COMPARTMENT syndrome is a potentially devastating perioperative complication that typically involves the legs or arms.1Most surgical patients have this problem while anesthetized and positioned in lithotomy or lateral decubitus positions.2We recently observed compartment syndrome of the hand in a patient who was anesthetized and positioned supine for a surgical procedure, a previously unreported perioperative complication in the absence of trauma or vascular obstruction in the upper extremity. A potential positioning cause for the compartment syndrome prompts this case report. To supplement this case report, we also have reviewed our experience with this perioperative problem during the past 15 yr, using a robust perioperative database to determine the frequency ratio and outcomes of this event.
Representative Case Report
A 43-yr-old man with a body mass index (BMI) of 36 kg/m2came to the operating room for colostomy takedown and simultaneous revision of a complex abdominal scar. He was positioned supine on the operating room table, and 18-gauge intravenous catheters were placed bilaterally in veins on the dorsum of his hands. General endotracheal anesthesia was initiated without difficulty. Subsequently, experienced personnel tucked the patient’s arms at his sides, with his palms facing inward against the lateral thighs. The elbows were padded with foam cushions, and the upper arms were externally rotated to reduce extrinsic pressure on the ulnar nerves in the medial epicondylar grooves. The tucks were then performed using a standard draw sheet under the patient’s back, looped over his arms while they were resting at his sides, and tucked under his chest, abdomen, and buttocks. Both intravenous catheters functioned well after the arms were tucked and throughout the case. The procedure lasted 5 h, and the patient received 5.2 l crystalloid during the procedure.
On arrival to the postanesthesia care unit, the patient reported severe, unrelenting left hand pain. He described his pain as burning and constant. It was not improved with several boluses of intravenous fentanyl. Examination of his left arm and hand revealed dorsal topography consistent with pressure caused by constrictive fabric (i.e. , the draw sheet) across the dorsal wrist and medial hand. The 18-gauge intravenous catheter in the forearm continued to function and was not infiltrated. The left palm was hyperemic, had distal phalangeal pallor, and was tense, swollen, and exquisitely tender over the thenar and hypothenar prominences. He could not actively abduct or oppose his thumb, and he could not tolerate passive extension of his thumb because of pain. Neither ice nor elevation relieved the pain, and a hand surgeon was rapidly consulted. The patient was returned to the operating room for tissue pressure measurement and fasciotomy. Pressures of the thenar, hypothenar, and first dorsal interosseous compartments were 81, 53, and 36 mmHg, respectively. The patient has not recovered well from this complication. Ten months after his fasciotomies, he had pain that awakened him at night and with any use of the hand, plus dysfunction that prevented him from using his hand for lifting or gripping most objects.
Retrospective Study Methodology
With Mayo Institutional Review Board approval, the medical database at the Mayo Medical Center, Rochester, Minnesota, was reviewed to glean all cases of patients who had undergone an index (i.e. , initial) surgical episode and within 5 days a subsequent fasciotomy of the hand during the 15-yr period of July 1, 1988, to June 30, 2003. Each unique anesthetic was considered to represent a single surgical episode, regardless of the number of procedures performed during that anesthetic. We attempted to glean only cases in which perioperative positioning or some unrecognized characteristic or event may have caused compartment syndrome of the hand. Therefore, cases of compartment syndrome that occurred in traumatized hands or hands that may have been subject to ischemia from vascular surgical procedures of the upper extremities were excluded. All surgical episodes must have been performed while patients underwent general anesthesia, regional anesthesia, or both or local anesthesia with or without sedation. A single trained reviewer abstracted all records. Outcomes of these patients at least 6 months after the index surgeries were obtained.
Description of Surgical Population and Report of Cases
During the study period, 782,883 patients underwent 902,412 surgical episodes. Nineteen percent (148,703) underwent more than one surgical episode. Slightly more than half of the 782,883 patients were female (52.6%, n = 411,796). The mean age (± SD) of the surgical population was 51.2 ± 19.1 yr, with ages ranging from 0 to 110 yr.
Overall, 79 of the 782,883 patients (1:9,909 or 10.1 per 100,000) underwent a fasciotomy of the hand within 5 days of their index procedures. Nearly two thirds of these patients (62.0%, n = 49) underwent this procedure secondary to trauma. Sixteen of these patients (20.2%) experienced a compartment syndrome of the hand and required fasciotomy within 48 h after a vascular surgical procedure. Six patients (7.6%) experienced the syndrome after an arterial embolic event, and 3 others had miscellaneous medical conditions that contributed to the compartment syndrome. There was no apparent preexisting cause for the compartment syndrome of the hand in 5 patients (6.3%), including the patient noted in the representative case reported here. However, 4 of these 5 patients were large men with BMIs greater than 35 kg/m2who underwent abdominal or pelvic procedures of at least 3 h in duration, were given more than 4 l intravenous fluids intraoperatively, had their arms tucked at their sides during the procedures, and received general anesthetics. The patient and procedure characteristics and outcomes of all five of these patients are described in table 1.
The overall frequency ratio of compartment syndrome of the hand requiring fasciotomy and with no apparent preexisting cause was 1:156,576 (0.6 per 100,000). These five cases occurred in 1990, 1992, 1998, 2003, and again in 2003. The outcomes of this problem in patients 6 months after their fasciotomies varied. Two patients had complete resolution of their symptoms and no disability or pain. One patient had no pain and only minor residual weakness of opposition, resulting in difficulty holding objects with handles (e.g. , golf clubs, racquets, hammers). The remaining two patients had significant pain and loss of hand function that prevented them from many routine uses of their upper extremity (e.g. , writing with a pen, typing, gripping a steering wheel, holding a glass).
We believe that this perioperative complication has not been previously reported. Fortunately, it is a rare event and, in four of our five cases, the outcomes have been reasonably good. However, prompt recognition of compartment syndrome of the hand in the immediate postoperative period is important to prevent muscle and nerve necrosis and, ultimately, severe disability.3
Importantly, these cases suggest that the frequency of this event can be reduced or its occurrence can be potentially eliminated. Four of the five cases were obese men undergoing prolonged abdominal or pelvic procedures. Their arms were tucked under a looped draw sheet at their sides. The representative case reported above describes the potential tourniquet effect of the distal (caudad) end of the draw sheet. Figure 1Ashows how a tightly looped draw sheet in this patient, especially at the wrist, could have contributed to prolonged partial venous obstruction from the hand and possibly even reduced arterial blood flow. Another potential risk of the use of a looped draw sheet may be direct compression of the musculature of the hand, especially in the thenar and hypothenar regions. Increased pressure on the musculature may directly occlude small arterioles and venules, or it may generate a compartment pressure higher than the arteriolar pressure and indirectly prevent blood inflow. This effect may be compounded in the presence of intravenous fluid infiltration or tissue edema.
Many of the operating room tables in use today are similar in width to those used several decades ago. Over this period of time, the mean BMI of the surgical population has increased considerably. For example, at our institution, the mean (± SD) BMI of all of our adult surgical patients in 1990 was 23.1 ± 6.3 kg/m2. In 2000, the mean BMI had increased to 25.7 ± 6.6 kg/m2, an increase of 11% in just one decade. Continued requests by surgeons to tuck patients’ arms at their sides for many abdominal and pelvic procedures may result in vigorous or overzealous use of the draw sheet as a mechanism for positioning the arms.
We propose that, whenever possible, alternatives to the use of draw sheets for arm positioning should be considered when the arms do not rest easily and with ample room at the patient’s sides. Two simple alternatives include adding width to the operating room table with expander attachments and abducting one or both arms to the sides and supporting them on arm boards. If the use of a draw sheet is used to tuck patients’ arms at their sides, we suggest that anesthesia providers and others confirm that the proximal (cephalad) and distal (caudad) ends of the draw sheet are loose and, for the hand, draped over the entire surface of its dorsum (fig. 1B). This confirmation should reduce the risk of vascular obstruction and potential for compartment syndrome of the upper extremity and hand.
In summary, we found that compartment syndrome of the hand with no apparent preexisting cause and requiring fasciotomy occurred rarely and, in most cases, resulted in minor disability after 6 months. Although it is possible that a tourniquet effect at the ends of draw sheets used to retain the arms of patients at their sides during the intraoperative period may be a contributing factor, other unknown mechanisms may be responsible, and additional investigations are needed.