
a consecutive group of patients. We observed a complication
rate of 32% and demonstrated that a delay in the time to fas-
ciotomy was predictive of the development of long-term
complications. These findings are analogous with the literature
for lower-limb compartment syndrome that has shown that
time to fasciotomy influences outcome, with the critical time
period ranging from six to twelve hours11,14-17. This emphasizes
the importance of a prompt diagnosis for all patients with a
suspected acute forearm compartment syndrome, with urgent
fasciotomy of all affected compartments.
The diagnosis of forearm compartment syndrome often
requires a combination of clinical signs and compartment
pressure monitoring, with a recent review finding that moni-
toring of the forearm is only used approximately 50% of the
time1,2,4. As would be expected, swelling was noted in all of our
patients. We suggest that this is the only reliable clinical sign,
given that pain was present in only 79% of the patients and
neurological symptoms in even less. Only a third of the patients
in our series underwent diagnostic compartment pressure
monitoring as this became protocol for the latter half of the
study period following new research findings in the unit1. Al-
though rarely seen, positive motor symptoms before fasciot-
omy were approaching significance in terms of determining
complications after surgery, as these have been shown to in-
fluence the outcome in patients with lower-limb compartment
A C U T E C O M PA R T M E N T S Y N D R O M E OF THE FOREARM
Complications P Value*
25 (31) NA
22.2 (4-55; 16.2; 16-29) 0.044‡
22 (88; 69-97) 0.018‡
syndrome17,18. It is intuitive that this would be the case, al-
though there may be difficulty in determining the presence of
such signs in a trauma patient who may have limited motor
function because of pain19.
Given the necessity for a timely diagnosis, combined with
the variable etiology and clinical signs that we have shown to be
associated with the presentation, we recommend compartment
pressure monitoring in all patients with a suspected acute
forearm compartment syndrome. The limited diagnostic value
of clinical signs in the diagnosis of lower-limb compartment
syndrome has a sensitivity ranging from 13% to 19%20. Fur-
thermore, monitoring has been shown to reduce the time
to fasciotomy, and thus subsequent complications, in tibial
fractures15.
A mean age of thirty-three years for our patient cohort
is comparable with that in the literature1,21,22. McQueen et al.
found that patients under the age of thirty-five years with a
distal radial fracture were at a significantly increased risk of
developing compartment syndrome of the forearm compared
with those over thirty-five years1. They also found a male
predominance, as we and others have demonstrated1,4,23. We
found that the most common cause of acute forearm com-
partment syndrome was a fracture of the distal end of the
radius, accounting for a third of all patients1,4,21. However, al-
though compartment syndrome is clinically associated with
fractures, it is important to appreciate that almost a third of the
cases arise in the absence of a forearm fracture4. As with our
series, there can be a disparate selection of causes, including
include crush injuries, crush syndrome, drug overdose, pene-
trating injuries (stab and injection), arterial injuries, and an-
ticoagulation1,7,22,24,25. Acute compartment syndrome in the
absence of fracture has been associated with a delay to diagnosis
and fasciotomy8. Given these variable presentations, a high
index of suspicion is necessary in young male patients with
high-energy forearm injuries, with or without an associated
fracture, as well as in patients with soft-tissue swelling sug-
gestive of forearm compartment syndrome, irrespective of age,
sex, or causality.
There is a noted morbidity attached to forearm com-
partment syndrome and subsequent fasciotomy, with split-
thickness skin-grafting having a notable effect on the cosmetic
and functional outcome for the patient6. Kalyani et al. carried
out a systematic review of the literature on forearm compart-
ment syndrome and found a split-thickness skin-grafting rate
 e63(6)
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O L U M E 94-A N U M B E R 10 M AY 16, 2 012
d d
of 61%, which is comparable with our rate of 58%4. We found
that younger age and mechanism of injury were predictive of
the need for a split-thickness skin graft for wound closure.
Younger age is predictive most likely because of the increased
muscle bulk of the patient, making delayed closure more dif-
ficult to achieve without skin tension. The mechanism of in-
jury, in particular a crush injury, was associated with the need
for split-thickness skin-grafting. When warfarin therapy was
causative, this was predictive of no requirement for the use of
split-thickness skin-grafting. This is presumably because once
fasciotomy, evacuation of clot, and hemostasis are achieved,
delayed closure is possible. Documented complications follow-
ing forearm compartment syndrome include forearm contrac-
tures, muscle necrosis, neurological deficits, fracture nonunion,
and chronic pain2,4,7,8. The rate of complications of 32% in those
studies is marginally less than the rate of 42% found in the
systematic review by Kalyani et al.4. However, neurological
complications were most frequently seen in both the present
study and that by Kalyani et al, which had comparable rates of
18% and 21%, respectively. Four patients in our study had a
delayed fracture union, which occurs also when tibial fractures
are complicated by compartment syndrome26.
We acknowledge that a limitation of our study is the
recognized degree of inaccuracy in determining the exact time
to fasciotomy, although we used an accepted method8. Fur-
thermore, although we identified a clear relationship between
time to fasciotomy and the rate of complications, the as-
References
1. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is
at risk? J Bone Joint Surg Br. 2000;82:200-3.
2. McQueen MM. Acute compartment syndrome. In: Bucholz RW, Court-Brown CM,
Heckman JD, Tornetta P, III, editors. Rockwood and Green’s fractures in adults. 7th
ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010. p 689-709.
3. Botte MJ, Gelberman RH. Acute compartment syndrome of the forearm. Hand
Clin. 1998;14:391-403.
4. Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV. Compartment syndrome of the
forearm: a systematic review. J Hand Surg Am. 2011;36:535-43.
5. Friedrich JB, Shin AY. Management of forearm compartment syndrome. Hand
Clin. 2007;23:245-54, vii.
6. Fitzgerald AM, Gaston P, Wilson Y, Quaba A, McQueen MM. Long-term sequelae
of fasciotomy wounds. Br J Plast Surg. 2000;53:690-3.
7. Eaton RG, Green WT. Volkmann’s ischemia. A volar compartment syndrome of
the forearm. Clin Orthop Relat Res. 1975;113:58-64.
8. Hope MJ, McQueen MM. Acute compartment syndrome in the absence of frac-
ture. J Orthop Trauma. 2004;18:220-4.
9. White TO, Howell GE, Will EM, Court-Brown CM, McQueen MM. Elevated intra-
muscular compartment pressures do not influence outcome after tibial fracture.
J Trauma. 2003;55:1133-8.
10. Heckman MM, Whitesides TE Jr., Grewe SR, Rooks MD. Compartment pressure
in association with closed tibial fractures. The relationship between tissue pressure,
compartment, and the distance from the site of the fracture. J Bone Joint Surg Am.
1994;76:1285-92.
11. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures.
The pressure threshold for decompression. J Bone Joint Surg Br. 1996;78:
99-104.
12. Gelberman RH, Zakaib GS, Mubarak SJ, Hargens AR, Akeson WH. Decom-
pression of forearm compartment syndromes. Clin Orthop Relat Res. 1978;134:
225-9.
A C U T E C O M PA R T M E N T S Y N D R O M E OF THE FOREARM
sumption of less than six hours is based on the limited available
literature2,11-13. We documented risk factors associated with
both skin-grafting and complications; however, with larger
numbers, other variables may have been significant.
In conclusion, acute forearm compartment syndrome
requiring fasciotomy predominantly affects males and can
occur following either a forearm fracture or soft-tissue injury.
We recommend compartment monitoring in all patients with
risk factors and clinical signs suggestive of acute compartment
syndrome. Age and mechanism of injury are important pre-
dictors of the requirement for skin-grafting for wound closure,
which is necessary in almost two-thirds of patients. Compli-
cations occur in a third of patients and are associated with a
delay in the time to fasciotomy. n
NOTE: The authors thank the Scottish Orthopaedic Research Trust into Trauma (SORT-IT) for their
assistance in performing this study.
Andrew D. Duckworth, MSc, MRCSEd
Sarah E. Mitchell, MRCSEd
Samuel G. Molyneux, MSc, MRCSEd
Timothy O. White, MD, FRCSEd(Tr&Orth)
Charles M. Court-Brown, MD, FRCSEd(Orth)
Margaret M. McQueen, MD, FRCSEd(Orth)
Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh,
51 Little France Crescent, Edinburgh EH16 4SU, United Kingdom.
E-mail address for A.D. Duckworth: andrew.duckworth@yahoo.co.uk
13. Ronel DN, Mtui E, Nolan WB 3rd. Forearm compartment syndrome: anatomical
analysis of surgical approaches to the deep space. Plast Reconstr Surg. 2004;
114:697-705.
14. Bhattacharyya T, Vrahas MS. The medical-legal aspects of compartment syn-
drome. J Bone Joint Surg Am. 2004;86:864-8.
15. McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in
tibial diaphyseal fractures. J Bone Joint Surg Br. 1996;78:95-8.
16. Mullett H, Al-Abed K, Prasad CV, O’Sullivan M. Outcome of compartment syndrome
following intramedullary nailing of tibial diaphyseal fractures. Injury. 2001;32:411-3.
17. Rorabeck CH. The treatment of compartment syndromes of the leg. J Bone Joint
Surg Br. 1984;66:93-7.
18. Bradley EL 3rd. The anterior tibial compartment syndrome. Surg Gynecol Obstet.
1973;136:289-97.
19. Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint
Surg Br. 2003;85:625-32.
20. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are
clinical findings predictive of the disorder? J Orthop Trauma. 2002;16:572-7.
21. Simpson NS, Jupiter JB. Delayed onset of forearm compartment syndrome: a
complication of distal radius fracture in young adults. J Orthop Trauma. 1995;9:411-8.
22. Morin RJ, Swan KG, Tan V. Acute forearm compartment syndrome secondary to
local arterial injury after penetrating trauma. J Trauma. 2009;66:989-93.
23. Stockley I, Harvey IA, Getty CJ. Acute volar compartment syndrome of the
forearm secondary to fractures of the distal radius. Injury. 1988;19:101-4.
24. Gelberman RH, Garfin SR, Hergenroeder PT, Mubarak SJ, Menon J. Compart-
ment syndromes of the forearm: diagnosis and treatment. Clin Orthop Relat Res.
1981;161:252-61.
25. Geary N. Late surgical decompression for compartment syndrome of the fore-
arm. J Bone Joint Surg Br. 1984;66:745-8.
26. Court-Brown C, McQueen M. Compartment syndrome delays tibial union. Acta
Orthop Scand. 1987;58:249-52.