What is the treatment for compartment syndrome in the wrist?

Treatment of Compartment Syndrome in the Wrist

Immediate surgical fasciotomy of all involved compartments is the only effective treatment for compartment syndrome in the wrist, and must be performed urgently to prevent irreversible tissue necrosis. 1, 2, 3

Immediate Emergency Management

Remove all constricting elements immediately when compartment syndrome is suspected:

• Remove all dressings, casts, splints, or bandages without delay 2
• Position the limb at heart level—do not elevate excessively as this further decreases perfusion pressure and worsens ischemia 1, 2, 3
• Arrange urgent surgical consultation for fasciotomy without any delay 1, 2

Measure compartment pressures if the diagnosis remains uncertain, particularly in:

• Obtunded or sedated patients who cannot reliably report pain 1, 2, 3
• Uncooperative patients 1, 2
• Cases where clinical findings are equivocal 1

The diagnosis is primarily clinical, but pressure measurement can confirm when doubt exists. 1, 4, 5

Clinical Recognition

Pain out of proportion to injury is the earliest and most reliable warning sign of compartment syndrome in the wrist. 1, 3, 5

Pain on passive stretch of the affected muscle compartment is the most sensitive early sign. 1, 3

Do not wait for late signs such as:

• Pulselessness, pallor, or paralysis—these indicate irreversible tissue damage has already occurred 1, 2, 3
• Motor deficits (paralysis) indicate significant tissue damage 1
• Sensory changes (paresthesia) result from nerve ischemia 1

The presence of severe pain alone gives only approximately 25% chance of correctly diagnosing compartment syndrome, but when pain, pain on passive stretch, and paralysis are all present, positive predictive value reaches 93%—however, by this point irreversible muscle ischemia may have already occurred. 1

Definitive Surgical Treatment

Perform immediate fasciotomy of all involved compartments when compartment syndrome is diagnosed:

• This is the only effective treatment to prevent irreversible tissue damage 1, 2, 3
• Fasciotomy releases the pressure within the closed fascial space 6, 4, 5
• Time is critical—prolonged elevated tissue pressure leads to permanent nerve and muscle necrosis 4, 5

Fasciotomy is indicated when:

• Compartment pressure exceeds 30 mmHg 3
• Differential pressure (diastolic blood pressure minus compartment pressure) is <30 mmHg 3
• Clinical diagnosis is made based on pain out of proportion and pain on passive stretch 1, 3

Post-Fasciotomy Management

Monitor for myoglobinuria and maintain urine output >2 ml/kg/h if myoglobinuria develops to prevent acute kidney injury from rhabdomyolysis. 1, 2, 3

Wound management:

• Consider early delayed primary closure if minimal tissue bulge is noted after fasciotomy or resolves with systemic diuresis and leg elevation 1, 3
• Use negative pressure wound therapy to reduce discomfort and facilitate closure in patients not candidates for delayed primary closure 1, 2, 3
• Provide diligent wound care to mitigate complications including infection and nerve injury 1, 2, 3

Monitor for compartment syndrome recurrence, particularly in severe cases. 1, 2, 3

Critical Pitfalls to Avoid

Never wait for late signs (pulselessness, pallor, paralysis) as these indicate significant irreversible tissue damage has already occurred. 1, 2, 3

Never rely solely on palpation for diagnosis—it is unreliable with sensitivity of only 54% and specificity of 76% in children. 1, 2

Never elevate the limb excessively when compartment syndrome is suspected, as this further decreases perfusion pressure and worsens the condition. 1, 2, 3

Never delay diagnosis in obtunded patients—measure compartment pressures earlier in these populations who cannot report pain. 1, 2, 3

Never miss compartment syndrome in patients without fractures—it can occur with soft tissue injuries alone, including crush injuries to the wrist. 1, 2, 3, 6

Special Considerations for the Wrist

While most literature focuses on lower extremity compartment syndrome, the same principles apply to the wrist. 7 The thenar compartment (controlling the thumb) is particularly susceptible to compartment syndrome even from relatively minor trauma. 6 Early recognition is critical as the small muscle compartments in the hand and wrist can develop irreversible damage rapidly. 6, 4