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Spontaneous compartment syndrome in a patient on long-term anticoagulation
SPONTANEOUS COMPARTMENT SYNDROME IN A PATIENT ON LONG-TERM ANTICOAGULATION D. GRIFFITHS and D. H. A. JONES From the Department of Orthopaedic Surgery, Ysbyty Gwynedd, Bangor, North Wales
The case is reported of a 35-year-old lady on long-term anticoagulation with warfarin who developed a spontaneous acute compartment syndrome in the forearm. Despite a delay in diagnosis, an extensive decompression resulted in complete recovery. Journal of Hand Surgery
(British and European
CASE REPORT A 35-year-old housewife receiving long-term Warfarin because of multiple pulmonary emboli was seen in the Accident and Emergency Department complaining of pain in her non-dominant wrist and forearm. She had fallen asleep on a couch some four hours earlier, and on awakening had noticed discomfort in her left wrist. Over the next two hours the pain increased and radiated proximally to the elbow. The casualty officer noticed that there was no external evidence of injury, but wrist movements were stiff and painful. Radiographs were normal and a provisional diagnosis of a sprained wrist was made. She was given analgesia and advised to rest the arm. By the following day the pain had increased and she was unable to extend her fingers fully. She was admitted to a medical ward where her international normalized ratio was found to be 3.2. only marginally greater than her therapeutic range of 2.5 to 3.0. Two days later, her symptoms were not settling and an orthopaedic opinion was requested. At this stage it was noted that the forearm flexor compartment was swollen, tense, and tender; the fingers were held in flexion, and passive extension was exquisitely painful (Fig 1). The radial pulse was palpable and there was no neurological deficit. She had continued to receive warfarin and therefore preparations were made to bring her coagulation status to a more manageable level before undertaking a decompression. However, she began to
Fig 1
Fixed flexion of fingers.
Volume, 1993)
18B : 41-42
develop symptoms of median nerve decompression and an immediate fasciotomy was performed (Fig 2). At operation, an extensive haematoma was evacuated from around the bellies of flexor digitorum profundus. All of the flexor muscles were found to be viable and no specific bleeding vessel was identified. The wound was closed three days later. The patient made a complete recovery, regaining a full range of painless finger movements within five days of operation (Fig 3). DISCUSSION In Volkmann’s original description of compartment syndrome, the vascular insufficiency resulting in contrac-
Fig 2
Decompression
Fig 3
Restoration
of volar compartment.
of full extension.
42
tures was attributed to tight bandages, Sir Robert Jones later concluded that the rise in pressure could be caused by intrinsic as well as extrinsic factors. The most common causes are fractures, blunt trauma and external compression, but the condition has been described after insults as diverse as burns, snake bites, and malignant infiltration (Southworth et al, 1990; Trumble, 1987). In the upper limb the flexor compartment of the forearm is most commonly involved and the diagnosis is principally by recognition that the degree of pain is disproportionate to the severity of the injury. The presence of the radial pulse is an unreliable sign and the most consistent feature is pain, particularly on passive extension of the fingers (Holden, 1979). It is well recognized that patients with haemorrhagic tendencies are more vulnerable to the development of a compartment syndrome after even relatively minor trauma. Ebraheim et al (1991) describe a case of anterior compartment syndrome of the thigh, after trauma, in a patient on prolonged anticoagulation and Graham and Loomer (1985) present a case of a patient who developed compartment syndrome in the lower leg after heparinization following internal fixation of a tibia1 plateau fracture. Parziale et al (1988) have reported the case of an anticoagulated patient who developed an acute volar forearm compartment syndrome following a median nerve block at the elbow. We have been unable to find a report of an acute compartment syndrome developing without any cause other than a bleeding propensity. The
THE
JOURNAL
OF HAND
SURGERY
VOL.
18B No.
1 FEBRUARY
1993
precipitating factor in this case may have been unrecognized compression of the forearm while the patient was asleep. A high index of suspicion is required to recognize the signs and symptoms of compartment syndrome in patients on prolonged anticoagulation who suffer even trivial trauma and whose anticoagulation is well controlled. References EBRAHEIM, N. A., HOEFLINGER, M. J., SAVOLAINE, E. R. and JACKSON, W. T. (1991). Anterior compartment syndrome of the thigh as a complication of blunt trauma in a patient on prolonged anticoagulation therapy. Clinical Orthopaedics and Related Research, 263: 18&184. GRAHAM, B. and LOOMER, R. L. (1985). Anterior compartment syndrome in a patient with fracture of the tibia1 plateau treated by continuous passive motion and anticoagulants: Report of a case. Clinical Orthopaedics and Related Research, 195: 197-199. HOLDEN, C. E. A. (1979). The pathology and prevention of Volkmann’s ischaemic contractwe. Journal of Bone and Joint Surgery, 61 -B : 3 : 296-300. PARZIALE, J. R., MARINO, A. R. and HERNDON, .I. H. (1988). Diagnostic peripheral nerve block resulting in compartment syndrome: Case report. American Journal of Physical Medicine and Rehabilitation, 67: 2: 82-84. SOUTHWORTH, S. R., O’MALLEY, N. P., EBRAHEIM, N. A., ZEFF, L. and CUMMINGS, V. (1990). Compartment syndrome as a presentation of non-Hodgkin’s lymphoma. Journal of Orthopaedic Trauma, 4: 4: 47&473. TRUMBLE, T. (1987). Forearm compartment syndrome secondary to leukemic infiltrates. Journal of Hand Surgery, 12-A : 4: 563-565. VOLKMANN, R. (1881). Die ischaemischen Muskelltimungen und Kontrakturen. Zentralblatt fiir Chimrgie, 51: 801-803.
Accepted: 19 March 1992 Mr D Griffiths, 3 Hordley Road, 0 1993 The British
Society
Tetchiil,
for Surgery
Shropshire,
of the Hand
SY12 9AX.
The case is reported of a 35-year-old lady on long-term anticoagulation with warfarin who developed a spontaneous acute compartment syndrome in the forearm. Despite a delay in diagnosis, an extensive decompression resulted in complete recovery. Journal of Hand Surgery
(British and European
CASE REPORT A 35-year-old housewife receiving long-term Warfarin because of multiple pulmonary emboli was seen in the Accident and Emergency Department complaining of pain in her non-dominant wrist and forearm. She had fallen asleep on a couch some four hours earlier, and on awakening had noticed discomfort in her left wrist. Over the next two hours the pain increased and radiated proximally to the elbow. The casualty officer noticed that there was no external evidence of injury, but wrist movements were stiff and painful. Radiographs were normal and a provisional diagnosis of a sprained wrist was made. She was given analgesia and advised to rest the arm. By the following day the pain had increased and she was unable to extend her fingers fully. She was admitted to a medical ward where her international normalized ratio was found to be 3.2. only marginally greater than her therapeutic range of 2.5 to 3.0. Two days later, her symptoms were not settling and an orthopaedic opinion was requested. At this stage it was noted that the forearm flexor compartment was swollen, tense, and tender; the fingers were held in flexion, and passive extension was exquisitely painful (Fig 1). The radial pulse was palpable and there was no neurological deficit. She had continued to receive warfarin and therefore preparations were made to bring her coagulation status to a more manageable level before undertaking a decompression. However, she began to
Fig 1
Fixed flexion of fingers.
Volume, 1993)
18B : 41-42
develop symptoms of median nerve decompression and an immediate fasciotomy was performed (Fig 2). At operation, an extensive haematoma was evacuated from around the bellies of flexor digitorum profundus. All of the flexor muscles were found to be viable and no specific bleeding vessel was identified. The wound was closed three days later. The patient made a complete recovery, regaining a full range of painless finger movements within five days of operation (Fig 3). DISCUSSION In Volkmann’s original description of compartment syndrome, the vascular insufficiency resulting in contrac-
Fig 2
Decompression
Fig 3
Restoration
of volar compartment.
of full extension.
42
tures was attributed to tight bandages, Sir Robert Jones later concluded that the rise in pressure could be caused by intrinsic as well as extrinsic factors. The most common causes are fractures, blunt trauma and external compression, but the condition has been described after insults as diverse as burns, snake bites, and malignant infiltration (Southworth et al, 1990; Trumble, 1987). In the upper limb the flexor compartment of the forearm is most commonly involved and the diagnosis is principally by recognition that the degree of pain is disproportionate to the severity of the injury. The presence of the radial pulse is an unreliable sign and the most consistent feature is pain, particularly on passive extension of the fingers (Holden, 1979). It is well recognized that patients with haemorrhagic tendencies are more vulnerable to the development of a compartment syndrome after even relatively minor trauma. Ebraheim et al (1991) describe a case of anterior compartment syndrome of the thigh, after trauma, in a patient on prolonged anticoagulation and Graham and Loomer (1985) present a case of a patient who developed compartment syndrome in the lower leg after heparinization following internal fixation of a tibia1 plateau fracture. Parziale et al (1988) have reported the case of an anticoagulated patient who developed an acute volar forearm compartment syndrome following a median nerve block at the elbow. We have been unable to find a report of an acute compartment syndrome developing without any cause other than a bleeding propensity. The
THE
JOURNAL
OF HAND
SURGERY
VOL.
18B No.
1 FEBRUARY
1993
precipitating factor in this case may have been unrecognized compression of the forearm while the patient was asleep. A high index of suspicion is required to recognize the signs and symptoms of compartment syndrome in patients on prolonged anticoagulation who suffer even trivial trauma and whose anticoagulation is well controlled. References EBRAHEIM, N. A., HOEFLINGER, M. J., SAVOLAINE, E. R. and JACKSON, W. T. (1991). Anterior compartment syndrome of the thigh as a complication of blunt trauma in a patient on prolonged anticoagulation therapy. Clinical Orthopaedics and Related Research, 263: 18&184. GRAHAM, B. and LOOMER, R. L. (1985). Anterior compartment syndrome in a patient with fracture of the tibia1 plateau treated by continuous passive motion and anticoagulants: Report of a case. Clinical Orthopaedics and Related Research, 195: 197-199. HOLDEN, C. E. A. (1979). The pathology and prevention of Volkmann’s ischaemic contractwe. Journal of Bone and Joint Surgery, 61 -B : 3 : 296-300. PARZIALE, J. R., MARINO, A. R. and HERNDON, .I. H. (1988). Diagnostic peripheral nerve block resulting in compartment syndrome: Case report. American Journal of Physical Medicine and Rehabilitation, 67: 2: 82-84. SOUTHWORTH, S. R., O’MALLEY, N. P., EBRAHEIM, N. A., ZEFF, L. and CUMMINGS, V. (1990). Compartment syndrome as a presentation of non-Hodgkin’s lymphoma. Journal of Orthopaedic Trauma, 4: 4: 47&473. TRUMBLE, T. (1987). Forearm compartment syndrome secondary to leukemic infiltrates. Journal of Hand Surgery, 12-A : 4: 563-565. VOLKMANN, R. (1881). Die ischaemischen Muskelltimungen und Kontrakturen. Zentralblatt fiir Chimrgie, 51: 801-803.
Accepted: 19 March 1992 Mr D Griffiths, 3 Hordley Road, 0 1993 The British
Society
Tetchiil,
for Surgery
Shropshire,
of the Hand
SY12 9AX.