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Case Report: Acute Forearm Compartment Syndrome Due to Sudden, Forceful Supination of the Hand
The Journal of Emergency Medicine, Vol. 39, No. 4, pp. e143– e146, 2010 Copyright © 2010 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter
doi:10.1016/j.jemermed.2007.06.006
Clinical Communications: Adults
CASE REPORT: ACUTE FOREARM COMPARTMENT SYNDROME DUE TO SUDDEN, FORCEFUL SUPINATION OF THE HAND Hardin A. Pantle,
MD, FAAEM, FAAP*
and Arjun Chanmugam,
MD, MBA, FACEP†
*Department of Emergency Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland and †Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland Reprint Address: Hardin A. Pantle, MD, FAAEM, FAAP, Department of Emergency Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, A5W Room 573, Baltimore, MD 21224
e Abstract—Acute compartment syndrome is a limbthreatening condition if not recognized and treated promptly. Appropriate management includes early fasciotomy, which often results in better functional outcomes. Although there are many causes of compartment syndrome, the common findings are significant pain, swelling, and limited range of motion. Diagnosis is usually based on physical findings in the setting of a compelling history. Before surgical intervention, the diagnosis is usually confirmed by measuring elevated compartment pressures. The patient described in this case report developed acute compartment syndrome of the forearm after his hand became trapped in machinery that applied sudden supination to the hand, and avulsed the distal portion of the left index finger. There was no direct trauma to the forearm. In this case, acute compartment syndrome was likely due to a combination of contained hemorrhage into the muscle sheath, closed muscle strain causing edema, and possibly axial traction applied to the tendons of the index finger. Acute compartment syndrome should be considered in the differential diagnosis for any patient complaining of severe pain in an extremity, even in the absence of commonly recognized mechanisms of injury. © 2010 Elsevier Inc.
ing to increased tissue pressure, which in turn causes compression of blood vessels and nerves. If tissue pressures are sufficiently elevated, a fasciotomy must be promptly performed to prevent permanent loss of function (1– 6). In most cases, mechanical, external compression injury that results in significant soft tissue swelling is easy to identify based on history. In some cases, the diagnosis of acute compartment syndrome may be delayed if the antecedent event is not deemed profound, or if the history and physical examination are limited due to a patient’s altered mental status. This case report documents acute compartment syndrome of the forearm due to sudden, forceful supination of the forearm and hand.
CASE REPORT A 50-year-old man was brought to the Emergency Department (ED) after his left index finger became caught in industrial equipment that rolls sheet metal. The machine forcefully supinated the left hand and forearm, and traumatically amputated the tip of the left index finger. Although he reported no injury to the left forearm, he complained of severe pain in that region. He denied other injuries, had no other complaints, and had not been ill recently. The past medical history was significant for hypertension and non-insulin-dependent diabetes. His medica-
e Keywords—compartment syndrome, forearm; finger avulsion; fasciotomy; trauma
INTRODUCTION Acute compartment syndrome of the extremities is caused by the common pathway of tissue swelling, lead-
RECEIVED: 21 April 2006; FINAL ACCEPTED: 22 March 2007
SUBMISSION RECEIVED:
13 February 2007; e143
e144
H. A. Pantle and A. Chanmugam
tions included rosiglitazone and metformin. He was a non-smoker, and denied any recent use of sedatives, hypnotics, or alcohol. On examination, he was in significant distress due to left forearm pain. Vital signs were: heart rate 94 beats/ min, blood pressure 171/81 mm Hg, respiratory rate 22 breaths/min, and temperature 35.5°C (98.4°F). The physical examination was normal except for the left forearm and left hand. The left forearm was extremely tender to palpation without point tenderness, and was firm to the touch. There was no ecchymosis, discoloration, or wound noted along the length of the left forearm. The left wrist and fingers had limited range of motion due to pain. Passive stretching of the left wrist and fingers elicited pain in the left forearm. The left hand was non-tender without edema or obvious trauma except for the avulsed tip of the left index finger. The patient reported slightly reduced sensation to light touch along the left thumb, left index, and left long fingers, and had diminished percep-
Figure 2. Radiographs of the left elbow and forearm revealed no fracture or dislocation.
Figure 1. Radiographs of the left hand revealed no bony injury except for an avulsion of the distal two-thirds of the distal phalanx of the left index finger.
tion of two-point discrimination along the base of the left index finger. Left radial and ulnar pulses were 2⫹ and equal in comparison with the right side, and capillary refill in the fingers of the left hand was ⬍ 2 s. A complete blood count and serum electrolytes were unremarkable. Radiographs of the left hand were normal except for an avulsion of the distal two-thirds of the distal phalanx of the left index finger (Figure 1). Radiographs of the left elbow and left forearm revealed no fracture or dislocation (Figure 2). The patient was treated with multiple intravenous doses of pain medication without significant relief. He also received cefazolin and a tetanus booster. Due to his persistent pain, and despite lack of evidence of direct forearm trauma, forearm compartment pressures were measured. A Stryker manometer (Stryker Instruments, Kalamazoo, MI) was used under sterile technique to obtain compartment pressure readings in the left forearm, with values ranging from 28 mm Hg to 32 mm Hg, indicating significantly elevated tissue compartment pressures.
Acute Compartment Syndrome
Based upon the physical examination in conjunction with the elevated compartment pressure readings, the patient was taken emergently to the operating room for a decompressive fasciotomy of the volar and dorsal compartments of the left forearm. At surgery, a small amount of hematoma was noted, without an obvious vascular source. After the fasciotomies, the muscle compartments were soft to palpation. Sharp debridement of the left index finger was performed and the skin wound was closed. The patient was discharged the day after surgery, and at follow-up 1 week later he was doing well with intact sensation and muscle function in the left hand and forearm.
DISCUSSION Compartment syndrome occurs when elevated pressure within an anatomical space reduces circulation to nerves and muscles, leading to tissue ischemia and compromised function. Acute compartment syndrome is classically described by the combination of pain, paresthesia, pallor, paresis, pulselessness, and rapid progression of symptoms. Not all of these findings, however, need to be present to establish the diagnosis of acute compartment syndrome. Because compartment syndrome is a dynamic process, patients initially complain of pain with passive stretching (1,2). Patients with compartment syndrome invariably have pain out of proportion to the injury, and their pain is notoriously difficult to control with narcotic pain medication. As the compartment syndrome progresses, nerves become ischemic and paresthesias typically develop (1,3). Patients with compromised nerve function will usually have abnormal two-point discrimination. The development of paresis, pallor, and pulselessness are late findings that are associated with a poor outcome. Left untreated, compartment syndrome leads to permanent nerve damage, muscle necrosis, and scarring, resulting in contractures and loss of function. Early recognition of the syndrome is critical to preventing permanent injury. Physical examination typically reveals a tense, firm muscle compartment. For patients who clearly have compartment syndrome, it is not necessary to measure compartment pressures—these patients require an emergent fasciotomy. However, when the diagnosis of compartment syndrome is less certain, compartment pressures should be measured directly through needle manometry. The normal compartment pressure is below 10 –12 mm Hg. Compartment pressures greater than an absolute value of 30 mm Hg are likely to represent compartment syndrome. In clinical practice, some surgeons prefer to diagnose compartment syndrome based on compartment
e145
perfusion pressure, rather than on absolute compartment pressures. Normal compartment perfusion pressures are ⬎ 70 – 80 mm Hg (4). Compartment perfusion pressures are calculated using mean arterial blood pressure and the measured compartment pressure using the following formula: (1) Compartment Perfusion Pressure ⫽ (Mean Arterial Pressure) ⫺ (Compartment Pressure) Compartment perfusion pressure decreases when either the blood pressure falls or the compartment pressure increases. In general, compartment pressures follow blood pressure trends except in pathological states. The risk of compartment syndrome increases when compartment perfusion pressure is 30 mm Hg or less (5,7). For the patient described in this report, the measured compartment pressures were 28 –32 mm Hg, with a simultaneous blood pressure of 148/68 mm Hg, resulting in a compartment perfusion pressure of 63 mm Hg. Anatomically, the muscle compartments of the forearm are divided into three groups: volar, dorsal, and lateral. The volar and dorsal muscle compartments are separated from each other by the interosseous membrane that runs between the radius and ulna. The mobile lateral compartment, also known as the “mobile wad,” lies on the radial aspect of the proximal forearm. When acute compartment syndrome of the forearm is present, the muscles of the volar compartment are typically the most severely injured, with the dorsal and lateral muscle compartments less severely involved (5,6). Acute forearm compartment syndrome is most frequently caused by a direct, high-energy mechanical injury. Fractures are often present, but contusions alone can lead to compartment syndrome, especially in coagulopathic patients (4,8,9). Patients taking coumadin or heparin (both low molecular weight and unfractionated) may develop acute compartment syndrome after minor injury or peripheral nerve blocks. Patients with hemophilia or those who have received rt-PA may develop spontaneous bleeding or bleeding at venipuncture sites, leading to acute compartment syndrome (3,10). Patients who have a history of narcotic, alcohol, or sedative abuse are at high risk for developing compartment syndrome due to prolonged compression of an extremity. Burns, vascular trauma, circular dressings and casts, and injection injuries also are associated with the development of acute compartment syndrome (11). Finally, there are case reports of acute compartment syndrome due to snake bites, spider bites, and prolonged extrication after a motor vehicle collision (12,13). This observation of acute forearm compartment syndrome caused by sudden, forceful supination of the forearm is unique. There are three case reports of traction injuries of fingers leading to acute forearm compartment
e146
H. A. Pantle and A. Chanmugam
syndrome (11). Traction injuries to the fingers are associated with injury at the junction between the muscle and tendon, or injury to the body of the muscle because the tensile strength of tendons is greater than the tensile strength of muscle (11,14). Closed muscle rupture can lead to acute compartment syndrome (15–17). Case reports also have documented acute compartment syndrome of the leg after inversion injury of the ankle (18 –20). For the patient described in this case report, no disruption of the muscle or the musculotendinous junction was visible when the fasciotomy was performed. Rather, acute compartment syndrome in this patient was likely due to a combination of edema, contained hemorrhage into the muscle sheath, closed muscle strain, and possibly, also axial traction applied to the tendons of the index finger. In summary, acute compartment syndrome is a limbthreatening condition, with early fasciotomy leading to better outcomes. Although there are numerous mechanisms leading to acute compartment syndrome, this case reveals that sudden, forceful supination of the hand may lead to acute compartment syndrome of the forearm. Acute compartment syndrome should be considered in the differential diagnosis for any patient complaining of severe persistent pain in an extremity, even in the absence of an antecedent crush event. If the possibility of acute compartment syndrome cannot be excluded based upon physical examination, compartment pressures should be measured. REFERENCES 1. Rorabeck C. The treatment of compartment syndromes of the leg. J Bone Joint Surg Br 1984;66:93–7. 2. Margles SW. Principles of management of acute hand injuries. Surg Clin North Am 1990;60:665– 86.
3. Naidu SH, Heppenstall RB. Compartment syndrome of the forearm and hand. Hand Clin 1994;10:13–27. 4. Kostler W, Strohm PC, Sudkamp NP. Acute compartment syndrome of the limb. Injury 2004;35:1221–7. 5. Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes. Br J Surg 2002;89:397– 412. 6. Botte MJ, Gelberman RH. Acute compartment syndrome of the forearm. Hand Clin 1998;14:391– 403. 7. Ozkayin N, Aktuglu K. Absolute compartment pressure versus differential pressure for the diagnosis of compartment syndrome in tibial fractures. Int Orthop 2005;29:396 – 401. 8. Khan M, Hodkinson SL. Acute compartment syndrome—presenting as severe pain in an extremity out of proportion with the injury. J R Army Med Corps 1997;143:165– 6. 9. Ilyas AM, Wisbeck JM, Shaffer GW, Thoder JJ. Upper extremity compartment syndrome secondary to acquired factor VIII inhibitor: a case report. J Bone Joint Surg Am 2005;87:1606 – 8. 10. Yip TR, Damaerschalk BM. Forearm compartment syndrome following intravenous thrombolytic therapy for acute ischemic stroke. Neurocrit Care 2005;2:47– 8. 11. Docker C, Titley OG. A case of forearm compartment syndrome following a ring avulsion injury. Injury 2002;33:274 –5. 12. Cohen J, Bush S. Case report: compartment syndrome after a suspected black widow spider bite. Ann Emerg Med 2005;45: 414 – 6. 13. Mallik K, Diduch DR. Acute noncontact compartment syndrome. J Orthop Trauma 2000;14:509 –10. 14. Ponnampalam MS. Rupture of muscles by traction. Injury 1974; 5:237– 8. 15. Gwynne Jones DP, Theis JC. Acute compartment syndrome due to closed muscle rupture. Aust N Z J Surg 1997;67:227– 8. 16. Thennavan AS, Funk L, Volans AP. Acute compartment syndrome after muscle rupture in a non-athlete. J Acad Emerg Med 1999; 16:377– 8. 17. Gainor BJ. Closed avulsion of the flexor digitorum superficialis origin causing compartment syndrome. J Bone Joint Surg Am 1984;66:467. 18. Moyer RA, Boden BP, Marchetto PA, Kleinbart F, Kelly JD 4th. Acute compartment syndrome of the lower extremity secondary to noncontact injury. Foot Ankle 1993;14:534 –7. 19. Mendelson S, Mendelson A, Holmes J. Compartment syndrome after acute rupture of the peroneus longus in a high school football player: a case report. Am J Orthop 2003;32:510 –2. 20. Gabison GG, Gentile DR. Acute peroneal compartment syndrome following ankle inversion injury. Am J Sports Med 2004; 32:1059 – 61.
doi:10.1016/j.jemermed.2007.06.006
Clinical Communications: Adults
CASE REPORT: ACUTE FOREARM COMPARTMENT SYNDROME DUE TO SUDDEN, FORCEFUL SUPINATION OF THE HAND Hardin A. Pantle,
MD, FAAEM, FAAP*
and Arjun Chanmugam,
MD, MBA, FACEP†
*Department of Emergency Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland and †Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland Reprint Address: Hardin A. Pantle, MD, FAAEM, FAAP, Department of Emergency Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, A5W Room 573, Baltimore, MD 21224
e Abstract—Acute compartment syndrome is a limbthreatening condition if not recognized and treated promptly. Appropriate management includes early fasciotomy, which often results in better functional outcomes. Although there are many causes of compartment syndrome, the common findings are significant pain, swelling, and limited range of motion. Diagnosis is usually based on physical findings in the setting of a compelling history. Before surgical intervention, the diagnosis is usually confirmed by measuring elevated compartment pressures. The patient described in this case report developed acute compartment syndrome of the forearm after his hand became trapped in machinery that applied sudden supination to the hand, and avulsed the distal portion of the left index finger. There was no direct trauma to the forearm. In this case, acute compartment syndrome was likely due to a combination of contained hemorrhage into the muscle sheath, closed muscle strain causing edema, and possibly axial traction applied to the tendons of the index finger. Acute compartment syndrome should be considered in the differential diagnosis for any patient complaining of severe pain in an extremity, even in the absence of commonly recognized mechanisms of injury. © 2010 Elsevier Inc.
ing to increased tissue pressure, which in turn causes compression of blood vessels and nerves. If tissue pressures are sufficiently elevated, a fasciotomy must be promptly performed to prevent permanent loss of function (1– 6). In most cases, mechanical, external compression injury that results in significant soft tissue swelling is easy to identify based on history. In some cases, the diagnosis of acute compartment syndrome may be delayed if the antecedent event is not deemed profound, or if the history and physical examination are limited due to a patient’s altered mental status. This case report documents acute compartment syndrome of the forearm due to sudden, forceful supination of the forearm and hand.
CASE REPORT A 50-year-old man was brought to the Emergency Department (ED) after his left index finger became caught in industrial equipment that rolls sheet metal. The machine forcefully supinated the left hand and forearm, and traumatically amputated the tip of the left index finger. Although he reported no injury to the left forearm, he complained of severe pain in that region. He denied other injuries, had no other complaints, and had not been ill recently. The past medical history was significant for hypertension and non-insulin-dependent diabetes. His medica-
e Keywords—compartment syndrome, forearm; finger avulsion; fasciotomy; trauma
INTRODUCTION Acute compartment syndrome of the extremities is caused by the common pathway of tissue swelling, lead-
RECEIVED: 21 April 2006; FINAL ACCEPTED: 22 March 2007
SUBMISSION RECEIVED:
13 February 2007; e143
e144
H. A. Pantle and A. Chanmugam
tions included rosiglitazone and metformin. He was a non-smoker, and denied any recent use of sedatives, hypnotics, or alcohol. On examination, he was in significant distress due to left forearm pain. Vital signs were: heart rate 94 beats/ min, blood pressure 171/81 mm Hg, respiratory rate 22 breaths/min, and temperature 35.5°C (98.4°F). The physical examination was normal except for the left forearm and left hand. The left forearm was extremely tender to palpation without point tenderness, and was firm to the touch. There was no ecchymosis, discoloration, or wound noted along the length of the left forearm. The left wrist and fingers had limited range of motion due to pain. Passive stretching of the left wrist and fingers elicited pain in the left forearm. The left hand was non-tender without edema or obvious trauma except for the avulsed tip of the left index finger. The patient reported slightly reduced sensation to light touch along the left thumb, left index, and left long fingers, and had diminished percep-
Figure 2. Radiographs of the left elbow and forearm revealed no fracture or dislocation.
Figure 1. Radiographs of the left hand revealed no bony injury except for an avulsion of the distal two-thirds of the distal phalanx of the left index finger.
tion of two-point discrimination along the base of the left index finger. Left radial and ulnar pulses were 2⫹ and equal in comparison with the right side, and capillary refill in the fingers of the left hand was ⬍ 2 s. A complete blood count and serum electrolytes were unremarkable. Radiographs of the left hand were normal except for an avulsion of the distal two-thirds of the distal phalanx of the left index finger (Figure 1). Radiographs of the left elbow and left forearm revealed no fracture or dislocation (Figure 2). The patient was treated with multiple intravenous doses of pain medication without significant relief. He also received cefazolin and a tetanus booster. Due to his persistent pain, and despite lack of evidence of direct forearm trauma, forearm compartment pressures were measured. A Stryker manometer (Stryker Instruments, Kalamazoo, MI) was used under sterile technique to obtain compartment pressure readings in the left forearm, with values ranging from 28 mm Hg to 32 mm Hg, indicating significantly elevated tissue compartment pressures.
Acute Compartment Syndrome
Based upon the physical examination in conjunction with the elevated compartment pressure readings, the patient was taken emergently to the operating room for a decompressive fasciotomy of the volar and dorsal compartments of the left forearm. At surgery, a small amount of hematoma was noted, without an obvious vascular source. After the fasciotomies, the muscle compartments were soft to palpation. Sharp debridement of the left index finger was performed and the skin wound was closed. The patient was discharged the day after surgery, and at follow-up 1 week later he was doing well with intact sensation and muscle function in the left hand and forearm.
DISCUSSION Compartment syndrome occurs when elevated pressure within an anatomical space reduces circulation to nerves and muscles, leading to tissue ischemia and compromised function. Acute compartment syndrome is classically described by the combination of pain, paresthesia, pallor, paresis, pulselessness, and rapid progression of symptoms. Not all of these findings, however, need to be present to establish the diagnosis of acute compartment syndrome. Because compartment syndrome is a dynamic process, patients initially complain of pain with passive stretching (1,2). Patients with compartment syndrome invariably have pain out of proportion to the injury, and their pain is notoriously difficult to control with narcotic pain medication. As the compartment syndrome progresses, nerves become ischemic and paresthesias typically develop (1,3). Patients with compromised nerve function will usually have abnormal two-point discrimination. The development of paresis, pallor, and pulselessness are late findings that are associated with a poor outcome. Left untreated, compartment syndrome leads to permanent nerve damage, muscle necrosis, and scarring, resulting in contractures and loss of function. Early recognition of the syndrome is critical to preventing permanent injury. Physical examination typically reveals a tense, firm muscle compartment. For patients who clearly have compartment syndrome, it is not necessary to measure compartment pressures—these patients require an emergent fasciotomy. However, when the diagnosis of compartment syndrome is less certain, compartment pressures should be measured directly through needle manometry. The normal compartment pressure is below 10 –12 mm Hg. Compartment pressures greater than an absolute value of 30 mm Hg are likely to represent compartment syndrome. In clinical practice, some surgeons prefer to diagnose compartment syndrome based on compartment
e145
perfusion pressure, rather than on absolute compartment pressures. Normal compartment perfusion pressures are ⬎ 70 – 80 mm Hg (4). Compartment perfusion pressures are calculated using mean arterial blood pressure and the measured compartment pressure using the following formula: (1) Compartment Perfusion Pressure ⫽ (Mean Arterial Pressure) ⫺ (Compartment Pressure) Compartment perfusion pressure decreases when either the blood pressure falls or the compartment pressure increases. In general, compartment pressures follow blood pressure trends except in pathological states. The risk of compartment syndrome increases when compartment perfusion pressure is 30 mm Hg or less (5,7). For the patient described in this report, the measured compartment pressures were 28 –32 mm Hg, with a simultaneous blood pressure of 148/68 mm Hg, resulting in a compartment perfusion pressure of 63 mm Hg. Anatomically, the muscle compartments of the forearm are divided into three groups: volar, dorsal, and lateral. The volar and dorsal muscle compartments are separated from each other by the interosseous membrane that runs between the radius and ulna. The mobile lateral compartment, also known as the “mobile wad,” lies on the radial aspect of the proximal forearm. When acute compartment syndrome of the forearm is present, the muscles of the volar compartment are typically the most severely injured, with the dorsal and lateral muscle compartments less severely involved (5,6). Acute forearm compartment syndrome is most frequently caused by a direct, high-energy mechanical injury. Fractures are often present, but contusions alone can lead to compartment syndrome, especially in coagulopathic patients (4,8,9). Patients taking coumadin or heparin (both low molecular weight and unfractionated) may develop acute compartment syndrome after minor injury or peripheral nerve blocks. Patients with hemophilia or those who have received rt-PA may develop spontaneous bleeding or bleeding at venipuncture sites, leading to acute compartment syndrome (3,10). Patients who have a history of narcotic, alcohol, or sedative abuse are at high risk for developing compartment syndrome due to prolonged compression of an extremity. Burns, vascular trauma, circular dressings and casts, and injection injuries also are associated with the development of acute compartment syndrome (11). Finally, there are case reports of acute compartment syndrome due to snake bites, spider bites, and prolonged extrication after a motor vehicle collision (12,13). This observation of acute forearm compartment syndrome caused by sudden, forceful supination of the forearm is unique. There are three case reports of traction injuries of fingers leading to acute forearm compartment
e146
H. A. Pantle and A. Chanmugam
syndrome (11). Traction injuries to the fingers are associated with injury at the junction between the muscle and tendon, or injury to the body of the muscle because the tensile strength of tendons is greater than the tensile strength of muscle (11,14). Closed muscle rupture can lead to acute compartment syndrome (15–17). Case reports also have documented acute compartment syndrome of the leg after inversion injury of the ankle (18 –20). For the patient described in this case report, no disruption of the muscle or the musculotendinous junction was visible when the fasciotomy was performed. Rather, acute compartment syndrome in this patient was likely due to a combination of edema, contained hemorrhage into the muscle sheath, closed muscle strain, and possibly, also axial traction applied to the tendons of the index finger. In summary, acute compartment syndrome is a limbthreatening condition, with early fasciotomy leading to better outcomes. Although there are numerous mechanisms leading to acute compartment syndrome, this case reveals that sudden, forceful supination of the hand may lead to acute compartment syndrome of the forearm. Acute compartment syndrome should be considered in the differential diagnosis for any patient complaining of severe persistent pain in an extremity, even in the absence of an antecedent crush event. If the possibility of acute compartment syndrome cannot be excluded based upon physical examination, compartment pressures should be measured. REFERENCES 1. Rorabeck C. The treatment of compartment syndromes of the leg. J Bone Joint Surg Br 1984;66:93–7. 2. Margles SW. Principles of management of acute hand injuries. Surg Clin North Am 1990;60:665– 86.
3. Naidu SH, Heppenstall RB. Compartment syndrome of the forearm and hand. Hand Clin 1994;10:13–27. 4. Kostler W, Strohm PC, Sudkamp NP. Acute compartment syndrome of the limb. Injury 2004;35:1221–7. 5. Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes. Br J Surg 2002;89:397– 412. 6. Botte MJ, Gelberman RH. Acute compartment syndrome of the forearm. Hand Clin 1998;14:391– 403. 7. Ozkayin N, Aktuglu K. Absolute compartment pressure versus differential pressure for the diagnosis of compartment syndrome in tibial fractures. Int Orthop 2005;29:396 – 401. 8. Khan M, Hodkinson SL. Acute compartment syndrome—presenting as severe pain in an extremity out of proportion with the injury. J R Army Med Corps 1997;143:165– 6. 9. Ilyas AM, Wisbeck JM, Shaffer GW, Thoder JJ. Upper extremity compartment syndrome secondary to acquired factor VIII inhibitor: a case report. J Bone Joint Surg Am 2005;87:1606 – 8. 10. Yip TR, Damaerschalk BM. Forearm compartment syndrome following intravenous thrombolytic therapy for acute ischemic stroke. Neurocrit Care 2005;2:47– 8. 11. Docker C, Titley OG. A case of forearm compartment syndrome following a ring avulsion injury. Injury 2002;33:274 –5. 12. Cohen J, Bush S. Case report: compartment syndrome after a suspected black widow spider bite. Ann Emerg Med 2005;45: 414 – 6. 13. Mallik K, Diduch DR. Acute noncontact compartment syndrome. J Orthop Trauma 2000;14:509 –10. 14. Ponnampalam MS. Rupture of muscles by traction. Injury 1974; 5:237– 8. 15. Gwynne Jones DP, Theis JC. Acute compartment syndrome due to closed muscle rupture. Aust N Z J Surg 1997;67:227– 8. 16. Thennavan AS, Funk L, Volans AP. Acute compartment syndrome after muscle rupture in a non-athlete. J Acad Emerg Med 1999; 16:377– 8. 17. Gainor BJ. Closed avulsion of the flexor digitorum superficialis origin causing compartment syndrome. J Bone Joint Surg Am 1984;66:467. 18. Moyer RA, Boden BP, Marchetto PA, Kleinbart F, Kelly JD 4th. Acute compartment syndrome of the lower extremity secondary to noncontact injury. Foot Ankle 1993;14:534 –7. 19. Mendelson S, Mendelson A, Holmes J. Compartment syndrome after acute rupture of the peroneus longus in a high school football player: a case report. Am J Orthop 2003;32:510 –2. 20. Gabison GG, Gentile DR. Acute peroneal compartment syndrome following ankle inversion injury. Am J Sports Med 2004; 32:1059 – 61.