(Kiosk 2) Case Report: A Unusual Cause and Clinical Presentation of Acute Forearm Compartment

Case Diagnosis: 68-year-old male with right forearm acute Compartment Syndrome (CS).

Case Description or Program Description: A 68-year-old male patient was admitted due to pulmonary embolism, bilateral leg deep vein thrombosis (DVT) on full-dose-anticoagulation, and gout flare-up. Was consulted to Physiatry (PM&R) due to physical deconditioning. The patient referred right forearm pain and swelling within one day after Arterial Blood Gas (ABG) sampling. Examination was remarkable for right distal upper extremity swelling, erythema, and limited range of motion at the wrist and phalanges with radial pulse present. Right arm X-rays and ultrasound were negative for fracture or DVT. He was started on colchicine for a suspected gout flare-up.

Setting: Tertiary care and hospitalization.

Assessment/Results: Bone scan and MRI were performed. MRI showed intramuscular hematoma. Elevated CPK. Semmes-Weinstein over 3.61. Findings were suggestive of acute CS. After six days of worsening symptoms, a fasciotomy was performed. After surgery, patient started the rehabilitation process with an initial adequate response.

Discussion (relevance): Acute CS can result in permanent nerve and muscle damage leading to decreased functional capacity and tissue necrosis, causing CPK elevation. Few cases of acute CS are reported after ABGs sampling. The mechanism is associated with repeated vessel laceration, leading to hematoma formation causing increasing intra-compartmental pressure. Acute CS is considered a clinical diagnosis; however, this patient had an unusual presentation with preserved radial pulse, sensation, and no pallor. Symptom progression and gout initially misdiagnosed became key factors in diagnosis and treatment.

Conclusions: Acute CS does not always present with the main characteristic signs. Patients with full dose anticoagulation have an increased risk of developing acute CS due to the risk of hematoma. Routine procedures such as ABGs should be considered as a cause of acute CS in the clinical setting. Fasciotomy is the definitive treatment, delays in management have devastating consequences in terms of ADLs functionality and prognosis.