import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Between FDS and FDP in volar compartment, approximately 2cm radial to midline incision. Most sensitive nerve to ischemia. **Protection**: Identify early when releasing volar superficial fascia. Trace distally between FDS tendons. Protect during deep compartment release by gentle retraction. **Location**: Ulnar border between FCU and FDP. Enters Guyon's canal at wrist between pisiform and hook of hamate. Ulnar artery runs with nerve. **Protection**: Volar incision along ulnar border identifies nerve superficially. Oblique wrist incision crosses lateral to Guyon's canal avoiding direct nerve pressure. **Location**: Deep between brachioradialis and ECRL/ECRB proximally. Becomes subcutaneous 8-10cm proximal to radial styloid, emerging between brachioradialis and ECRL tendons. **Protection**: Identify when releasing mobile wad from dorsal approach. Trace carefully in distal third where it becomes superficial. Gentle retraction only. **Location**: Motor branch of radial nerve. Deep to supinator proximally. Runs between superficial and deep extensor layers in extensor compartment. **Protection**: Typically safe during standard dorsal fasciotomy as it runs deep. Risk increases if extensive proximal dissection or supinator release required. **Location**: Radial border of forearm between brachioradialis and FCR proximally. Becomes superficial at wrist 5cm proximal to radial styloid, between FCR and brachioradialis tendons. **Protection**: ULNAR volar approach avoids radial artery completely. If radial approach used (not recommended), radial artery lies in direct path - must identify and protect. **Location**: Pure motor branch of median nerve arising 5cm distal to medial epicondyle. Runs on interosseous membrane with anterior interosseous artery in deep volar compartment. **Protection**: Identified during deep volar compartment release. Innervates FPL, radial FDP, pronator quadratus. Injury causes inability to make 'OK' sign (AIN syndrome). ## Forearm Compartment Syndrome - Recognition and Decision-Making ### High-Risk Injuries **Pediatric**: - Supracondylar humerus fractures (most common cause in children - 10-20% risk) - Both-bone forearm fractures with significant displacement - Floating elbow (ipsilateral humerus and forearm fractures) **Adult**: - Both-bone forearm fractures (radius and ulna) - Isolated radius or ulna fractures with severe soft tissue injury - Crush injuries (machinery, motor vehicle collision) - Prolonged limb ischemia (brachial artery injury with delayed repair) - Ischemia-reperfusion injury after revascularization - Burns (circumferential eschar) - Tight casts or dressings - Snake bites (rare but recognized) ### Clinical Diagnosis - CRITICAL **EXAM KEY**: Forearm compartment syndrome is a CLINICAL DIAGNOSIS. Do NOT wait for compartment pressure measurements - they delay treatment and increase morbidity. Classic teaching: 'Pain out of proportion to injury' but this is subjective. More reliable: Pain on PASSIVE FINGER EXTENSION (stretches volar flexor compartment) - earliest and most specific sign. **Five Ps** (late signs - do not wait for all): 1. **Pain** - out of proportion to injury, progressive 2. **Pain on passive stretch** - MOST RELIABLE early sign 3. **Pressure** - tense, swollen forearm compartments on palpation 4. **Paresthesias** - median nerve most sensitive (thumb-index numbness, thenar weakness) 5. **Pulselessness** - LATE sign (compartment syndrome can occur with intact pulses) 6. **Pallor** - LATE sign 7. **Paralysis** - LATE sign (indicates severe ischemia) **Key Clinical Findings**: - Pain on passive finger extension (stretches volar compartment) - EARLIEST sign - Pain on passive finger flexion (stretches dorsal compartment) - Tense, swollen forearm (compartments firm on palpation) - Progressive pain despite adequate analgesia - Median nerve symptoms (most sensitive) - thenar weakness, thumb-index numbness - Ulnar nerve symptoms - intrinsic weakness, ulnar-sided numbness - Radial nerve symptoms - wrist drop, thumb extension weakness ### Associated Carpal Tunnel Syndrome Carpal tunnel syndrome occurs in 20-30% of acute forearm compartment syndrome cases. Mechanism: Combined effect of forearm swelling transmitted distally plus local carpal tunnel swelling. EXAM TIP: If median nerve symptoms present (especially if confined to median distribution at hand), assess for Tinel's sign at wrist. Release carpal tunnel FIRST before forearm fasciotomy to prevent ongoing median nerve compression. ### Timing - Critical Factor - Less than 6 hours: Excellent prognosis with early fasciotomy - 6-12 hours: Good prognosis if immediate fasciotomy - 12-24 hours: Permanent damage likely, Volkmann's contracture risk - More than 24 hours: Established Volkmann's contracture, fasciotomy may not help **EXAM ANSWER**: "Forearm compartment syndrome is a CLINICAL DIAGNOSIS - I do not wait for pressure measurements. Classic presentation: pain out of proportion, tense forearm, pain on passive finger extension (stretches volar compartment - earliest sign). High-risk injuries include supracondylar fractures in children and both-bone forearm fractures. I assess for concurrent carpal tunnel syndrome (20-30% of cases) - if present, I release carpal tunnel first. Timing critical - fasciotomy within 6 hours gives excellent prognosis, delay beyond 12 hours risks permanent Volkmann's contracture." ## Forearm Compartments and Neurovascular Anatomy ### Three (Four) Compartments **1. Volar Superficial Compartment**: - **Muscles**: Pronator teres, FCR (flexor carpi radialis), palmaris longus (15% absent), FCU (flexor carpi ulnaris) - **Nerves**: Median nerve (runs between FDS tendons), ulnar nerve (under FCU at ulnar border) - **Vessels**: Radial artery (radial border, between BR and FCR), ulnar artery (with ulnar nerve) - **Borders**: Antebrachial fascia (superficial), FDS muscle (deep) **2. Volar Deep Compartment**: - **Muscles**: FDP (flexor digitorum profundus - ulnar four fingers), FPL (flexor pollicis longus - thumb), pronator quadratus (distal forearm) - **Nerves**: Median nerve (between FDS and FDP), anterior interosseous nerve (motor branch on interosseous membrane) - **Vessels**: Anterior interosseous artery (with AIN on interosseous membrane) - **Borders**: FDS (superficial), interosseous membrane (deep) **3. Dorsal/Extensor Compartment**: - **Muscles**: Superficial (ECRL, ECRB, EDC, EDM, ECU) and Deep (APL, EPB, EPL, EIP) - **Nerves**: Posterior interosseous nerve (motor branch, deep between layers), superficial radial nerve (sensory, becomes subcutaneous distal third) - **Vessels**: Posterior interosseous artery - **Borders**: Extensor fascia (superficial), interosseous membrane (deep) **4. Mobile Wad (Radial/Lateral Compartment)**: - **Muscles**: Brachioradialis (elbow flexion), ECRL and ECRB (wrist extension) - **Nerves**: Radial nerve (deep proximally, becomes superficial 8-10cm above wrist between BR and ECRL) - **Vessels**: Radial recurrent artery proximally - **Borders**: Between volar and dorsal compartments on radial side ### Critical Neurovascular Anatomy **Median Nerve**: - Enters forearm between two heads of pronator teres - Runs between FDS (superficial) and FDP (deep) in volar compartment - Approximately 2cm radial to midline in mid-forearm - MOST SENSITIVE to ischemia - first to show symptoms - Gives off anterior interosseous nerve (AIN) 5cm distal to medial epicondyle - AIN is pure motor: FPL, radial FDP (index/middle), pronator quadratus **Ulnar Nerve**: - Enters forearm between two heads of FCU - Runs along ulnar border between FCU (superficial) and FDP (deep) - Accompanied by ulnar artery - Enters hand through Guyon's canal (between pisiform and hook of hamate) - Both motor (intrinsics, hypothenar) and sensory (ulnar 1.5 digits) **Radial Nerve**: - Divides into deep (posterior interosseous - PIN) and superficial branches at level of radiocapitellar joint - PIN: pure motor, deep to supinator, innervates all extensors except ECRL - Superficial radial: pure sensory, deep to brachioradialis proximally - Becomes subcutaneous 8-10cm proximal to wrist between BR and ECRL tendons - Provides sensation to radial dorsum of hand **Radial Artery**: - Radial border of forearm between brachioradialis and FCR - Becomes superficial at wrist 5cm proximal to radial styloid - REASON for ulnar volar approach - radial approach risks radial artery injury ### Surgical Approaches - Rationale **Volar Ulnar Approach**: - PREFERRED volar approach - Avoids radial artery completely - Median nerve ~2cm radial to incision - easier to identify and protect - Access to both volar superficial and deep compartments - Can extend to palm for carpal tunnel release **Dorsal Approach**: - Releases dorsal/extensor compartment - Provides access to mobile wad - Superficial radial nerve at risk in distal third (becomes subcutaneous) - Relatively straightforward - fewer critical structures than volar **EXAM ANSWER**: "Forearm has THREE main compartments: Volar superficial (PT, FCR, PL, FCU), volar deep (FDP, FPL, PQ), and dorsal/extensor (all wrist and finger extensors). Mobile wad (BR, ECRL, ECRB) is often considered a fourth compartment. I use ULNAR volar approach for volar compartments - starts 2cm distal-medial to medial epicondyle, extends along ulnar forearm. This is safer than radial approach - avoids radial artery and reduces median nerve injury risk. Median nerve runs between FDS and FDP ~2cm radial to ulnar incision. Dorsal incision releases extensor compartment and mobile wad. All compartments must be assessed and released." ## Step-by-Step Surgical Technique ### Patient Preparation **Positioning**: - Supine with affected arm on radiolucent hand table - Arm abducted approximately 90 degrees - Entire upper extremity prepped from shoulder to fingertips - Sterile draping allows full visualization from shoulder to hand **Equipment**: - No tourniquet inflation (need to assess perfusion and muscle viability) - Tourniquet applied for emergency use only - Have STSG instruments available (may need immediate grafting) **Anesthesia**: - General anesthesia preferred - Regional anesthesia (axillary block) acceptable if GA contraindicated - Ensure adequate muscle relaxation for compartment assessment ### Step 1: Assessment for Carpal Tunnel Release **EXAM KEY**: "I always assess for concurrent carpal tunnel syndrome before starting forearm fasciotomy. CTS present in 20-30% of forearm compartment syndrome cases. If median nerve symptoms (thenar weakness, thumb-index numbness) or high suspicion, I release carpal tunnel FIRST via extended volar incision into palm. This prevents ongoing median nerve compression during and after forearm decompression." **Clinical Assessment**: - Test median nerve: thenar strength (APB - thumb abduction), thumb-index sensation - Tinel's sign at wrist (tap over carpal tunnel) - If positive or high suspicion: plan extended volar incision into palm Missing concurrent carpal tunnel syndrome leads to persistent median nerve symptoms despite adequate forearm fasciotomy. Always assess and have low threshold for concurrent release. ### Step 2: Volar Incision and Skin Exposure **Incision Design** (ULNAR approach): - Start: 2cm distal AND 2cm medial to medial epicondyle (avoids median nerve bifurcation at elbow) - Course: Straight line along ulnar border of forearm - At wrist: Oblique across wrist crease toward hypothenar eminence (lateral to Guyon's canal) - Extension: To mid-palm if carpal tunnel release needed - Total length: Typically 25-30cm from proximal forearm to palm **Skin Incision**: - Scalpel through skin and subcutaneous tissue - Preserve basilic vein if possible (may be needed for future access) - Identify and protect superficial veins and cutaneous nerves - Avoid crossing wrist crease at 90 degrees (causes contracture scar) **EXAM KEY**: "I use ULNAR volar approach - safer than radial approach. Incision starts 2cm distal and 2cm medial to medial epicondyle, extends along ulnar forearm, crosses wrist obliquely to hypothenar area avoiding Guyon's canal, extends to mid-palm if carpal tunnel release needed. This avoids radial artery completely and places median nerve ~2cm radial to incision where it's easier to identify and protect." ### Step 3: Volar Superficial Compartment Release **Fascial Identification**: - Identify antebrachial fascia (glistening white layer) - Incise longitudinally with scissors or scalpel - Full-length release from proximal forearm to wrist **Compartment Contents**: - Muscles bulge when fascia released: PT, FCR, palmaris longus (if present), FCU - Identify median nerve between FDS tendons (~2cm radial to incision) - Identify ulnar nerve and artery at ulnar border deep to FCU **Nerve Protection**: - Median nerve: trace between FDS tendons, gentle retraction - Ulnar nerve: runs with ulnar artery under FCU at ulnar border - Do NOT dissect nerves extensively - just identify and protect Median nerve injury most common complication of volar forearm fasciotomy. Nerve runs between FDS tendons approximately 2cm radial to ulnar incision. Identify early, trace course, protect with gentle retraction. Avoid extensive dissection. ### Step 4: Volar Deep Compartment Release **Access to Deep Compartment**: - Deep compartment lies BENEATH flexor digitorum superficialis - Elevate or gently split FDS muscle belly to access deep space - Avoid aggressive muscle splitting - may devascularize muscle **Fascial Release**: - Release fascia over FDP muscle belly (ulnar four fingers) - Release fascia over FPL muscle belly (thumb) - Release fascia over pronator quadratus distally - Muscles should bulge - if still tense, extend fascial release **Deep Neurovascular Structures**: - Median nerve: between FDS (superficial) and FDP (deep) layers - Anterior interosseous nerve: motor branch on interosseous membrane - AIN innervates: FPL, radial FDP (index/middle), pronator quadratus - Anterior interosseous artery: runs with AIN **EXAM KEY**: "Volar deep compartment accessed by elevating or splitting FDS muscle. Contains FDP, FPL, and pronator quadratus. I release fascia over each muscle carefully. Median nerve lies between FDS and FDP - must protect. Anterior interosseous nerve (AIN) is pure motor branch on interosseous membrane - innervates FPL, radial FDP, PQ. Injury causes inability to make 'OK' sign (AIN syndrome)." ### Step 5: Carpal Tunnel Release (If Indicated) **If concurrent CTS suspected**: - Extend volar incision into palm (already designed for this) - Identify transverse carpal ligament at wrist - Incise TCL longitudinally under direct vision - Protect median nerve and recurrent motor branch - Release complete when median nerve visible and mobile **Verification**: - Median nerve should decompress and become less tense - Test thumb abduction (APB - recurrent motor branch) ### Step 6: Dorsal Incision and Extensor Compartment Release **Dorsal Incision**: - Start: 3cm distal to lateral epicondyle (avoids posterior interosseous nerve) - Course: Along dorsal forearm between radius and ulna, slightly radial to midline - End: 3cm proximal to Lister's tubercle (avoids superficial radial nerve) - Total length: 20-25cm **Fascial Release**: - Incise skin and subcutaneous tissue - Identify and incise extensor fascia longitudinally - Release extensor retinaculum distally if needed - Extensor muscles bulge: EDC, EIP, EDM, EPL, EPB, APL, ECU, ECRL, ECRB **Nerve Protection**: - Superficial radial nerve: becomes subcutaneous 8-10cm above wrist between BR and ECRL - Identify in distal third, protect during dissection - Posterior interosseous nerve: stays deep, typically not at risk Superficial radial nerve becomes subcutaneous in distal third of forearm, emerging between brachioradialis and ECRL tendons approximately 8-10cm proximal to radial styloid. Injury causes numbness over radial dorsum of hand and painful neuroma. Identify and protect carefully in distal forearm. ### Step 7: Mobile Wad Release **From Dorsal Approach**: - Mobile wad located radially between volar and dorsal compartments - Contains: brachioradialis, ECRL, ECRB - Release fascia over each muscle - Muscles should bulge when released **Nerve Consideration**: - Radial nerve becomes superficial radial nerve between BR and ECRL - Identify approximately 8cm above wrist - Gentle retraction only - do not dissect extensively **Alternative Access**: - Can be released from volar incision by extending radially - Dorsal approach generally easier and safer ### Step 8: Systematic Verification of Complete Release **EXAM KEY**: "After releasing all compartments, I systematically verify complete decompression. Four compartments to check: (1) Volar superficial - PT, FCR, PL, FCU bulging and soft. (2) Volar deep - FDP, FPL, PQ bulging and soft. (3) Dorsal/extensor - all extensors bulging and soft. (4) Mobile wad - BR, ECRL, ECRB bulging and soft. Palpate each - should be SOFT, not tense. If carpal tunnel released, confirm no compression at wrist." **Systematic Check**: 1. Volar superficial: palpate - should be soft, muscles bulging 2. Volar deep: palpate - should be soft, muscles bulging 3. Dorsal/extensor: palpate - should be soft, muscles bulging 4. Mobile wad: palpate - should be soft, muscles bulging 5. Re-release any residual tight fascia 6. Verify no constricting bands at wrist or elbow ### Step 9: Muscle Viability Assessment (Four Cs) **Four Cs Assessment**: 1. **Color**: Pink or red = viable; pale, white, or dark = necrotic 2. **Contractility**: Stimulate with forceps - viable muscle contracts 3. **Consistency**: Firm = viable; mushy, soft = necrotic 4. **Capacity to bleed**: Cut edge bleeds = viable; no bleeding = necrotic **Debridement**: - Clearly necrotic muscle must be debrided - Prevents rhabdomyolysis, myoglobinuria, renal failure - Prevents infection - Marginal muscle can be observed at return to OR **Nerve Function Testing**: - Median: thenar contraction (APB), thumb opposition - Ulnar: interossei (finger abduction/adduction), hypothenar - Radial: thumb extension (EPL), wrist extension (ECRL, ECRB) Necrotic muscle releases myoglobin causing renal failure. Debride clearly necrotic muscle. Ensure adequate hydration, monitor urine output and color (myoglobinuria = tea-colored urine). Consider alkalinization of urine and mannitol in severe cases. Monitor creatinine kinase (CK) levels. ### Step 10: Wound Management - Never Close Primarily **Hemostasis**: - Achieve meticulous hemostasis with bipolar cautery - Avoid monopolar near nerves - Ligate large vessels if needed **Irrigation**: - Copious irrigation with normal saline - Remove any devitalized tissue debris **Open Wound Management**: - NEVER close primarily - risk of recurrent compartment syndrome - Apply moist dressings: Xeroform or saline-soaked gauze - Bulky absorbent outer dressing - Allow for continued swelling **Splinting**: - Position of function critical to prevent contracture - Wrist: neutral to 20 degrees extension - MCPs: 60-70 degrees flexion - IPs: full extension (0 degrees) - Thumb: abducted (safe position) - This is "intrinsic-plus" or "safe position" **EXAM KEY**: "I NEVER close forearm fasciotomy wounds primarily - this risks recurrent compartment syndrome. I leave wounds open with moist dressings (Xeroform or saline gauze) and bulky absorbent dressing. Critical: Splint in POSITION OF FUNCTION - wrist neutral to slight extension, MCPs flexed 60-70 degrees, IPs extended, thumb abducted. This prevents flexion contracture and maintains muscle-tendon length. Plan return to OR 48-72 hours for reassessment." ### Step 11: Planning Return to OR **Timing**: 48-72 hours **Goals**: - Reassess muscle viability - Debride any additional necrotic tissue - Assess for delayed primary closure vs STSG **Closure Options**: 1. Delayed primary closure (7-10 days if minimal tension) 2. Vessel loop or shoelace technique for gradual approximation 3. Split-thickness skin graft (10-14 days if cannot close) 4. Negative pressure wound therapy (VAC) to facilitate closure ## Complications and Management ### Complication Rate Summary - Volkmann's contracture: 10-40% if fasciotomy delayed beyond 12 hours - Nerve injury: 5-15% (median most common) - Need for STSG: 60-70% of cases - Infection: 5-10% - Rhabdomyolysis: 20-30% (usually subclinical) - Chronic stiffness: 30-50% despite appropriate treatment ## Recovery and Rehabilitation ### Immediate Postoperative (0-48 hours) **Positioning**: - Arm elevated on pillows (reduces swelling) - Hand above elbow, elbow above heart - Splint maintains position of function **Wound Care**: - Moist dressings (Xeroform or saline-soaked gauze) - Bulky absorbent outer dressing - Changed daily or if strike-through occurs - Monitor for bleeding, excessive drainage **Monitoring**: - Neurovascular checks every 2 hours initially - Assess: finger motion, sensation (median, ulnar, radial), perfusion - Compartment tension (should remain soft) - Temperature, WBC (infection surveillance) **Medical Management**: - IV antibiotics (cefazolin 2g Q8h or per institutional protocol) - Adequate analgesia (nerve pain component - consider gabapentin) - IV hydration (maintain urine output, prevent renal injury) - Monitor CK levels if rhabdomyolysis suspected - DVT prophylaxis (SCDs, consider chemoprophylaxis based on bleeding risk) ### Return to OR (48-72 hours) **Assessment**: - Reassess muscle viability (four Cs) - Debride any additional necrotic muscle - Irrigate copiously - Check compartment pressures (should be normal) **Closure Options**: 1. **Too Early for Closure** (significant swelling): - Repeat dressing change - Return again in 48-72 hours - Consider VAC therapy 2. **Delayed Primary Closure** (minimal swelling, edges approximate): - Vessel loop or shoelace technique for gradual approximation - Tighten gradually over 3-7 days - Close when no tension 3. **Split-Thickness Skin Graft** (cannot close without tension): - Usually needed by 10-14 days - Harvest 0.012-0.015 inch STSG from thigh - Meshed 1:1 or 1.5:1 (allows drainage, accommodates swelling) - VAC or bolster dressing for 5-7 days 4. **VAC Therapy** (bridge to closure): - Facilitates granulation tissue formation - Reduces edema - May allow delayed primary closure in 7-10 days - Otherwise prepares for STSG ### Hand Therapy (Critical for Outcome) **Phase 1: Immediate (0-2 weeks)**: - Passive ROM exercises started immediately after first dressing change - Gentle passive finger extension/flexion in splint - Tendon gliding exercises (hook fist, straight fist, full fist) - Edema control (elevation, compression if tolerated) **Phase 2: Early Active (2-6 weeks)**: - Active ROM exercises as pain allows - Light resistance exercises (therapy putty) - Scar massage once wounds healed - Splinting continues between therapy sessions **Phase 3: Strengthening (6-12 weeks)**: - Progressive resistance exercises - Grip strengthening (hand dynamometer) - Functional activities (writing, buttoning, etc.) - Desensitization if hypersensitivity present **Phase 4: Functional Return (3-6 months)**: - Work conditioning if return to manual labor - Adaptive equipment if residual weakness - Ongoing home exercise program **EXAM KEY**: "Hand therapy is CRITICAL and must start early. I initiate passive ROM exercises immediately after first dressing change to prevent stiffness. Active ROM starts as pain allows, typically by 2 weeks. Early motion prevents tendon adhesions and joint contractures. Splinting in position of function continues between therapy sessions. Despite optimal treatment, 30-50% of patients have residual stiffness and functional limitation." ### Long-Term Monitoring (Months to Years) **Nerve Recovery**: - Median nerve: Monitor thenar strength, opposition, sensation - Ulnar nerve: Monitor intrinsic strength, claw hand development - Radial nerve: Monitor thumb/wrist extension - Recovery may take 3-12 months - Consider EMG/NCS at 3 months if no improvement **Functional Assessment**: - Grip strength (compared to contralateral) - ROM measurements (goniometer) - Functional tasks (Jebsen-Taylor Hand Function Test) - Return to work/activities **Complications**: - Volkmann's contracture may require late reconstruction - Chronic pain may need pain management referral - Tendon adhesions may require tenolysis ### Expected Outcomes **Early Fasciotomy (less than 6 hours)**: - 80-90% good to excellent function - Most nerve function recovers - Minimal contracture **Delayed Fasciotomy (6-12 hours)**: - 50-70% good to excellent function - Variable nerve recovery - Some contracture common **Late Fasciotomy (over 12 hours)**: - 20-40% good to excellent function - Permanent nerve damage common - Volkmann's contracture likely ## References 1. Shadgan B, Menon M, O'Brien PJ, et al. Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma. 2008;22(8):581-587. PMID: 18758292. *Systematic review of diagnostic techniques - emphasizes clinical diagnosis over compartment pressure measurements* 2. Leversedge FJ, Moore TJ, Peterson BC, et al. Compartment syndrome of the upper extremity. J Hand Surg Am. 2011;36(3):544-559. PMID: 21371630. *Comprehensive review of upper extremity compartment syndrome including forearm - discusses anatomy, diagnosis, surgical technique* 3. Prasarn ML, Ouellette EA, Livingstone A, et al. Acute pediatric upper extremity compartment syndrome in the absence of fracture. J Pediatr Orthop. 2009;29(3):263-268. PMID: 19305277. *Pediatric series highlighting supracondylar fractures as leading cause - discusses diagnosis and outcomes* 4. Kostler W, Strohm PC, Sudkamp NP. Acute compartment syndrome of the limb. Injury. 2005;36(8):992-998. PMID: 16005007. *Evidence-based review of compartment syndrome management - discusses timing of fasciotomy and outcomes* 5. Mubarak SJ, Owen CA, Hargens AR, et al. Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg Am. 1978;60(8):1091-1095. PMID: 701337. *Classic article describing compartment pressure measurement - but emphasizes clinical diagnosis remains primary* 6. Ouellette EA. Compartment syndromes in obtunded patients. Hand Clin. 1998;14(3):431-450. PMID: 9742423. *Discusses upper extremity compartment syndrome diagnosis and management - includes volar and dorsal approach technique* 7. Gelberman RH, Zakaib GS, Mubarak SJ, et al. Decompression of forearm compartment syndromes. Clin Orthop Relat Res. 1978;(134):225-229. PMID: 729244. *Original description of forearm fasciotomy technique - volar and dorsal approaches* 8. Finkelstein JA, Hunter GA, Hu RW. Lower limb compartment syndrome: course after delayed fasciotomy. J Trauma. 1996;40(3):342-344. PMID: 8601846. *Discusses outcomes based on timing of fasciotomy - emphasizes importance of early intervention to prevent Volkmann's contracture* 9. Tsuge K. Treatment of established Volkmann's contracture. J Bone Joint Surg Am. 1975;57(7):925-929. PMID: 1184640. *Classic article describing Tsuge classification of Volkmann's contracture (mild, moderate, severe) and treatment options* 10. Seddon HJ. Volkmann's ischaemia in the lower limb. J Bone Joint Surg Br. 1966;48(4):627-636. PMID: 5953797. *Classic description of pathophysiology of ischemic contracture following compartment syndrome - applicable to forearm*

Volar and Dorsal Forearm Fasciotomy

Volar and Dorsal Forearm Fasciotomy