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Spring 2015

ARTICLES

Acute compartment syndrome of the posterior upper arm following a


prolonged seizure: a review of literature and case report
S Woods1, A Soni2

1)
2)

Mr Simon Woods BA, BMBS, MRCS, Orthopaedic Core Trainee in Yorkshire and the Humber.
Mr Ashish Soni MRCS, Dip SEM, FRCS (Orth) Orthopaedic Registrar in Yorkshire and the Humber.

Abstract
A 26 year old diabetic and epileptic man was found having a seizure due to diabetic ketoacidosis (DKA). The
seizure was estimated to persist for one hour. His seizure was controlled with a general anaesthetic in the
emergency department before he was transferred to ICU for management of his DKA. His left upper arm was
tense and swollen, and so orthopaedic input was urgently sought. Intracompartmental pressure measurements
confirmed compartment syndrome in the extensor compartment of the upper arm and he underwent emergency
fasciotomy. Two further procedures were required to achieve closure of the wound, but he recovered well.
Acute Compartment Syndrome (ACS) is a common phenomenon, but rarely found in the upper arm, possibly due
to the laxity of the fascia within the region. ACS typically results from a fracture, but can also be due to burns,
dislocation, vascular or penetrating injury, iatrogenic or crush injury. To the best of the authors knowledge there
are no previous cases of ACS in the upper arm due to prolonged seizure reported.
The principal symptom of ACS is pain disproportionate to injury. In this case pain was not a reported due to the
patient being anaesthetised. Other clinical features include firmness to palpation, loss of distal pulses, weakness,
and pain on passive stretch. Definitive diagnosis is by measurement of compartmental pressures in comparison to
diastolic blood pressure.
We recommend high clinical suspicion and urgent intervention with compartment pressure measurement,
monitoring and fasciotomy to avoid morbidity in this group of clinically challenging, obtunded patients.

Summary

Case

We present a case of Acute Compartment

A 26 year old man was found having a seizure at

Syndrome

extensor

home. When the paramedics arrived he had a

compartment following prolonged seizure. Clinical

GCS of 3, a capillary glucose of 27 and was

vigilance

of

ketotic. IV access was not possible and rectal

compartments ensured avoidance of significant

diazepam failed to control the seizure. He was

muscular necrosis and morbidity. Compartment

transported to A&E resus where intraosseous

syndrome of the posterior upper arm is extremely

access was obtained and he underwent rapid

rare condition, we are first to report its association

sequence induction. It is estimated he was

with prolonged seizure. We recommend high

seizing for over 1 hour. Bloods on admission

clinical suspicion, rapid investigation in terms of

showed a Haemoglobin of 162, White cell count

compartment pressure measurement and urgent

of 27.3, blood glucose of 31, creatinine of 157,

fasciotomy to avoid morbidity in this group of

and urea of 7.

of
and

the

upper

prompt

arm

decompression

clinically challenging patients.

MMJ: Mid Yorks Medical Journal

Picture 1: Swollen, tense, erythematous upper arm

His medical records were consulted, and he was

pain or neuromuscular function. Compartment

found to be a known epileptic with type 1

pressure measurement using an arterial line

diabetes. He had recently been admitted to ICU

pressure transducer showed significantly elevated

due to diabetic ketoacidosis. He was also known

posterior compartment pressure at 57mmHg

to have suffered previous hypoxic brain injury as

(systolic BP 66mmHg) but pressure within normal

limits in the anterior compartment and forearm

result

of

prolonged

seizure

secondary to DKA.

compartments.

In A&E the left shoulder and arm was noted to be

He was diagnosed with acute compartment

swollen and tense but well perfused. Plain

syndrome of the posterior compartment of the left

radiographs showed congruent shoulder with no

arm, and taken to theatre for urgent fasciotomy.

visible fractures. He remained unconscious and

Serum Creatine Kinase (CK) was measured and

was transferred to ICU intubated and ventilated.

found to be 78506 IU/L. His urine was also noted


to be dark brown in colour (picture 2).

The following morning the intensivist noted his


swollen, tense and erythematous left upper arm

He underwent a single incision fasciotomy with

(picture 1) and requested an urgent orthopaedic

the incision from the point of deltoid insertion to

review due to concerns about compartment

4cm proximal to the lateral epicondyle. The

syndrome.

triceps were found to be bulging, but on


decompression of the compartment the muscles

On examination the left upper arm was swollen,

were noted to be healthy in appearance and

erythematous and tense to palpation but distal

bleeding (picture 3).

pulses

were

present.

The

patient

was

unconscious and so it was not possible to assess

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Spring 2015

Picture 2: Brown cola coloured urine

Picture 3: bulging, but healthy appearance of triceps muscles

Picture 4: Demonstration of the radial nerve in the lateral intramuscular septum

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MMJ: Mid Yorks Medical Journal


The radial nerve was identified (picture 4) and the

iatrogenic (tourniquets, bandages), vascular injury

anterior compartment was also decompressed.

or

The surgical site was then washed and left open,

penetrating trauma. Cases have also been

with a gelonet dressing providing cover.

reported of compartment syndrome due to

bleeding,

intramuscular

dislocation 5,6,

haemorrhage

infection

and

following

Two days later the patient was returned to theatre

injury7or

for a wound check. The muscle appeared healthy

anticoagulated patient. Patients with a decreased

and there was moderate oedema to the wound

GCS are also at risk of compartment syndrome

edges. The proximal wound was approximated

due to prolonged limb compression against a

with 1-0 ethilon. A shoe string tension free

solid surface9, compounded by the lack of muscle

vascular sling was applied to the rest of the

tone in the obtunded patient10.

tendon

ruptures8,

minor

typically

in

the

wound using surgical clips.


Compartment syndrome of the upper arm is rare,
Complete wound closure was achieved at day 6

with no previous reported cases secondary to

without a need of skin grafting, whilst the patient

seizure that the authors could find.

was still intubated and ventilated. He was


extubated 4 days following closure and was noted

Anatomy

to have good function of his arm.

The upper arm consists of 2 compartments: the


anterior

compartment

containing

the

biceps

Discussion

brachii, coracobrachialis and brachialis; and the

Compartment Syndrome

posterior compartment containing the triceps

Compartment

syndrome

the

along with the aconeus and the articularis cubiti.

pressure within an anatomical compartment

These compartments are separated by the medial

compromises

that

and lateral intermuscular septi and the humerus

compartment . In acute compartment syndrome

bone centrally. The fascia of the upper arm is

(ACS) the pressure within a compartment builds

more yielding than that of the forearm and leg,

up due to oedema, typically following trauma.

contributing to the rarity of ACS in the upper

This initially prevents venous drainage, leading to

arm11.

the

occurs

circulation

when
to

a decrease in arteriovenous pressure gradient, in


turn diminishing the arterial supply to the

As demonstrated in picture 4 the radial nerve is at

compartment as the arterioles collapse under the

risk in the intermuscular septum of the arm when

pressure, ultimately causing tissue ischaemia .

performing a fasciotomy. It originates from the


posterior cord of the brachial plexus, passing into

Approximately 75% of ACS is secondary to long

the posterior compartment of the arm and winding

bone fractures3, most commonly the tibia4. Other

around

reported causes of compartment syndrome to the

accompanied by the profunda brachii artery.

extremities

include

crush

injuries,

burns,

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the

humerus

in

the

spiral

groove

Spring 2015
Diagnosis

30mmHg is a positive diagnosis for compartment

The Pathognomonic symptom of compartment

syndrome and an indication for emergency

syndrome is pain disproportional to injury. Other

fasciotomy14.

symptoms include paraesthesia and increased


pain on compartmental stretch. On examination

As ACS develops and ischaemia occurs the

the classical signs include a tense woodiness on

compartmental muscles break down, resulting in

palpation,

the

rhabdomyolysis. The leakage of myoglobin can

decreased

result in myoglobinuria and acute renal failure. It

sensation and weakness indicate advanced

is therefore essential have a high index of

damage, possibly irreversible from untreated

suspicion for compartment syndrome in patients

compartment syndrome. In this case the patient

with suggestive injuries, raised serum CK and

was anaesthetised, intubated and ventilated and

darkened urine. It is also essential to monitor

so unable to report any pain. When managing an

renal function throughout.

pain

compartment.

on

passive

Absent

stretch

pulses,

of

obtunded patient who has suffered potential


trauma or prolonged lie on a dependant it is

The cornerstone of management for ACS is to

essential

of

remove all causes of increased pressure. This

compartment syndrome, including firmness of a

includes tight clothing, dressings and casts.

limb,

Ultimate treatment for compartment syndrome is

to

be

darkening

vigilant
of

to

the

the

urine,

signs
and

acute

fasciotomy of all compartments involved. Any

deterioration of renal function.

delay to fasciotomy increases the potentially


Upon suspicion of ACS prompt investigation,

irreversible

referral and management is essential, a delay of

compartment. It is therefore vital that the time

more than 12 hours may lead to irreversible

from clinical suspicion to diagnosis and surgery is

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damage

to

contents

of

the

muscle and nerve damage . The diagnosis is

minimalised to prevent morbidity and potentially

clinical with measurement of compartmental

mortality.

pressures a useful adjunctive investigation. This


can be done using a needle and arterial line

Conclusion

pressure inducer, such as in this case, or with

Compartment

specifically designed handheld manometers (e.g.

compartment of the upper arm is rare in clinical

a Stryker device).

practice

and

unconscious

syndrome
difficult
patient.
with

to

the

posterior

diagnose

When

in

the

managing

an

The pressure within a compartment begins to

obtunded

compromise perfusion when it reaches a level

prolonged gravitational pressure on an extremity

within 10-30mmHg of diastolic pressure13. The

it is essential to exercise a high index of suspicion

diastolic blood pressure minus the compartment

and be vigilant to the signs of compartment

pressure is known as the delta pressure and it is

syndrome. When compartment syndrome is

suggested that a delta pressure is less than

suspected it is vital that definitive investigation

13

patient

of

potential

trauma

or

MMJ: Mid Yorks Medical Journal


and treatment with fasciotomy is undertaken as a matter of urgency before irreversible tissue
damage can occur.
Consent
Full consent was obtained from the patient.
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