Compartment syndrome is common in the forearm and leg, but rare in the upper arm with only a handful of cases reported in the literature. Our patient’s anticoagulated state predisposed him to the development of compartment syndrome.1-5 To our knowledge, only 1 other case has been reported in the literature of an upper arm compartment syndrome following biceps tendon rupture in a patient on warfarin.2 This article presents a case of upper arm compartment syndrome following a biceps tendon rupture in a 77-year-old man on warfarin.
A 77-year-old right-hand dominant man reported injuring his right shoulder while playing tennis. He presented with significant swelling and ecchymosis in the upper arm. Past medical history was significant for aortic valve replacement 5 years prior to which he had been taking warfarin.
Physical examination revealed a clinical diagnosis of biceps tendon rupture of the right arm. The patient was neurovascularly intact, and radiographs showed no fractures or dislocations. His arm was placed in a sling, and he was advised to rest from activities and sports, apply ice, and take Tylenol as needed for pain. A 2-week follow-up visit was scheduled.
The patient returned the next day with increased swelling and pain. On physical examination, the right arm had increased swelling and ecchymosis. The right arm at mid-biceps level measured 15 ½ inches circumferentially compared to 12 ¾ inches on the left, and just distal to the elbow on the right measured 12 inches compared to 10 inches on the left. Significant ecchymosis was noted extending from the axilla to the proximal forearm, with mild ecchymosis into the hand.
The patient had no difficulty with supination or pronation. Radial pulses were intact bilaterally and there was no neurological deficit. A complete blood cell count was ordered to evaluate patient’s blood loss, a compression stocking was applied to the right arm, and the patient was rescheduled for close follow-up.
On day 3, the patient presented to the emergency room with increased pain and swelling. The patient had removed his compression stocking because he felt it was too tight. He had numbness and tingling in the first 3 fingers of his right hand since that morning. His radial pulse was diminished on the right, 2+ on the left. He had the weakness with elbow flexion and was unable to flex his thumb interphalangeal joint. A large palpable mass was noted in his proximal anterior humeral compartment in the area of his anterior deltoid. The entire anterior humeral compartment was tense, most significantly proximally. Motor function was intact in posterior interosseous nerve and ulnar nerve distributions.
Laboratory values revealed a hemoglobin and hematocrit of 11.8 g/dL and 35.4% respectively, and a supratherapeutic international normalized ratio of 6.5, prothrombin time of 57.4 seconds and partial thromboplastin time of 118.6 seconds. The patient’s arm was elevated and treatment with fresh frozen plasma was initiated immediately. Preoperatively, while undergoing transfusion of fresh frozen plasma, the patients radial pulse diminished and was no longer palpable but a Doppler ultrasound signal could still be obtained.
A diagnosis of compartment syndrome of the right upper arm was made. The patient underwent fasciotomy of the upper arm with the evacuation of hematoma and application of long arm splint. The patient was administered prophylactic antibiotics, placed under general anesthesia, intubated and prepped with povidone-iodine.
A 12-cm superficial skin incision was made along the medial border of the biceps beginning proximally at pectoralis major muscle and curved laterally at its distal aspect, crossing the antecubital fossa. The fascia of the anterior humeral compartment was released sharply and care was taken to avoid the underlying neurovascular structures. The lacertus fibrosis was also released. Proximally a tense mass was still palpable so the incision was extended proximally 5 cm. Blunt finger dissection into the distal aspect of the deltopectoral interval evacuated approximately 60 cc hematoma from the proximal portion of the humerus within the biceps brachii, deep to the anterior deltoid muscle. There was no evidence of necrosis of the muscle or nerve injury. The wound was irrigated, a drain was placed, and the skin was loosely approximated. A splint and soft dressing were applied.
Postoperatively the patient reported considerably less pain. Numbness and tingling were still present in his first three fingers, and he had not regained active flexion of the interphalangeal joint of his thumb. His hospital stay was complicated by anemia and pneumonia. The patient was discharged 2 weeks postoperatively.
Three weeks postoperatively the patient presented with minimal swelling and resolving ecchymosis. The wound was healing by granulation, and sutures were removed. He still had to tingle
of his first 3 fingers and had no flexion of his interphalangeal joint of the thumb. He was prescribed physical therapy.
At 1-month follow-up, the patient was neurovascularly intact with no numbness or tingling and had regained full motor function throughout.
Compartment syndrome is a condition in which elevated pressures within an osseofascial compartment causes vascular compromise and injury to the structures within the compartment. Compartment syndrome is most common in the anterior and deep posterior compartments of the leg and the volar compartment of the forearm, however, it can occur anywhere a compartment is present, including the hand, abdomen, buttock, foot, upper arm, and thigh.
Acute and chronic forms of compartment syndrome have been described. Acute compartment syndrome is most commonly caused by fractures, blunt trauma, penetrating injuries, crush injuries, burns, and limb compression. Chronic compartment syndrome is most commonly caused by the increase in muscle volume or overuse injuries leading to inflammation and swelling. Symptoms include tingling numbness or burning sensations, deep throbbing pain out of proportion to injury increased with movement, and increased compartment pressure that manifests as tight shiny warm skin. Late symptoms include pallor, paralysis, and pulselessness that can lead to muscle necrosis and permanent functional impairment. Diagnosis of compartment syndrome is mainly clinical, compartment pressures >30 mmHg measured using a pressure monitor (Stryker, Kalamazoo, Michigan) are also suggestive. Definitive therapy for compartment syndrome involves emergent fasciotomy, followed by debridement of any necrotic material, and skin closure.1,6
Biceps tendon ruptures most commonly occur in middle-aged men secondary to chronic wear of the tendons. It is also common in young men following trauma, heavy lifting, or sporting injuries. Over 96% of all biceps brachii muscle ruptures occur through the tendon of its long head, but can also occur through the tendon of the short head 1% of the time, the distal tendon 3% of the time, and the muscle itself.5
Patients typically present with a sudden sharp pain in the shoulder that may be associated with a snapping sensation or a popping sound. A bulge may be visible in the distal arm with ecchymosis along the inner aspect of the distal arm. The strength of flexion and supination may be slightly decreased but not enough to affect the functioning of the arm.
Conservative treatment is indicated for most patients with a biceps tendon rupture, which consists of resting the affected joint, ice packs, nonsteroidal anti-inflammatory drugs, and physical therapy. Most of these patients are able to regain full functioning with minimal decrease in the strength of flexion and supination. Surgical repair is indicated for young patients for both cosmetic and functional reasons, and patients whose occupation requires full supination strength.1,7
The patient we presented was on long-term warfarin therapy for an aortic valve replacement. He presented to the emergency department with a supratherapeutic international normalized ratio of 6.5. Long-term anticoagulation is a well-known risk factor that may predispose a patient to compartment syndrome.1-5 Many cases have been presented to patients on long-term anticoagulation therapy who developed compartment syndrome. In addition, patients on long-term anticoagulation are more prone to develop unusual compartment syndromes such as spontaneously,4 in the thigh,5 or upper arm.2
Compartment syndrome of the upper arm is a rare occurrence. Previous cases have occurred due to malposition of blood pressure cuffs,8 injections,9 venepuncture,10 trauma,11 tourniquets,12 shoulder dislocation,13,14 surgical complication,15subatmospheric pressure induced,16 biceps rupture,2 and triceps rupture.3 The fascia of the upper arm is relatively more thin and distensible than the fascia of the leg or forearm; this creates more room for the compartment to swell before pressures build up to a significant level.9,13 Thus, a significantly increased amount of pressure needs to build up before compartment syndrome. Anticoagulation, anabolic steroids, hemophilia, severe trauma, and prolonged compression are all factors that may increase a patient’s risk of developing compartment syndrome. It is important to identify compartment syndrome early in its course to avoid long-term complications.
- Canale ST. Campbell’s Operative Orthopaedics.10th ed. Carlsbad, CA: Mosby Inc; 2003.
- Richards AM, Moss ALH. Biceps rupture in a patient on long-term anticoagulation leading to compartment syndrome and nerve palsies. J Hand Surg [Br].1997; 22(3):411-412.
- Alford JW, Palumbo MA, Bamum MJ. Compartment syndrome of the arm: a complication of noninvasive blood pressure monitoring during thrombolytic therapy for myocardial infarction. J Clin Monit.2002; (17):163-166.
- Griffiths D, Jones DH. Spontaneous compartment syndrome in a patient on long-term anticoagulation. J Hand Surg [Br].1993; 18(1):41-42.
- Ebraheim NA, Hoeflinger MJ, Savolaine ER. Anterior compartment syndrome of the thigh as a complication of blunt trauma in a patient on prolonger anticoagulation therapy. Clin Orthop Relat Res.1991; (263):180-184.
- Seiler JG III, Casey PJ, Binford SH. Compartment syndromes of the upper extremity. J South Orthop Assoc. 2000; 9(4):233-247.
- Hamilton W, Ramsey ML. Rupture of the distal tendon of the biceps brachii. University of Pennsylvania Orthopedic Journal.1999; 12(1):21-26.
- Sutin KM, Longaker MT, Wahlander S, Kasabian AK, Capan LM. Acute biceps compartment syndrome associated with the use of a noninvasive blood pressure monitor. Anesth Analg. 1996; 83(6):1345-1346.
- Knapke DM, Truumees E. Posterior arm and deltoid compartment syndrome after vitamin B12 injection. Orthopedics. 2004; 27(5):520-521.
- Nixon RG, Brindley GW. Hemophilia presenting as compartment syndrome in the arm following venipuncture. A case report and review of the literature. Clin Orthop Relat Res.1989; (244):176-181.
- Bahia H, Platt A, Hart NB, Baguley P. Anabolic steroid accelerated multicompartment syndrome following trauma. Br J Sports Med.2000; 34(4):308-309.
- Greene TA, Louis DS. Compartment syndrome of the arm. A complication of the pneumatic tourniquet. J Bone Joint Surg Am.1983; 65:270-273.
- Ridings P, Gault D. Compartment syndrome of the arm. J Hand Surg [Br].1994; 19(2):147-148.
- Yen CY, Yeh WL, Tu YK. Inferior dislocation of the glenohumeral joint combined with the compartment syndrome of the upper arm: case report. Changgeng Yi Xue Za Zhi. 1998; 21(3):358-361.
- Fike EA, Lucas GL. Compartment syndrome of the arm following intramedullary rodding of the humerus. Medscape General Medicine. 1999; 1(1).
- Bluman EM, Tashjian RZ, Graves PE. Subatmospheric pressure-induced compartment syndrome of the entire upper extremity. A case report. J Bone Joint Surg Am.2004; 86(9):2041-2044.
Dr Fung is from the Surgery Department, University of California, San Diego, California; and Drs Frey and Grossman are from the Department of Orthopedic Surgery, Monmouth Medical Center, Long Branch, NJ 07740.
Drs Fung, Frey, and Grossman have no relevant financial relationships to disclose.
Correspondence should be addressed to Daniel A. Fung, MD, Office of Medical Education, SW229, 300 2nd Ave, Long Branch, NJ 07740.
Compiled by Dr. Nidhi Bhatnagar
The author is M.D., Radio-diagnosis, Ph.D. ( Hony. Seoul) and Assistant Professor, General Secretary, Musculoskeletal Ultrasound Society, Dept of Radiologist and Ultrasonologist, She is a member Editorial Board, Radiology at Specialty Medical Dialogues.