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- Hand (N Y)
- v.6(4); 2011 Dec
- PMC3213254
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Hand (N Y). 2011 Dec; 6(4): 442–444.
Published online 2011 Oct 8. doi:10.1007/s11552-011-9364-2
PMCID: PMC3213254
PMID: 23204974
Amanda L. Johnson, David Maish, and Michael Darowish
Author information Copyright and License information Disclaimer
Introduction
Anatomically, the forearm has been shown to have a superficial and deep volar compartment, a pronator quadratus compartment [3], a dorsal compartment, and a compartment containing the mobile wad [1]. There are no reports in the literature of the EDC presenting with an isolated compartment syndrome without involving the other muscles in the dorsal compartment.
Case Report
A 47-year-old right-handed female presented to the emergency department with right forearm swelling, erythema, and severe pain. Five days prior to presentation, she had performed significant physical activities, specifically mucking horse stalls. She had no trauma to the area; no skin breakage occurred. She had no symptoms for the 3days following this. Two days prior to presentation, she noted onset of pain in the dorsal radial aspect of her forearm. The pain increased in intensity over the next 24h. Her pain was worse with movement, specifically with finger extension. She developed an extensor lag of her long finger MCP joint at the time of presentation (Fig.1). She did not describe any sensory loss. She did not describe a history of discrete trauma, infection, insect bite, or other etiology for her symptoms. Her past medical history was significant for seronegative lupus.
Fig. 1
Extensor lag of long finger at MCP joint
On initial examination, the patient was in significant pain. The dorsal compartment her forearm was firm and was not compressible; the firmness seemed to be isolated to the EDC only. No firmness was noted over her extensor carpi ulnaris (ECU) or extensor carpi radialis brevis or longus (ECRB/L). The volar forearm was soft and compressible. She had a 40° extensor lag of the metacarpophalangeal joint of her long finger. She was able to fully extend her other fingers, thumb, and wrist. She had pain with passive flexion of her fingers. The remaining motor function in her forearm and hand was intact. She had intact sensation to light touch in all nerve distributions in the forearm. She had a strong and palpable 2+ radial and ulnar pulse. Her skin was intact without evidence of trauma and was erythematous over her dorsal forearm.
Because of the atypical presentation, with the presence of erythema overlying the affected musculature, and with the patient’s symptoms isolated solely to her extensor digitorum, with no evidence of involvement of her wrist extensors, we elected to obtain an emergent MRI of her forearm to evaluate for abscess. This revealed increased signal specific to her EDC muscle, with the greatest signal enhancement at the myotendinous junction (Fig.2). There was no evidence of an abscess.
Fig. 2
MRI showing enhanced signal in EDC
These findings, as well as the patients’ physical exam, led us to suspect an isolated compartment syndrome. A Stryker monitor was used to determine her compartment pressure. This was introduced in the dorsal compartment centered in the location of the EDC. This measured 90mmHg, with a diastolic blood pressure of 80mmHg, indicating a compartment syndrome.
The patient was taken emergently to the OR for fasciotomy, muscle debridement, and muscle biopsy. This was done through a dorsal incision directly over the EDC, and the fascia over this muscle was released. The muscle immediately bulged from the fascia (Fig.3). The muscle was contractile and had a pink color at that time, and was felt to be viable. A small amount was debrided and sent for biopsy and culture. The remainder of the forearm musculature was unremarkable, with no evidence of increased intracompartmental pressure. The surrounding fascia was healthy appearing, with no evidence of infection or fasciitis.
Fig. 3
Dorsal incision directly over the EDC
The next day the patient’s pain had improved, but by post-operative day2, her pain and swelling had increased in severity, and she reported increased pain with finger motion. The patient was returned to the OR for repeat debridement. At this time, about 50% of the proximal muscle of her EDC was not viable and was debrided. Muscle biopsy and culture was obtained. The rest of the EDC muscle was healthy and contractile, as was the ECU and ECRB/L. Her forearm was soft and compressible at the conclusion of the case. There was no evidence of infection or purulence.
Post-operatively the patient recovered well, and at 2weeks post-operation she had a 10° extensor lag at the metacarpophalangeal joint of the long finger, and otherwise full function of her hand and fingers.
Pathologic and microbiologic evaluation of the EDC tissue did not give any indication as to the etiology of the increased intracompartmental pressure. Intra-operative cultures were negative, and her muscle biopsies from both the first and second surgery showed only necrotic tissue. Laboratory workup, including CBC, infection markers, electrolytes, and a hypercoagulable workup, was unremarkable. Multiple markers for autoimmune disease were negative. The patient did develop some nonspecific folliculitis of her legs 1month post-operatively, without evidence of infection.
Discussion
Compartment syndrome develops when swelling and pressure increases to such a degree that tissue cannot perfuse and tissue viability is at risk. Isolated compartment syndrome affecting a single muscle in the forearm is only sporadically reported in the literature. We could not find a description of an isolated compartment syndrome that only affected the EDC muscle. We did find reports of isolated exercise induced compartment syndrome of the anconeus [4] and flexor carpi ulnaris [5]. We also found a report of isolated traumatic pronator quadratus compartment syndrome [3].
Many causes of compartment syndrome are described, including trauma, post-operative swelling, tight external wraps, vascular reperfusion, infection, exertion, hypercoagulable state leading to thrombocytopenia [2], neuroleptic malignant syndrome, DVT, mass, reflex sympathetic dystrophy vasospasm, and thermal injury, to name a few. The etiology of compartment syndrome and muscle necrosis in our patient is unknown. Our patient does have a history of seronegative lupus, and we were concerned that this may have contributed to a hypercoagulable state that could have caused her symptoms. However, extensive studies were negative for any coagulation abnormality. There is a report in the literature of a patient who developed compartment syndrome of the hand that was felt to be due to vasculitis secondary to lupus [6]. This patient was treated effectively with fasciotomy and steroids. Our patient showed no evidence of vasculitis on pathologic evaluation, or on examination.
Compartment syndrome in the forearm is an uncommon condition and is exceedingly rare in an isolated muscle in the forearm. This case highlights an unusual example of this in the EDC and should serve to increase awareness of this condition and thus improve patient outcome with prompt and effective treatment.
Contributor Information
Amanda L. Johnson, Phone: +1-215-4982298, Fax: +1-717-5310498, Email: moc.liamg@23nosnhojLadnama.
David Maish, Phone: +1-717-5310003, Fax: +1-717-5310498, Email: ude.usp.cmh@hsiamd.
Michael Darowish, Phone: +1-717-5312948, Fax: +1-717-5310498, Email: ude.usp.cmh@hsiworadm.
References
1. Chan PS, Steinberg DR, Pepe MD, Beredjiklian PK. The significance of three volar spaces in forearm compartment syndrome: a clinical and cadaveric correlation. J Hand Surg. 1998;23A:1077–81. [PubMed] [Google Scholar]
2. Chokshi BV, Lee S, Wolfe SW. Recurrent compartment syndrome of the hand: a case report. J Hand Surg. 1998;23A:66–9. [PubMed] [Google Scholar]
3. Schumer E. Isolated compartment syndrome of the pronator quadratus compartment: a case report. J Hand Surg. 2004;29(2):299–301. doi:10.1016/j.jhsa.2003.10.021. [PubMed] [CrossRef] [Google Scholar]
4. Steinmann S, Bishop A. Chronic anconeus compartment syndrome: a case report. J Hand Surg. 2000;25A:959–61. [PubMed] [Google Scholar]
5. Tompkins D. Exercise myopathy of the extensor carpi ulnaris muscle: report of a case. J Bone Joint Surg. 1977;59A:407–8. [PubMed] [Google Scholar]
6. Wirth J, Sheka K, Gheewala A, et al. Acquired immune deficiency syndrome and systemic lupus erythematosis: potential causes of surgical emergencies of the hand. Ann Plast Surg. 2008;61:35–9. doi:10.1097/SAP.0b013e318155a141. [PubMed] [CrossRef] [Google Scholar]
Articles from Hand (New York, N.Y.) are provided here courtesy of American Association for Hand Surgery
FAQs
What is compartment syndrome of extensor digitorum? ›
Compartment syndrome develops when swelling and pressure increases to such a degree that tissue cannot perfuse and tissue viability is at risk. Isolated compartment syndrome affecting a single muscle in the forearm is only sporadically reported in the literature.
What is the attachment of extensor digitorum communis? ›...
Extensor digitorum muscle.
| Origin | Lateral epicondyle of humerus (common extensor tendon) |
|---|---|
| Insertion | Extensor expansions of digits 2-5 |
Compartment syndrome of the forearm is primarily a clinical diagnosis. Patients often present within a few hours of the inciting event, sometimes even within 48 hours. They present with a swollen, tense, tender forearm with overlying skin that is often pink.
What happens if compartment syndrome is not treated? ›If this pressure is high enough, blood flow to the compartment will be blocked. This can lead to permanent injury to the muscle and nerves. If the pressure lasts long enough, the muscles may die and the arm or leg will no longer work. Surgery or even amputation may be done to correct the problem.
How do you fix compartment syndrome? ›Acute compartment syndrome must get immediate treatment. A surgeon will perform an operation called a fasciotomy. To relieve pressure, the surgeon makes an incision (cut) through the skin and the fascia (compartment cover). After the swelling and pressure go away, the surgeon will close the incision.
What nerve is extensor digitorum communis? ›The extensor digitorum muscle (also known as extensor digitorum communis) is a muscle of the posterior forearm present in humans and other animals. It extends the medial four digits of the hand. Extensor digitorum is innervated by the posterior interosseous nerve, which is a branch of the radial nerve.
What is the function of the extensor digitorum communis? ›Function. Primarily, the extensor digitorum communis extends medial four digits at the metacarpophalangeal joints and secondarily at the interphalangeal joints. It also acts to extend the wrist joint.
How do you strengthen extensor digitorum communis? ›Sit upright in a chair. Place your affected arm on a table with your palm facing down and your fingers flat on the table. Bend the end and middle joints of your fingers, keeping your knuckles straight. Use your unaffected hand to resist the knuckles of your fingers from bending backwards towards the ceiling.
What is the meaning of digitorum? ›a Latin word meaning "of the fingers or toes," used in the medical names and descriptions of some muscles. SMART Vocabulary: related words and phrases. The hand.
What is a common extensor tendon injury? ›Rupture or tear of the common extensor tendon is the most common acute tendon injury of the elbow. The most frequent pathology of the common extensor tendon is epicondylitis and is characterized by loss of normal tendon structure.
How serious is compartment syndrome? ›
Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury and is extremely painful. Without treatment, it can lead to permanent muscle damage.
What is the first symptom of compartment syndrome? ›Common symptoms observed in compartment syndrome include a feeling of tightness and swelling. Pain with certain movements, particularly passive stretching of the muscles, is the earliest clinical indicator of compartment syndrome. A patient may report pain with active flexion.
How is compartment syndrome of the hand treated? ›The aim of treatment is to prevent permanent damage. For acute compartment syndrome, surgery is needed right away. Delaying surgery can lead to permanent damage. The surgery is called fasciotomy and involves cutting the fascia to relieve pressure.
Can you get rid of compartment syndrome without surgery? ›Options to treat chronic exertional compartment syndrome include both nonsurgical and surgical methods. However, nonsurgical measures are typically successful only if you stop or greatly reduce the activity that caused the condition.
How do you fix compartment syndrome without surgery? ›Doctors may recommend non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen to reduce inflammation and swelling in the affected muscle compartments and alleviate pain. These medications are available without a prescription and are taken by mouth.
Does an MRI show compartment syndrome? ›Although MR imaging may be sensitive in the evaluation of compartment syndrome, it is not specific.
Can you fully recover from compartment syndrome? ›If weight-bearing exercises don't cause pain in the affected limb, you may begin to incorporate high-impact activity. Complete recovery from compartment syndrome typically takes three or four months.
What are the 7 signs of compartment syndrome? ›The classic signs of acute compartment syndrome include the 6 'P's': pain, paresthesia, poikilothermia, pallor, paralysis, and pulselessness. Pain is usually the initial complaint and should trigger the workup of acute compartment syndrome.
Does compartment syndrome get worse over time? ›Pain caused by chronic exertional compartment syndrome typically follows this pattern: Begins consistently after a certain time, distance or intensity of exertion after you start exercising the affected limb. Progressively worsens as you exercise.
Where is the extensor digitorum in the leg? ›The extensor digitorum longus is a pennate muscle, situated at the lateral part of the front of the leg. The mucous sheaths of the tendons around the ankle.
What is the central tendon of the extensor digitorum? ›
The Extensor Digitorum Communis (EDC) tendon at each finger splits into three bands or slips. These slips are: the central tendon/slip, which inserts on the base of the middle phalanx; and two lateral bands/slips, which rejoin as the terminal tendon/slip to insert into the base of the distal phalanx.
What nerve controls extensor muscles? ›Deep Branch of the Radial Nerve: Extensor carpi radialis brevis — extends and abducts the wrist.
What is the problem with the extensor digitorum muscle? ›A common type of injury that can affect extensor digitorum is tennis elbow. This injury is typically caused by overuse of the extensor muscles which attach at the elbow. Symptoms of tennis elbow include marked weakness in the wrist and hand along with pain localized to the outside of the elbow.
Why does my extensor digitorum hurt? ›Extensor tendinitis is usually caused by repetitive motions that build up irritation in your tendons over time and overload your tendons with increased weight or tension. The most common causes are using your hands or feet for work, as a part of a sport you play or activity you do often.
What does the extensor digitorum do in the leg? ›Function. The primary action of the extensor digitorum longus is to extend the lateral four toes at metatarsophalangeal joint.
How do you relax extensor digitorum? ›Raise your knees of the floor, keep your heels and knees together and feet on the floor. Hold for between 10 and 30 seconds. Tibialis Anterior - Extensor Digitorum Longus - Extensor Hallucis Longus. This stretch is really effective but you must be careful and make sure you have something to hold on to!
How do you massage extensor digitorum? ›Sit down in a cross-legged position and place the ball beneath the muscle. Apply pressure on the foot using your hands, but only if you require additional pressure. If you are unable to sit completely cross-legged, you may sit bending only the leg you are massaging.
How do you treat extensor digitorum tendon injury? ›How are extensor tendon injuries treated? Cuts that split the tendon may need stitches or surgical repair, but tears caused by jamming injuries are usually treated with splints. Splints stop the healing ends of the tendons from pulling apart and should be worn at all times until the tendon is fully healed.
What exercises can you do for the extensor digitorum? ›Lift your toes and front of your foot off the ground and pull them up towards your knee with the heel still touching the ground; Lift your toes and forefoot as high as possible and squeeze the muscles of the foot for a two-second count; and. Return to the starting position.
What does the extensor digitorum feel like? ›You will feel a muscle tensing; this is the Extensor Digitorum. There are usually two trigger points on it, closer to the elbow-side of your forearm.
Is extensor tendonitis serious? ›
With extensor tendonitis, the tendons become inflamed and swollen, usually due to overuse or excessive pressure on the tendon. Over time, the tendon can weaken and cause scarring, which can lead to further weakening and reduced flexibility.
What is extensor digitorum in medical terms? ›extensor digitorum communis
noun. : a muscle on the back of the forearm that extends the fingers and wrist.
The flexor digitorum superficialis functions to flex (bend) the fingers, while the extensor digitorum superficialis functions to extend (straighten) the fingers.
What is the muscle with digitorum in its name? ›The flexor digitorum profundus (FDP) is an extrinsic hand muscle that flexes the metacarpophalangeal and distal interphalangeal joints of the index, middle, ring, and little fingers.
What surgery repairs common extensor tendon? ›Your surgeon will move aside soft tissues to view the common extensor tendon and its attachment on the lateral epicondyle and then trims or releases the tendon and reattaches it to the bone. Any scar tissue present will be removed as well as any bone spurs.
How long does it take for extensor to heal? ›The tendon may take four to eight weeks, or longer in some patients, to heal completely. Removing the splint early may result in drooping of the fingertip, which may then require additional splinting.
What is the recovery time for extensor tendon surgery? ›Recovery: your tendon(s) will not be strong enough for light everyday activities until 4 weeks after surgery. Please wear your splint at all times for 4 weeks. It takes a further 4 weeks for the tendon to fully heal and be able to withstand strenuous activity eg: manual work, contact sport.
What are the 5 stages of compartment syndrome? ›Classically, the presentation of acute compartment syndrome has been remembered by "The Five P's": pain, pulselessness, paresthesia, paralysis, and pallor.
What are 3 ways to treat compartment syndrome? ›- avoid the activity that caused them – if you run, switching to a low-impact exercise, such as cycling, may help.
- use anti-inflammatory painkillers to reduce the pain and discomfort.
- have physiotherapy.
- use inserts (orthotics) in your shoes if you start running again.
Compartment syndrome is a painful syndrome caused by dangerously high pressure build up in a group of muscles. The high pressure can decrease blood flow, preventing nourishment and oxygen from reaching nerve and muscle cells. Acute compartment syndrome is a medical emergency that needs urgent surgery.
How painful is compartment syndrome? ›
Acute compartment syndrome usually develops over a few hours after a serious injury to an arm or leg. Some symptoms of acute compartment syndrome include: A new and persistent deep ache in an arm or leg. Pain that seems greater than expected for the severity of the injury.
Do you elevate leg with compartment syndrome? ›In cases with impending compartment syndrome, the extremity should not be elevated since this reduces the already impaired blood flow. A diagnosed compartment syndrome needs immediate fasciotomy as an emergency surgical procedure to release pressure from the affected compartment.
How long are you in the hospital for compartment syndrome? ›For acute compartment syndrome, a more extensive incision may be required, and your surgeon may need to address other injuries such as a fracture or soft tissue damage before closing the incisions. Your doctor may recommend that you stay in the hospital for observation for one or more nights.
What is the hallmark of compartment syndrome? ›Classically, the hallmark signs and symptoms of compartment syndrome are a swollen/tense compartment associated with the five Ps: pain, paresthesias, paralysis, pallor, and pulselessness. These are all present in late stages of ACS in adults but are not all seen early on and not nearly as reliable in children.
Is compartment syndrome a disability? ›But compartment syndrome can qualify you for disability benefits, as long as there is a corresponding injury or cause that you can point to that occurred during your term of service.
What happens when the extensor digitorum is damaged? ›Introduction. An extensor tendon injury is damage to the tissues on the back of the hand and fingers. It can make it hard for you to extend your wrist, open your hand, or straighten your fingers. The inability to perform these functions can severely limit hand and upper extremity function.
What are the 5 characteristic signs of a compartment syndrome? ›Common Signs and Symptoms: The "5 P's" are oftentimes associated with compartment syndrome: pain, pallor (pale skin tone), paresthesia (numbness feeling), pulselessness (faint pulse) and paralysis (weakness with movements).
What are the signs symptoms of compartment syndrome? ›- pain in a muscle – this may feel like a burning pain or a deep ache (moving the body part can make the pain even worse)
- swelling or bulging of the muscle.
- numbness, weakness or pins and needles.
- tightness or difficulty moving the affected body part.
Rest: Avoid the activity that irritated your tendons. Don't overuse your hand or foot while it heals. Ice: Apply a cold compress to your hand or foot for 15 minutes at a time, four times a day. Compression: You can wrap the painful area in an elastic bandage to help reduce swelling.
What is the action of the extensor digitorum communis? ›Function. Primarily, the extensor digitorum communis extends medial four digits at the metacarpophalangeal joints and secondarily at the interphalangeal joints. It also acts to extend the wrist joint.
When is compartment syndrome an emergency? ›
Acute compartment syndrome occurs when there is increased pressure within a closed osteofascial compartment, resulting in impaired local circulation. Acute compartment syndrome is considered a surgical emergency since, without proper treatment, it can lead to ischemia and eventually necrosis.
What is the first indicator of compartment syndrome? ›Common symptoms observed in compartment syndrome include a feeling of tightness and swelling. Pain with certain movements, particularly passive stretching of the muscles, is the earliest clinical indicator of compartment syndrome.
What is the most reliable indicator of compartment syndrome? ›The classic sign of acute compartment syndrome is severe pain, especially when the muscle within the compartment is stretched. The pain is more intense than what would be expected from the injury itself. Using or stretching the involved muscles increases the pain.
What is one major action that results when the extensor digitorum contracts? ›The extensor hood spreads out further distally into a median band which attaches to the middle phalanx and two lateral bands which attach to the distal phalanx. Contraction of the extensor digitorum muscle tightens this tendon which acts on these attachments and extends the fingers.
What nerve goes to extensor digitorum? ›Extensor digitorum is innervated by the posterior interosseous nerve, which is a branch of the radial nerve.