Introduction

Compartment syndrome occurs when pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischemia. The report of compartment syndromes of upper arm is conspicuously rare in medical literature ₁. The causes in arm are trauma, burns, infection, Fracture neck of Humerus, Triceps avulsion, and steroid use in athletes, thrombolytic therapy and prolonged pressure on the arm during sleep or unconsciousness as a result of alcohol or other drugs ₂, ₃. We wish to report our experience with an upper arm compartment syndrome.

Case Report

54 year old gentleman presented to us with pain and marked swelling in his left upper arm. He was found in semi-conscious state in his house after a heavy binge drinking over night. The past history included the hypertension and depression. The vital signs were normal with GCS of 14/15.There was no other injury. The pulses in left arm were palpable. The active flexion was restricted to 45 degrees and pain intensified on passive flexion which was limited to 90 degrees. Sensory examination was not possible because of conscious level. The compartment pressure in the arm was measured immediately which was 32 mmHg. It was repeated after 1 hour and was raised to 49 mm Hg. The blood showed W.B.C of 27.1, urea 7.3mmol/l, creatinine 323uml/l, K 6.9 meq/l, GGT 58 u/l and creatinine kinase (C.K) of 61000u/l (normal 10-186 u/l).The diagnosis of upper arm compartment syndrome was made. It was also obvious that the patient had rhabdomyolysis resulting into acute renal failure as he became oliguric. The immediate fasciotomy of arm was done extending from axilla arcing over the biceps down to extensor compartment of the arm (Fig 1 and 2).

Figure 1

Figure 1: Surgical incision for decompression of upper arm compartment

Figure 2

Figure 2: Surgical incision extending to forearm for decompression

There was no obvious muscle necrosis. The patient underwent haemodialysis. Further wound debridements were done for late my necrosis and wound was closed on 10^th day after admission. The patient was discharged after 4 weeks when renal function became normal. He was put into extensive rehabilitation and physiotherapy of the arm.

By 13 weeks postoperative, the patient had regained full range of motion of the elbow and follow-up x-rays showed no signs of myositis ossificans. Strength at 6 month follow-up as normal.

Discussion

The upper arm has two compartments-the extensor (triceps) compartment and the flexor (biceps) compartment. The arm has fewer rigid and broad ligaments and tendons than the leg or forearm, and the brachial fascia tends to yield more and, therefore, has a greater capacity for swelling prior to pressure increase within the compartment ₁. When these critical level are reached a true compartment syndrome can occur. The clinical signs and symptoms of compartment syndrome are pain out of proportion to clinical situation, a palpably tense compartment, pain with passive muscle stretch, paresis and paresthesia ₃

The muscles were noted to have functional impairment after 2 to 4 hours and of ischemia and irreversible functional loss after 4 to 12 hours. Nerves have found to show abnormal function after 30 minutes of ischemia with irreversible functional loss after 12 to 24 hours ₄, ₅. Rhabdomyolysis and subsequent renal failure are among the most severe complications as a result of muscle necrosis. Rising serial CK measurements are indicative of a rhabdomyolysis due to developing Compartment syndrome ₆. Muscle has considerable ability to regenerate by forming new muscle cells. Therefore, it is extremely important to decompress ischemic muscle as early as possible. In medical literature Fasciotomy has been proposed when compartment pressure rises within 10 to 30 mmHg of diastolic pressure ₆, ₇. If the compartment pressure is more than 40 mm Hg, a fasciotomy is usually performed emergently.

Higher index of suspicion for the diagnosis should be considered in patients with acute spontaneous arm swelling who are obtunded or unconscious like drug addicts, alcoholics and patients in ITU ₈. We stress on the early diagnosis of condition with appropriate history and clinical examination and a low threshold for surgical exploration and fasciotomy as it is associated with good outcome and functional recovery.

Correspondence to

Mr. Imran Rafiq Clinical Research Fellow Wrightington Wigan and Leigh NHS Trust Appley Bridge Lancashire, WN6 9EP United Kingdom Phone No. +441257251329 Mobile No. +447865086702 Fax No. +441257256369 E-mail: imranrafiq@doctors.org.uk