A seventy-three-year-old woman presented to the emergency department (ED) with symptoms of excruciating and worsening pain with swelling in the dominant, right upper arm, with numbness and tingling extending into the hand. She stated that the pain began four to five days prior when she presented to the ED for chest pain and had an antecubital venipuncture performed for laboratory testing. No intravenous line was placed, and no fluids or medications were administered through the antecubital region. Since that visit to the ED, she had noticed progressive bruising, swelling, and pain, as well as nausea.
The medical history included a transient ischemic attack, hypertension, hyperlipidemia, osteoporosis, sleep apnea, atrial fibrillation, and ulcerative colitis. The medications she used included warfarin and antihypertensive agents. The physical examination was unremarkable except for elevated systolic blood pressure of 190 mm Hg, likely associated with the symptom of severe pain and the previously diagnosed hypertension. The right upper extremity was ecchymotic in the antecubital region, and the biceps compartment was rigidly swollen and exquisitely tender to palpation as well as with passive flexion and extension. The elbow had a flexion contracture of 15°. The triceps and forearm compartments were nontender, soft, and compressible. Additionally, the patient had palpable radial and ulnar pulses, and motor function and sensation were grossly intact. Laboratory tests showed a therapeutic international normalized ratio of 2.0.
Compartment pressures were not measured because of the unavailability of appropriate equipment. An ultrasound of the right upper arm was performed and demonstrated a nonpulsatile hematoma in the anterior brachium. The brachial artery was not visualized. However, the radial and ulnar arteries were patent. The patient received fresh-frozen plasma to reverse the effects of the warfarin so that she could undergo fasciotomy without excessive bleeding.
When assessed preoperatively approximately two hours after presentation, the patient had no palpable distal pulses in the upper extremity, and the systolic blood pressure was 190 mm Hg. A standard anterolateral incision was extended into an anterior volar curvilinear incision over the forearm. The anterior brachial and forearm volar compartments were released. Once the fascia was released, the systolic blood pressure immediately dropped to 120 mm Hg. Blunt finger dissection between the biceps brachii and the brachialis muscles exposed a hematoma approximately 8 cm in diameter beneath the biceps tendon. Additional blunt dissection revealed a smaller hematoma beneath the pronator teres muscle. After both hematomas were evacuated, the muscles of the volar forearm were well perfused and had excellent contractility. However, some of the lateral fibers of the biceps and brachialis muscles were dusky and brown and did not contract when stimulated by electrocautery. All noncontractile muscle fibers were sharply debrided. Fibers with marginal viability were not debrided. At the end of the procedure, the elbow could be fully passively extended. The wound was left open. Saline-moistened dressings (4” × 4”) were placed over the wound, abdominal battle dressing (ABD) bandages were added, and then a bulky soft dressing was applied.
At the time of follow-up wound exploration seventy-two hours later, the muscle fibers that previously appeared marginally viable were red and contractile. However, approximately 40% to 50% of the biceps muscle belly was necrotic and required debridement. All other muscles appeared viable. The wound (measuring 37 cm) was closed primarily. The arm was placed in a padded splint with the elbow at 60° of flexion. The wound healed uneventfully, and physical therapy began nineteen days after the index surgical procedure. By postoperative day seventy-three, the patient had full active elbow and forearm motion and good biceps strength as determined by a physical therapist. The only remaining symptom was night pain, which she treated by applying ice.
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