Patients with mutilating hand and finger injuries often present first to orthopaedic, plastic, or general surgeons covering emergency room call and sometimes present only by telephone consultation. The present report describes a patient who presented with a severe finger avulsion in whom the most urgent issue was an ipsilateral forearm compartment syndrome secondary to the avulsion. The patient was informed that data concerning the case would be submitted for publication, and he consented.
A fifty-five-year-old man was using a high-speed rotary tool, which caught a nylon cord that became wrapped around the right, dominant index finger. He presented to the emergency room with an open dislocation of the proximal interphalangeal joint. The soft tissues were nearly circumferentially avulsed (Fig. 1). Distally, the finger was dusky and insensate. The remaining fingers had normal color and capillary refill. The patient was otherwise healthy and denied taking any regular medications, including Coumadin (warfarin) and anti-inflammatory medications.
The patient complained of severe and worsening pain in the forearm and required 8 mg of intravenous hydromorphone in one hour. Physical examination revealed tense swelling and tenderness, which was greatest at the volar aspect of the middle part of the forearm and was worse with passive extension of the uninjured digits. He also complained of numbness in the median and ulnar nerve distributions, where he had corresponding decreased sensibility on examination. Radial and ulnar pulses were palpable at the wrist. Radiographs of the hand reflected dislocation of the proximal interphalangeal joint of the index finger. Radiographs of the forearm revealed only swelling. No fractures were identified.
The clinical diagnosis of forearm compartment syndrome was made, and the patient was taken to the operating room for emergent forearm fasciotomies within three hours after the injury. Prior to incision, the compartment pressure measured 46 and 49 mm Hg in the superficial and deep flexor compartments, respectively; 26 mm Hg in the extensor compartment; and 25 mm Hg in the mobile wad. A volar longitudinal incision was used to release the volar forearm muscles. The incision was extended over the carpal tunnel distally and to the antecubital fossa proximally. On release of the antebrachial fascia, the forearm muscles bulged out. Large amounts of hematoma were evacuated from the area of the avulsed musculotendinous junctions of the flexor digitorum profundus and superficialis to the index finger. The muscle tissue was mostly viable and contractile, although small areas appeared dusky and were sharply débrided with scissors. The transverse carpal ligament and lacertus fibrosus also were released. A dorsal longitudinal incision was used to decompress the extensor compartment muscles and the mobile wad, both of which appeared viable and unremarkable.
Both index digital neurovascular bundles were severely avulsed and were unsuitable for reconstruction. The flexor digitorum profundus and flexor digitorum superficialis tendons were delivered through the wound with minimum resistance, and the finger was removed in continuity with its flexor tendons (Fig. 2). Partial ray amputation was performed through the metacarpal shaft, and primary closure was achieved.
The patient had rapid improvement in terms of pain and swelling postoperatively. The fasciotomy wounds were closed two days later, and the patient was discharged on the following day. At one week, he was placed in a removable volar splint and began full active and passive motion exercises. The forearm was moderately swollen but minimally painful. At one month, the patient had a normal-appearing forearm with moderate stiffness of the remaining extrinsic finger flexors and other forearm muscles. By two months, the median and ulnar nerve symptoms had resolved, and sensibility had returned to normal. The patient was able to make a full fist, with grip strength measuring 14 kg (as compared with 45 kg on the uninjured side). He continued to progress well and was tentatively scheduled to return to modified duty at four months. Unfortunately, he sustained a ruptured cerebral aneurysm at three months after the injury and died.
Compartment syndrome occurs when elevated pressure within a closed space compromises circulation, tissue perfusion, and, ultimately, viability. The diagnosis is clinical and usually includes unremitting pain, often exacerbated by passive muscle stretch, along with swelling and tenderness. Compartment pressure measurements may help when the examination is equivocal or when pain cannot be assessed in an unresponsive patient1.
In the present case, a forearm compartment syndrome resulted following a nearly complete avulsion of the index finger. The mechanism was a severe degloving injury at the proximal interphalangeal joint, resulting in a proximal avulsion of the finger flexors at their musculotendinous junctions in the forearm. This led to an intracompartmental forearm hematoma and surrounding edema, which likely caused the compartment syndrome.
A previous report discussed compartment syndrome after closed avulsion of the entire humeral origin of the flexor digitorum superficialis2. That case involved an adult in whom the hand was injured while it was on the steering wheel during a motor-vehicle accident. Another report discussed closed rupture of the musculotendinous junction of the flexor digitorum profundus3. That case involved a toddler who was injured in a "tug-of-war." In both of those cases, there were no signs of digital trauma, and thus the pain and swelling in the forearm were the focus of observation from the time of presentation. Both cases were successfully treated with fasciotomies.
A report that was more comparable with the present one described a ring avulsion injury that occurred during a fall from a ladder4. In that case, the finger was already amputated at the time of presentation, with 15 cm of exposed tendon being the only connection between the finger and the remaining extremity. The proximal musculotendinous avulsion was obvious on inspection, and the finger was removed by simple transection of the tendons in the emergency department, followed later by forearm fasciotomies. In the present case, the proximal tendon avulsion was not evident as the finger remained attached and the tendons were not well visualized in the wound.
A mutilating finger injury from machinery is often a focus of attention and a diagnosis unto itself, as in the cases of table-saw and snowblower injuries. Those injuries involve primarily lacerating mechanisms, and generally only localized digital trauma. The avulsion mechanism in the case of our patient led to more remote damage. Physicians always should be aware of the potential for proximal injury when examining the patient in person or when being consulted by telephone. In the present case, the prompt and thorough assessment of the entire extremity, including an appreciation of the importance of pain and swelling in the forearm, led to the correct diagnosis of compartment syndrome and the appropriate intervention with forearm fasciotomies. Delay in treatment for the sake of transfer to a hand specialist, perhaps because of an assessment that was incompletely performed or secondarily reported through another provider, could have resulted in an unsatisfactory outcome. 