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Eur J Cardiothorac Surg 1999;16:580-581
© 1999 Elsevier Science NL

Case report

Forearm fasciotomy post cardiac surgery

Department of Cardiothoracic Surgery, National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, Hammersmith Hospital, Du Cane Road, East Action, London, W12 0NN, UK

Corresponding author. Tel.: +44-181-743-2030; fax: +44-181-740-7019
e-mail: mpoullis{at}rpms.ac.uk

	Abstract

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Compartment syndrome is an uncommon diagnosis in the field of cardiac surgery. Early diagnosis and prompt operative decompression are essential for a successful outcome in terms of functional status of the limb concerned and mortality. The management of a compartment syndrome of the forearm is identical to that of the leg.

Key Words: Forearm • Compartment syndrome • Fasciotomy • Cardiac surgery • Cardiopulmonary bypass

	1. Introduction

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Fasciotomy for compartment syndrome is a rare complication of cardiac surgery, with an incidence of approximately 0.1% of cases that involve cardiopulmonary bypass [1]. It is almost exclusively confined to the lower limbs, most commonly following the insertion of the intra aortic balloon pump, but can also be solely due to cardiopulmonary bypass itself [2]. In the upper limb, axillary vein thrombosis should be excluded, however this does not exclude venous obstruction during the operative period when the sternum is retracted.

	2. Case report

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
A 48-year-old gentleman who had previously undergone aortic valve replacement with a Starr Edwards prosthesis for congenital bicuspid aortic stenosis in 1988, presented with shortness of breath and was found to have a significant paraprosthetic leak and an enlarged aortic root.

Resternotomy and cardiopulmonary bypass at 28°C was performed via right atrial and high aortic cannulation. Aortotomy revealed partial dehiscence between prosthesis and the annulus in the non-coronary sinus. The aortic annulus was reduced by a V-shaped incision in the mid non-coronary sinus and an aortic root replacement with a 32-mm Carbomedics composite conduit containing a 29-mm valve was then performed.

The patient was successfully weaned from bypass on 0.06 µg/kg per min of adrenaline. The following morning, 15 h post-operatively, he developed a painful cold left hand. The axillary and brachial pulses were palpable. Doppler studies revealed good triphasic flow in the radial, ulnar, mid palmer arch, and digital vessels. He had no sensory loss. The pain in his left forearm increased and was exacerbated by extension, and it became tender. The hand became cyanosed, and had decreased capillary refill. Axillary vein thrombosis was excluded by the fact that the superficial veins were not distended. The patient had received no intravenous infusions into his left arm, and the arterial cannula was sited in the right arm. The diagnosis of compartment syndrome of the forearm was made on clinical grounds so compartment pressures were not measured, and urgent fasciotomy was performed.

An anterior forearm incision, (Henry's approach) from the elbow to the hand, a posterior incision, and a dorsum of hand incision, over the interossei were performed. Bulging muscle and oedema was noted. A carpal tunnel decompression was also performed to protect the median nerve.

The wounds were left open to allow the oedema to resolve and closed electively 1 week later. The patient was discharged home well, with full movement of his forearm and hand 16 days after operation.

	3. Discussion

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 
Compartment syndrome which is swelling of soft tissues within a confined osseofascial space is usually the result of trauma or severe prolonged ischaemia, but can also be due to excessive unaccustomed use. Intra aortic balloon pumps are associated with 86% of compartment syndromes post bypass due to the associated limb ischaemia it can induce [1]. An ipsilateral femoral venous line or venous dialysis catheter may also increase the risk due to the associated venous outflow obstruction that can result [3]. Compartment syndrome may, however, develop after bypass secondary to the generated inflammatory response without any of these recognised risk factors being present [1]. In the case of the upper arm the effect of venous obstruction should be considered. In our case there was no evidence of axillary vein thrombosis, however this does not exclude venous obstruction during the period that the sternum was retracted.

In this condition the arteries may continue to pulsate, even while ischaemia develops and the contained swelling produces a rise in tissue pressure to the point of exceeding the capillary filling pressure [4]. Since nerve tissue is more susceptible than muscle tissue to ischaemia, initial symptoms include paraesthesia and pain in the involved extremity. Pain can be severe, especially when the limb is passively moved. Thus the presence of distal pulses does not exclude a compartment syndrome since they are usually present early in the course and may even persist until complete and irreversible necrosis has occurred [5].

Compartment pressures can be determined by direct measurements, with a Wick catheter or plastic cannula inserted directly into the involved muscle or compartment. A compartment pressure above 40 mmHg, or a pressure above 30 mmHg, which is sustained for greater than 4 h, indicates the need for surgical intervention [6]. If compartment pressures can not be obtained, which can be due to a lack of free fluid in the compartment or oedematous tissues blocking the measuring cannula, the clinical situation should determine the need for surgical intervention.

Irreversible myonecrosis will result within 12 h of unrelieved compartment syndrome and result in Volkman's ischaemic contracture [6]. The myonecrosis can be so severe that acute tubular necrosis, necessitating both amputation of the limb and haemofiltration/haemodialysis secondarily to myoglobinuria can result, with an associated mortality in excess of 60% [7].

To our knowledge this is the first description of a case of successful treatment of forearm compartment syndrome post cardiopulmonary bypass. It is clinically identical to compartment syndrome of the leg and can occur in the presence of distal pulses [8]. Prevention of sequelae depends upon early recognition and prompt surgical decompression of the relevant compartments [9].

	References

Top Abstract 1. Introduction 2. Case report 3. Discussion References

 

1. Allen R.C., Schneider J., Longenecker L., Kosinski A.S., Smith R.B., Lumsden A.B. Acute lower extremity ischemia after cardiac surgery. Am J Surg 1993;166:124-129.[Medline]
2. Davidson J., Baumgariner F., Omari B., Milliken J. Intra-aortic balloon pump: indications and complications. J Natl Med Assoc 1998;90:137-140.[Medline]
3. Williams P.H., Bhatnagar N.K., Wisheart J.D. Compartment syndrome in a five-year-old child following femoral cannulation for cardiopulmonary bypass. Eur J Cardio-thorac Surg. 1989;3:474-475.[Abstract]
4. Schwartz S.I. Fractures and joint injuries. Principles of surgery, third ed New York: McGraw Hill, 1984:1966.
5. Kitka M.J., Meyer J.P., Bishara R.A., Goodson S.F., Schuler J.J., Flanigan P. Crush syndrome limb compression. Arch Surg 1987;122(9):1078-1082.[Abstract]
6. Cusheri A., Giles G.R., Moosa A.R. Vascular trauma. Essential surgical practice, second ed London: Wright, 1988:311.
7. Thadhani R., Pascual M., Bonventure J.V. Acute renal failure. New Engl J Med 1996;334:1448-1459.[Free Full Text]
8. Botte M.J., Gelberman R.H. Acute compartment syndrome of the forearm. Hand Clin 1998;14(3):391-403.[Medline]
9. Jameson J.S., Sayers R.D., Macpherson D.S., Spyt T.J. Management of lower limb ischaemia associated with the use of intra-aortic balloon pumps during cardiac surgery. Eur J Vasc Endovasc Surg 1995;10:327-329.[Medline]

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