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Acute Compartment Syndrome of Forearm from Gunshot Wound
Peter D Gibson, MD; Omkar Baxi, MD; John S Hwang, MD; Nicholas D Steaks, BS; Mark Adams, MD
Rutgers-NJMS, Newark, NJ
Introduction: Acute compartment syndrome of the upper extremity is a surgical emergency which requires prompt intervention. Delay in diagnosis or intervention can result in devastating consequences including neurologic dysfunction, ischemic contractures, muscle dysfunction and loss of life or limb. Penetrating injuries causing compartment syndrome have been largely ignored in the current literature, yet are a significant burden within many urban centers. The objective of this study was to determine causes, complications, and clinical outcomes associated with forearm compartment syndrome of the upper extremity resulting from gunshot wounds.
Methods: All patients that underwent forearm fasciotomy with associated gunshot were identified from our orthopedic trauma from 2001-2013. Retrospective chart review was performed recording demographic information, means of diagnosis (pressure monitor vs clinical) associated neurovascular injury, time to fasciotomy, pre- and post-fasciotomy neurovascular status, time to fasciotomy closure, and method of closure.
Results: Twenty-five patients who underwent forearm fasciotomies due to gunshot were identified over a 14-year period. All patients were males with a mean age of 28 years old. Seventy-two percent(n=18)suffered the gunshot wound to the elbow region, and60%(n=15) suffered an associated fracture. Injury to a named artery occurred in 48%, with the most common injury involving the brachial artery. A clinical diagnosis (with or without Stryker monitor)was made in 14 cases, and made with Stryker monitor alone in 7 cases (5 of the patients were intubated, and 2 of the patients had unreliable exam due to nerve injury).
Neurological sensory and motor deficits were noted in 13 and 6 patients respectively prior to fasciotomy, with 38%(n=8) recovering full sensory function and 33% (n =2) recovering full motor function.A mean of 2.7 operative procedure were performed for wound management(I&D, closure, etc.) (Range 0-23, SD-4.4) after fasciotomy, with 12 patient requiringskin graft or free flap.
Only 20% of patients recovered full function on most recent follow up, with the remaining 80% suffering from one or more of the following: neurologic deficit(56%), Chronic pain in extremity(28%), decreased range of motion(32%).
Discussion Forearm compartment syndrome from a gunshot is a difficult diagnosis due to its association with fractures, soft tissue damage, and neurovascular injury. Diligent and frequent clinical examination should be performed in all individual with abnormal vascular status. Compartment pressure monitoring should be considered in all intubated patients, and those who have lost protective sensation due to neurologic injury. Acute compartment syndrome of the forearm is a significant morbidity often with permanent neurologic injury/complication.
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