what to put on bruised hand after iv
Oxf Med Example Reports. 2018 Dec; 2018(12): omy098.
Hand compartment syndrome as a result of intravenous contrast extravasation
Ioannis M Stavrakakis
1General Hospital of Agios Nikolaos, Orthopaedics, Knossou iv, Agios Nikolaos, GR, Greece
Ioannis I Daskalakis
2Full general Infirmary of Agios Nikolaos, General Surgery, Agios Nikolaos, GR Greece
Emmanouil Panagiotis Due south Detsis
2General Hospital of Agios Nikolaos, General Surgery, Agios Nikolaos, GR Greece
Chrysanthi A Karagianni
2General Hospital of Agios Nikolaos, General Surgery, Agios Nikolaos, GR Hellenic republic
Sofia North Papantonaki
2Full general Hospital of Agios Nikolaos, Full general Surgery, Agios Nikolaos, GR Greece
Maria S Katsafarou
2General Hospital of Agios Nikolaos, General Surgery, Agios Nikolaos, GR Greece
Received 2018 May 24; Revised 2018 Aug 8; Accepted 2018 Sep viii.
Abstract
Hand compartment syndrome is a rare condition which can result from crush injuries, fractures, burns, intravenous fluid extravasation, etc. Declining to recognize and treat it early leads to significant functional deficits of the hand. Few cases of iatrogenic hand compartment syndrome accept been described in the literature so far. We present a case of a hand intravenous (Four) contrast medium extravasation injury in a 72-twelvemonth-old female patient, during a CT browse. Equally soon as the swelling of the hand was noticed, elevation of the limb was suggested and ice was applied. Few hours later though the patient adult compartment syndrome of the manus with paresthesias and severe pain with passive movement of the fingers. Left manus emergent fasciotomies were performed leading to a expert functional outcome.
Introduction
IV fluid extravasation is a common complication in daily medical practice, causing local swelling and mild to moderate tenderness. Almost of the times, this condition subsides with conservative treatment, such equally limb superlative, water ice and analgesia. It is possible though that a big volume of extravasation, peculiarly of a fluid irritative for the soft tissues, can cause significant soft tissue injury, astringent swelling and neurovascular harm [ane, iv–6]. In the current commodity, we present a instance of a 72-twelvemonth-old patient, who developed a mitt compartment syndrome, due to Iv dissimilarity extravasation during a CT browse. The patient underwent an urgent fasciotomy of all hand compartments, leading to firsthand relief of symptoms and practiced functional result.
Case Report
A 72-twelvemonth-sometime female person patient, who was hospitalized in the internal medicine section, was evaluated by the on call Orthopaedic Surgeon, because of hurting and swelling of her left manus afterward a CT scan with Four dissimilarity, which was performed in gild to exclude pulmonary embolus. The patient had a past medical history of claret hypertension and diabetes. The cause of the swelling was 4 contrast medium extravasation from a mal positioned vein catheter on the dorsal surface of her left hand. About 110 ml of Iopromide were diffused in the soft tissue of the hand. The vein catheter was removed by the consultant radiologist equally soon as the swelling was noticed.
The patient was evaluated three h post-CT scan and she was found to exist in severe pain and significant swelling with peel baking (Fig. i). Initially, the mitt was elevated and ice was applied. No medical antidote, such as hyalouronidase was given to the patient, considering it was non available. Needle drainage was non possible, because of diffuse swelling. Two hours later no comeback was identified. On the opposite, the pain was nonresponsive to painkillers, the hand was sitting in an intrinsic minus position (Fig. two), soft tissue edema was increased and paresthesias were developed. The mitt looked pale and in that location was astringent pain on stretching the interrosseoi muscles, besides as delayed capillary refill. All these signs were considered to exist uniform with the diagnosis of compartment syndrome and an urgent fasciotomy was decided. There was no need to measure the intracompartmental pressures as clinical exam was typical.
Preoperative view of the hand: astringent swelling, skin tension and blisters of the dorsal surface are observed.
Preoperative view of the hand, sitting in intrinsic minus position.
Operation was performed using an axillary block, as the patient suffered from a chest infection and a general anesthesia was considered to be of a high hazard. In theater, all hand compartments were opened. Two dorsal incisions were performed, 1 over the 2nd metacarpal (to open the adductor, the first and second dorsal interosseous and the first palmar interosseous compartment), i over the fourth metacarpal (to open the compartment of the tertiary and quaternary dorsal interosseous and the second and third palmar interosseous), one over the thenar surface area and i over the hypothenar area. Finally a carpal tunnel release was performed. A tourniquet was practical, only it was used but for the carpal tunnel release. A large hematoma along with fluid dye was drained, particularly from the dorsal incisions. Immediately subsequently the fasciotomy, the swelling was significantly subsided, capillary refill returned to normal and skin closure was possible with iii/0 nylon tension-free sutures (Figs iii–5).
Intraoperative view of the hand where fasciotomy of thenar and carpal tunnel release are visible on the palmar surface.
Postoperative view of the hand. Immediate tension-free skin closure was possible every bit the swelling subsided.
Intraoperative view of the hand where fasciotomies are visible on the dorsal surface.
Postoperatively, the patient was admitted to the Orthopaedic Section and IV cefuroxime was applied. Iii days later, the patient was discharged pain free. Fifteen days post-surgery the wounds healed uneventfully, normal mitt function has returned and the patient was discharged from clinics.
Discussion
Compartment syndrome is a effect of increased pressure level in a closed myofascial space reducing the capillary blood perfusion below the level necessary for the tissue viability. Considering of a compromised circulation, all the structures inside the involved compartment volition be affected [2].
Diverse causes of hand compartment syndrome have been described, including fractures, beat injuries, burns, arterial injuries, snake bites, infection, etc [2, 3]. Extravasation of dissimilarity material is a common complexity of enhanced imaging studies and there have been a few reports of compartment syndrome of the mitt or forearm secondary to that [1, 4–6]. Patient'southward and contrast textile'due south characteristics are of import in this type of injury. The osmolality, ionic or nonionic nature as well as the extravasated book of the contrast medium are factors that make up one's mind the pathogenesis and progression of extravasation injuries [7–9].
Early diagnosis is of a swell importance in this type of cases. The clinical presentation of contrast extravasation ranges from mild to moderate redness and swelling of the tissue to severe edema and compartment syndrome. A manus with compartment syndrome presents as a tense, swollen extremity, sitting in an intrinsic minus position. Skin baking might be present likewise. Some finger range of movement may be possible every bit extrinsic muscles are outside the compartments of the paw. Disproportionate pain, nonresponsive to painkillers, forth with tenderness while stretching the intrinsic muscles of the hand (i.eastward. bringing the hand in an intrinsic plus position) indicates compartment syndrome. Sensory deficits might be absent-minded if the carpal tunnel is unaffected, as other sensory nerves are located exterior the hand's compartments [11]. In case of an singular clinical image or in sedated or pediatric patients, intracompartmental pressure measurement might be necessary. Pressure more than than thirty mmHg or delta pressure (diastolic blood pressure minus intracompartmental pressure less than xxx mmHg) indicates compartment syndrome. Missing diagnosis may lead to muscle necrosis resulting to significant functional deficits [2]. A hand presenting with the v P's described by Griffiths (pain, pallor, parasthesia, paralysis and pulselessness) [ten], indicates a delayed diagnosis of compartment syndrome and loss of function is likely to occur.
Regarding direction of extravasation, there is no general understanding about which arroyo is the all-time. It is considered by many surgeons that the majority of extravasation injuries tin can heal without surgery. Conservative treatment includes limb meridian and ice. It is a matter of argue though whether to apply warm or cold compresses [9]. Medications such as hyalouronidase, corticosteroids, vasodilators and a diverseness of other agents have also been proposed, but their effectiveness has not been proven. There are reports of successful treatment of IV dissimilarity media extravasation injuries using hyalouronidase [7–9]. Nonetheless, in case compartment syndrome develops, emergency fasciotomies and carpal tunnel release must be performed within the beginning 6 h to relieve neurovascular compromise [1, 2, half-dozen]. Ii dorsal incisions over the second and fourth metacarpal bones, ane thenar, one hypothenar incision, equally well as carpal tunnel release are described, in order to decompress all hand compartments [1, ii]. Mostly, wounds are left open to avoid suturing under tension [two]. In our case, though completely tension-free skin closure was possible and it was performed.
Paw compartment syndrome is a rare condition which necessitates emergent evaluation and treatment. Failing to recognize and treat this condition is detrimental to the hand functional status. We believe that a low threshold of surgical intervention of those limb threatening iatrogenic injuries should exist used, as among others there are also medicolegal issues that might come upwardly.
Disharmonize OF Interest STATEMENT
No conflicts of involvement.
FUNDING
No sources of funding.
CONSENT
Patient'due south consent form bachelor if needed.
GUARANTOR
Guarantor: Ioannis M. Stavrakakis.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6247138/
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