Hand clinics
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Necrotizing fasciitis is a severe, fulminant infection most commonly encountered in patients with diabetes mellitus, alcohol abuse, and intravenous drug abuse. The infection can spread-unrecognized along fascial planes beneath seemingly normal skin. The relatively benign appearance of the extremity is misleading and often results in delay in diagnosis and increased morbidity or death. ⋯ Diabetic gangrene typically occurs in those diabetic patients with severe peripheral vascular or renal disease. The infections are usually polymicrobial. Treatment involves broad-spectrum antibiotics and multiple surgical debridements or amputation.
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High clinical suspicion is of paramount importance in evaluating the hand or wrist for an evolving compartment syndrome. A detailed history coupled with a thorough physical examination form the basis for the diagnosis. The use of techniques to measure compartment pressures forms the objective foundation to assist in formulating the correct treatment plan. ⋯ Once the damage is done, it is permanent. A thorough understanding of the pertinent anatomy is critical to safe, efficacious treatment. Handled promptly and judiciously, compartment syndrome of the hand and wrist can be managed effectively, decreasing the morbidity associated with this potentially devastating and debilitating process.
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Fractures are associated with the majority of compartment syndromes in children. Respect for associated soft-tissue injuries and recognition of specific fractures that can put a limb at risk for compartment syndrome are essential for prevention or successful treatment with early decompressive fasciotomies. In those limbs at risk for compartment syndrome, percutaneous pinning or intramedullary fixation provides fracture stabilization and prevents problems noted with standard cast treatment. ⋯ In particular, the agitated child with increasing analgesia requirements requires a thorough evaluation. The child's behavior should not be attributed to young age, fear, or fracture pain. This is a trap that must be avoided to prevent the disastrous outcomes of a missed compartment syndrome.
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The forearm is the most common site for compartment syndrome in the upper extremity. The three compartments of the forearm include the volar (anterior or flexor), the dorsal (posterior or extensor), and the mobile wad. Both-bone forearm fractures and distal radius fractures are common initial injuries in adults that lead to acute forearm compartment syndrome. ⋯ If symptoms do not resolve rapidly, fasciotomy is indicated. Decompression fasciotomy of the forearm is performed through volar or dorsal approaches. The medial nerve is decompressed throughout its course, including high-risk areas deep to the lacertus fibrosus; between the humeral and ulnar heads of the pronator teres, the proximal arch, and deep fascial surface of the flexor digitorum superficialis; and the carpal tunnel.
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A high index of suspicion for a compartment syndrome in the upper extremity should be maintained in all obtunded patients who are at risk for the condition. Obtunded patients are those with a dulled or altered physical or mental status secondary to injury, illness, or anesthesia; those with diminished or absent sensation in the upper extremity because of nerve injury or anesthesia; and those whose ability to communicate is impeded, such as infants and young children and the mentally ill or disabled. These patients represent a vulnerable group whose inability to demonstrate the hallmark symptoms and signs of the syndrome puts them in jeopardy of a late diagnosis of a compartment syndrome and its potentially devastating sequelae. ⋯ Intracompartmental pressure measurement provides a useful adjunct to the physical examination and history in these patients and may be diagnostic if other symptoms and signs are obscured. Once the compartment syndrome is diagnosed, emergent fasciotomy is indicated. To avoid a loss of function in the obtunded patient, special care must be taken postoperatively to assure that early motion exercises are carried out.