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▎WuXi AppTec content team editor
.
Usually, whether it is a fracture or bruising and swelling, the pain after a traumatic hand injury can be relieved
by taking painkillers.
However, in some diseases, patients will not only experience swelling and bruising after injury, but also gradually increase the pain as the disease progresses, and even symptoms
such as paresthesia, pulselessness and paralysis may occur.
A recent case published in the British Medical Journal tells the story of a middle-aged man who accidentally hit his right hand at work and developed progressive diffuse pain with swelling and bruising.
The first and corresponding author of the study is Tun Hing Lui
, an orthopedic and traumatologist at Sheung Shui North District Hospital in Hong Kong, China, and a professor at Shenzhen University.
Screenshot source: The BMJ
The patient, a man in his 50s, was admitted to the hospital
with diffuse pain when his right hand was hit by a metal tube.
The patient, a construction worker, was accidentally hit
by a metal pipe during work.
After two hours, the patient developed diffuse pain in his right hand, which worsened
with finger movement.
The right hand is swollen and the palm is bruised
.
The patient was subsequently diagnosed with soft tissue injury and treated with painkillers
.
But as the pain intensifies, painkillers gradually become ineffective
.
Five hours after the injury, the patient went to the emergency department
.
The patient has no prior history of coagulopathy and is not using anticoagulants
.
Post-admission examination
Radial and ulnar pulses
can be palpated.
Fingers flex and the hand feels intact
to the touch.
Increased
pain in all fingers passively extended, adducted, and abducted.
▲ Photograph of the patient's right hand, with a large bruise on the palm (left) and no bruise on the back of the hand (right) (Image source: Reference [1]) X-ray
film shows: fourth and fifth metacarpal fractures
.
diagnosis
refers to all closed anatomical spaces (i.
e.
, fascial chambers) composed of bone, interosseous membrane, muscle septum, deep fascia, etc.
, due to various endogenous or exogenous factors causing interstitial pressure to exceed perfusion pressure, blocking microcirculation in fascial compartments.
A series of syndromes
resulting from acute ischemia of intrafascial tissues (muscles and nerves).
Acute compartment syndrome is an orthopedic emergency in which increased intrafascial pressure leads to capillary collapse, perfusion closure, tissue hypoxia, and finally intrafascial muscle and nerve death
.
The main clinical signs are the classic "6P" sign: pain, pallor, hypothermia (chills in the affected limb), paresthesia, pulselessness, and paralysis
.
Increased or disproportionate increase in pain due to passive stretching of the affected muscle should not be attributed to an underlying fracture but is an early hallmark sign
of acute compartment syndrome.
Other signs of acute compartment syndrome may be delayed and inconsistent in individual presentation, and it is impractical to wait for late signs to appear, which can lead to permanent damage to nerves and muscles in the compartment and even loss of limbs
.
In contrast to compartment syndrome in other sites, compartment syndrome in the hand usually lacks sensory deficits because there are no sensory nerves
in the compartment of the fascia of the hand.
If paresthesias develop, carpal or ulnar tunnel
may be involved.
Blood tests are not necessary for diagnosis and no further tests
are usually needed.
In this emergency situation, surgical management should not be delayed, and fasciotomy can be performed
on a clinical basis alone.
If in doubt, the perfusion pressure
in the chamber can be measured.
Treatment and prognosis
.
The injured hand should not be raised to avoid further damage
by tissue perfusion.
Patients must be urgently referred to the orthopaedic team
.
Intravenous cefazoline
is given perioperatively.
Early fasciotomy relieves intrafascial intraventricular pressure and prevents permanent damage
to nerves and muscles.
Early closure of the fasciotomy wound within 4-5 days reduces the risk of
infection.
Metacarpal fractures are fixed
with a Kirschner needle.
Emergency 10-compartment (macrofish, small, adductor muscle, 4 dorsal interosseous, 3 volar interosseous) fasciotomy, hematoma drainage, carpal tunnel release, and fracture fixation
were performed.
Patients do not have muscle necrosis
.
A second wound closure is performed after 5 days
.
Follow-up found that the fracture healed and the hand returned to fine motor control
.
Key points to learn
Patients with crush injuries and severe pain should be considered for compartment syndrome
.Clinical diagnosis of compartment syndrome usually relies on signs and does not require measurement of intraventricular pressure
.
