(P101) Saturday Night Compartment Syndrome

Chief Complaint : Hand swelling

History of Present Illness : 36 year-old male with a PMHx of alcohol use disorder presents after a fall with left hand pain. Patient reported that, on the day prior to arrival, he was drinking alcohol throughout the day and eventually fell out of bed and landed on his left side. He did not attempt to get off the floor and slept in that position, bearing his entire body weight on his left hand overnight. In the morning, he felt severe pain in the left hand, which became progressively more swollen, erythematous, and numb. He also reported eventual onset of weakness in the hand. On average, he drinks a pint of whiskey every other day and is an everyday smoker. Denies other drug use. No previous injuries or procedures to hand.

Pertinent Physical Exam: General: Appears uncomfortable. Diaphoretic. AOx3.
Pulmonary: Lungs clear.
Heart: Tachycardic. Regular rate.
Left upper extremity: Diffuse swelling and erythema of left hand extending to forearm, with hand fixed in claw position. Small bullae over thenar eminence and tip of 2nd digit. Compartments firm. Tenderness over thenar eminence. Pain with passive range of motion. Unable to extend thumb at IP or MCP. Weak extension of digits 2-5, most pronounced at digit 2. Able to flex digits 2-5. Able to flex, extend wrist. Extremity warm. Palpable radial pulse. Reduced sensation over median, radial, ulnar distributions.

Pertinent Laboratory Data: BP 126/84, HR 104, temp 36.5C, RR 18.
CPK 106,200. Na 134, K 6.4, Cl 94, BUN 17, creatinine 2.0, glucose 185, anion gap 18.1. pH 7.34, pCO2 47, lactate 3.6.
WBC 24.8, Hgb 15.6, Plt 297.
AST 1,225, ALT 177, alk phos 83.
EKG: normal sinus without peaked T-waves.
X-rays of the left hand, wrist, and forearm showed no fracture or dislocation.

Case Discussion: This presentation was most concerning for left hand compartment syndrome with rhabdomyolysis and acute kidney injury (AKI). Orthopedics was immediately paged, who took the patient to the OR for emergent fasciotomy and debridement. Patient underwent open carpal tunnel release and was admitted to the SICU for management of rhabdomyolysis and AKI. He required continuous renal replacement therapy and underwent hyperbaric oxygen therapy. He had a prolonged hospital course complicated by two returns to the OR for left hand I&D and washout.

Compartment syndrome is a potentially devastating condition characterized by elevation in compartment pressure leading towards ischemia and tissue compromise. Acute compartment syndrome (ACS) of the extremities most commonly occurs after trauma involving long bone fractures, although trauma without fracture can also cause ACS, including crush injuries, burns, or use of casts. While rare, even minor injuries can cause ACS, and here we present an unusual case of ACS caused by sleeping on a hand after a fall from bed while intoxicated. Similar to the colloquial association between intoxication and arm compression causing radial nerve damage (i.e., “saturday night palsy”), intoxicated individuals may not be able to reflexively correct their sleep positioning, increasing their risk for ACS.

Early signs and symptoms of ACS include progressive pain of the affected limb that worsens with passive range of motion. Additional signs include tense compartments, sensory deficits, paresthesia, pallor, and muscle weakness, though not all of these features may be present. Patients may also have bullae over the affected limb. For hand ACS in particular, the hand is often found in the intrinsic minus position (MCP hyperextension and IP joint flexion; “claw hand”), as in this patient.

Without prompt intervention, ACS may lead to disability, necrosis, and death. Thus, prompt identification of ACS by the Emergency Department provider is crucial.

References and Acknowledgements (Optional): N/A