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How To Measure Compartment Pressure in a Forearm

By

Puneet Gupta

, MD, Harbor-UCLA

Last full review/revision Sep 2020| Content last modified Sep 2020
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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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Compartment pressure is measured to assist in diagnosing compartment syndrome. Measurement of compartment pressure is a hospital-based procedure that requires considerable technical skill; an orthopedic or general surgeon is typically consulted.

Compartment pressures can be measured in the 3 compartments of the forearm (volar, dorsal, and mobile wad).

The Stryker® system, a commercially available instrument, is used here. Know what equipment is available at your particular institution.

(See also Compartment Syndrome.)

Indications

  • Suspected compartment syndrome

Compartment syndrome is suggested by worsening pain of the involved compartment that is disproportionate to the apparent severity of the injury and exacerbated by passive stretching of compartment muscles. On palpation, the compartment may be swollen and tense.

Contraindications

Absolute contraindications

  • None

Relative contraindications

  • Infection of skin or deeper tissues at the anticipated site of needle insertion: If possible, use an alternate, uninfected site.

  • Bleeding diathesis, which may need to be corrected before compartment pressure measurement

Complications

  • Erroneously high or low pressure measurements that may be due to poorly placed or obstructed needles, faulty or inaccurately calibrated devices, patient agitation, or excess test saline injected into the compartment. These measurement errors can lead to incorrect treatment.

  • Infection, bleeding, or tissue damage resulting from needle insertion may occur.

Equipment

  • Sterile gowns, gloves, and drapes

  • Sterile gauze

  • The Stryker® system, containing a needle, tubing, and transducer

  • Mild antiseptic cleanser (eg, 2% chlorhexidine)

  • Local anesthetic (eg, 1 or 2% lidocaine)

  • 25- to 27-gauge needle

  • About a 3- to 5-mL syringe for local anesthetic injection

  • Sterile dressings

  • If procedural sedation is needed, appropriate drugs (eg, propofol, ketamine) and pulse oximetry or capnometry

Additional Considerations

  • Sterile technique is required to prevent microbial contamination of the compartment tissues.

  • Maintain a low threshold for measuring compartment pressure in at-risk patients because deep compartments may not have palpable tenseness or swelling, pain is nonspecific, and, in obtunded patients, symptoms and signs can be absent or nonspecific.

  • Diagnosis must be made and treatment started before pallor or pulselessness develops.

Relevant Anatomy

The forearm has 3 compartments:

  • Volar compartment: Includes the flexor carpi ulnaris, flexor pollicis longus, flexor digitorum profundus, flexor digitorum superficialis, palmaris longus, and flexor carpi radialis muscles and also the ulnar, superficial radial, and median nerves and the radial, ulnar, and anterior interosseus arteries

  • Dorsal compartment: Includes the extensor pollicis longus, abductor pollicis longus, extensor digitorum, extensor digiti minimi, and the extensor carpi ulnaris muscles and also the posterior interosseus nerve and posterior interosseus artery

  • Mobile wad compartment: Includes the brachioradialis, the extensor carpi radialis brevis, and the extensor carpi radialis longus muscles

The volar compartment is most commonly affected by compartment syndrome.

Positioning

  • Position the patient with the affected arm at heart level and so that the needle can enter the skin at an angle perpendicular to the compartment being measured.

Step-by-Step Description of Procedure

Prepare the equipment

  • Open the Stryker® system and remove the contents onto a sterile field.

  • Place the needle firmly onto the tapered stem of the diaphragm chamber. Remove the cap on the pre-filled syringe and attach it to the stem on the opposite side.

  • Open the cover of the monitor and place the chamber into the pressure monitor with the black surface down. Carefully push it until it is seated in place. Snap the cover of the monitor closed.

  • Hold the needle at a 45° angle upward and depress the plunger to purge the system of air. Do not allow saline to trickle down the needle into the transducer well.

  • Turn on the monitor and check for a numeric reading to appear in the display window.

  • Calibrate the device: Hold the device at the intended angle of insertion. Press the "zero" button and ensure that, after a few seconds, the display reads “00.” The display must read “00” before continuing. For each additional measurement, the unit must be recalibrated to “00.”

General steps for all compartments

  • Do a pre-procedure neurovascular examination of the affected forearm.

  • Prepare the skin overlying the area with an antiseptic cleanser such as chlorhexidine. Drape the area.

  • Using a 25- to 27-gauge needle, place a wheal of local anesthetic over the needle entry site. Avoid injecting anesthetic into the deeper tissues of the muscle and fascia. Doing so may falsely elevate the compartment pressure measurement.

  • Hold the assembled and calibrated pressure monitor perpendicular to the compartment being measured and insert the needle as gently as possible through the skin to a depth appropriate for the target compartment.

  • Slowly inject 0.3 mL of saline into the compartment.

  • Wait for the display window to show equilibrium has been reached and record the resultant pressure.

  • For each additional measurement, recalibrate the unit to "00" and repeat the process.

  • A measured pressure of more than about 30 mm Hg or within about 30 mm Hg of diastolic blood pressure supports the diagnosis of compartment syndrome and indicates consideration for immediate fasciotomy.

  • Compartment syndrome is possible even if compartment pressure is not elevated; if suspected based on clinical findings, the diagnosis should be presumed and compartment pressures should be measured serially.

Specific steps for the volar compartment

  • Position the patient supine with the forearm supinated.

  • Identify the palmaris longus tendon and its proximal course.

  • Insert the needle just medial to the palmaris longus at the junction of the proximal and middle thirds of the forearm.

  • Advance the needle perpendicularly and direct it toward the posterior border of the ulna to a depth of 1 to 2 cm.

  • Confirm proper needle placement by observing a rise in pressure when you press with your finger over the volar compartment just proximal or distal to the needle insertion site and with extension of the fingers and wrist.

Specific steps for the dorsal compartment

  • Position the patient supine with the forearm pronated.

  • Palpate the posterior aspect of the ulna at the level of the junction of the proximal and middle thirds of the forearm.

  • Insert the needle at this level, 1 to 2 cm lateral to the posterior aspect of the ulna.

  • Advance the needle perpendicularly to a depth of 1 to 2 cm.

  • Confirm proper needle placement by observing a rise in pressure when you press with your finger over the dorsal compartment just proximal or distal to the needle insertion site and with flexion of the wrist or fingers.

Specific steps for the mobile wad compartment

  • Position the patient supine with the arm supinated.

  • Identify the most lateral portions of the forearm at the junction of its proximal and middle thirds.

  • Insert the needle at this level and lateral to the radius.

  • Advance the needle perpendicularly to a depth of 1 to 1.5 cm.

  • Confirm proper needle placement by observing a rise in pressure when you press with your finger over the mobile wad just proximal or distal to the needle entry site and with ulnar deviation of the wrist.

Aftercare

  • Apply sterile dressings to all needle entry sites.

  • Repeat the neurovascular examination of the arm.

Warnings and Common Errors

  • Compartment syndrome is a clinical, often difficult, diagnosis to make.

  • Presence of distal pulses and capillary refill and even normal compartment pressures do not rule out compartment syndrome.

  • Measure pressures for all possibly affected compartments in the involved extremity.

Tips and Tricks

  • To maximize accuracy, measure pressure at sites of trauma or maximum palpable tension.

Drugs Mentioned In This Article

Drug Name Select Trade
XYLOCAINE
KETALAR
DIPRIVAN
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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version

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