KENNETH TOWERS, AGE 22, is transferred from the emergency department to your orthopedic unit at 1400 in stable condition. After binge drinking the night before, he was found unconscious, lying on his right arm. No one knows how long his arm was compromised. Kenneth was admitted with pain, which he rated as a 4 on a scale of 1 to 10, and swelling in his right forearm and hand. He’s receiving Vicodin (acetaminophen and hydrocodone) for his pain.
His blood pressure is 128/82 mm Hg; pulse, 88 beats per minute; respirations, 16 per minute; oxygen saturation, 98% on room air; and temperature, 99º F (37.2º C). His bilateral pulses are grade 2+. His fingers are warm and have full sensation and range of motion. Capillary refill is less than 2 seconds, and blanching is greater than 15 seconds. His right arm has erythema above the elbow and is swollen from his elbow to his fingertips.
When you assess him an hour later, the pain remains at 4 out of 10, and the fingers of his right hand are still warm, with full sensation and range of motion.
At 0730 the next day, you note that Kenneth’s right forearm is grossly swollen. He now rates his pain as 10 out of 10. His fingers are dusky and cold. Using a Doppler stethoscope, you detect a faint pulse at the radial and ulnar arteries. He complains of paresthesia and an inability to move his right arm. An attempt to passively move his fingers causes extreme pain. You suspect compartment syndrome and know that without treatment, he could lose his arm.
Call for help
You immediately put his arm at heart level and call the attending physician, who orders a vascular consult and a STAT ultrasound of the right arm. The ultrasound shows markedly decreased blood velocity in the forearm, but no evidence of deep vein thrombosis.
On the scene
After the ultrasound, you detect no pulse below the brachial artery. Kenneth’s forearm is cold, and he can’t move his fingers. The arm is hard and red, and any attempt to passively move his fingers produces excruciating pain. You call the resident. On arrival, he calls for an operating room (OR) surgeon and an orthopedic surgeon to meet him in the OR.
The orthopedic surgeon performs a fasciotomy of the forearm and a carpal-tunnel release. The superficial compartments are released along with muscle release, and arterial flow to the hand is restored. The fasciotomy wounds are left open for several days to allow swelling to decrease. After 48 hours, Kenneth is taken to the OR for irrigation and debridement. On his fourth postoperative day, the wound is closed.
Kenneth has a mild loss of function in the right arm, which should improve with physical therapy.
Education and follow-up
You teach Kenneth the signs and symptoms of compartment syndrome. You also explain how to care for the surgical site and why he must continue physical therapy after discharge.
Of the body’s 46 compartments, 38 are in the arms and legs. Each compartment consists of muscles, bones, nerves, blood vessels, tendons, ligaments, and inelastic fascial tissue that bind the contents together. And each is just large enough to hold its contents.
When pressure in a compartment increases or compartment size decreases, the result is compartment syndrome. Capillary blood flow decreases, leading to tissue necrosis, which can cause a loss of function and may require amputation of the limb.
The signs and symptoms, which can appear between 2 hours and 6 days after the injury, are the five P’s: pain out of proportion during passive stretch of the fingers or toes, pallor, paresthesia, pulselessness, and paralysis.
Pain and paresthesia are the most common, but keep in mind that the five P’s aren’t diagnostic. When you are caring for a patient with any of the five P’s, follow your instincts and perform accurate neurovascular function checks. You might just save a limb.
Delilah Hall, MSN, RN, CNS, is a Clinical Nurse Specialist in the Center for Rehabilitation at The Cleveland Clinic in Cleveland, Ohio.