Trans-Ulnar Single Incision Fasciotomy for Decompression of Forearm Compartment Syndrome: A Cadaveric Study

Abstract

Objectives: Acute compartment syndrome (ACS) is a medical emergency that requires timely intervention, and delays in treatment can lead to severe complications such as nerve injury, muscle necrosis, amputation, and even death. Definitive treatment of ACS requires a fasciotomy. Currently, there is no consensus on the best approach for a forearm fasciotomy; compartment release is most commonly done through volar or combined volar and dorsal incisions. A trans-ulnar single incision approach has been demonstrated to be effective in a case report. This study investigates if a trans-ulnar single incision decompresses both deep volar and dorsal forearm compartments to less than 30 mmHg in a cadaveric model of ACS.

Methods: Ten fresh, frozen cadaveric upper extremities were injected with egg whites and compartment pressures were measured to determine successful simulation of ACS. A single trans-ulnar incision was made between the Flexor Carpi Ulnaris (FCU) and Extensor Carpi Ulnaris (ECU), extending from 4 to 5 cm (2″) proximal to the ulnar styloid to 6 to 8 cm (3″) distal to the olecranon. After blunt dissection to release the compartments, pressures were measured to confirm decompression.

Results: ACS was successfully simulated in all upper extremities to above 30 mmHg. The mean volume of saline injected to simulate local anesthetic was 38.0 ± 4.2 mL. The mean operative time was 10.1 min. The mean compartment readings 1-min post-fasciotomy were 7.1 ± 3.0 mmHg for the deep volar compartment and 9.4 ± 5.6 mmHg for the dorsal compartment. All fasciotomies reduced deep volar and dorsal compartment pressures below the clinical threshold of 30 mmHg, with significant differences between pre- and post-fasciotomy pressures.

Conclusions: All 10 fasciotomies successfully reduced deep volar and dorsal compartment pressures to below the clinical threshold of 30 mmHg, demonstrating the success of the trans-ulnar single incision fasciotomy to decompress compartment syndrome in cadaveric forearms.

Keywords

compartment syndrome / fascial release / fasciotomy / forearm / trans-ulnar incision

References

[1] D. Chandwani and M. Varacallo, “Exertional Compartment Syndrome,” in StatPearls (StatPearls Publishing, 2024).

[2] M. M. McQueen and A. D. Duckworth, “The Diagnosis of Acute Compartment Syndrome: A Review,” European Journal of Trauma and Emergency Surgery 40, no. 5 (2014): 521-528, https://doi.org/10.1007/s00068-014-0414-7.

[3] B. Shadgan, M. Menon, D. Sanders, et al., “Current Thinking About Acute Compartment Syndrome of the Lower Extremity,” Canadian Journal of Surgery 53, no. 5 (2010): 329-334.

[4] A. M. Torlincasi, R. A. Lopez, and M. Waseem, “Acute Compartment Syndrome,” in StatPearls (StatPearls Publishing, 2025).

[5] A. Hanandeh, V. R. Mani, P. Bauer, A. Ramcharan, and B. Donaldson, “Identification and Surgical Management of Upper Arm and Forearm Compartment Syndrome,” Cureus 11, no. 10 (2019): e5862, https://doi.org/10.7759/cureus.5862.

[6] F. J. Leversedge, T. J. Moore, B. C. Peterson, and J. G. Seiler, “Compartment Syndrome of the Upper Extremity,” Journal of Hand Surgery 36, no. 3 (2011): 544-559, https://doi.org/10.1016/j.jhsa.2010.12.008.

[7] K. I. Khoshhal, E. F. Alsaygh, O. F. Alsaedi, A. A. Alshahir, A. F. Alzahim, and M. S. Al Fehaid, “Etiology of Trauma-Related Acute Compartment Syndrome of the Forearm: A Systematic Review,” Journal of Orthopaedic Surgery and Research 17, no. 1 (2022): 342, https://doi.org/10.1186/s13018-022-03234-x.

[8] B. Long, A. Koyfman, and M. Gottlieb, “Evaluation and Management of Acute Compartment Syndrome in the Emergency Department,” Journal of Emergency Medicine 56, no. 4 (2019): 386-397, https://doi.org/10.1016/j.jemermed.2018.12.021.

[9] R. V. Ormiston and R. Marappa-Ganeshan, “Fasciotomy,” in StatPearls (StatPearls Publishing, 2024).

[10] K. Ipaktchi, J. Wingfield, and S. Colakoglu, “Fasciotomy: Upper Extremity,” in Compartment Syndrome: A Guide to Diagnosis and Management, ed. C. Mauffrey, D. J. Hak, and M. P. Martin (Springer, 2019), https://doi.org/10.1007/978-3-030-22331-1_7.

[11] Y. Marwan, A. Addar, N. Algarni, N. Algarni, M. Burman, and P. A. Martineau, “Endoscopic Fasciotomy for Chronic Exertional Compartment Syndrome of the Forearm: Systematic Review of Outcomes and Complications,” World Journal of Orthopedics 12, no. 5 (2021): 320-328, https://doi.org/10.5312/wjo.v12.i5.320.

[12] B. S. Kalyani, B. E. Fisher, C. S. Roberts, and P. V. Giannoudis, “Compartment Syndrome of the Forearm: A Systematic Review,” Journal of Hand Surgery 36, no. 3 (2011): 535-543, https://doi.org/10.1016/j.jhsa.2010.12.007.

[13] T. Suzuki, N. Inaba, and K. Sato, “Acute Compartment Syndrome in the Forearm With Trans-Ulnar Single Incision,” Journal of Hand Surgery (Asian-Pacific Volume) 21, no. 1 (2016): 99-102, https://doi.org/10.1142/S2424835516720036.

[14] N. I. Ojike, S. R. Alla, C. T. Battista, and C. S. Roberts, “A Single Volar Incision Fasciotomy Will Decompress All Three Forearm Compartments: A Cadaver Study,” Injury 43, no. 11 (2012): 1949-1952, https://doi.org/10.1016/j.injury.2012.08.006.

[15] L. Benamran and A. C. Masquelet, “A Cadaver Study Into the Number of Fasciotomies Required to Decompress the Anterior Compartment in Forearm Compartment Syndrome,” Surgical and Radiologic Anatomy 40, no. 3 (2018): 281-287, https://doi.org/10.1007/s00276-017-1947-3.

[16] N. A. Ebraheim, A. A. Abdelgawad, M. A. Ebraheim, and S. R. Alla, “Bedside Fasciotomy Under Local Anesthesia for Acute Compartment Syndrome: A Feasible and Reliable Procedure in Selected Cases,” Journal of Orthopaedics and Traumatology 13, no. 3 (2012): 153-157, https://doi.org/10.1007/s10195-012-0196-9.

[17] H. Huflage, J.-P. Grunz, T. S. Patzer, et al., “Potential of Unenhanced Ultra-Low-Dose Abdominal Photon-Counting CT With Tin Filtration: A Cadaveric Study,” Diagnostics 13, no. 4 (2023): 603, https://doi.org/10.3390/diagnostics13040603.

[18] J. R. Jackowski, E. P. Wellings, A. Cancio-Bello, et al., “Computed Tomography Provides Effective Detection of Traumatic Arthrotomy of the Elbow,” Journal of Shoulder and Elbow Surgery 32, no. 6 (2023): 1280-1284, https://doi.org/10.1016/j.jse.2023.01.028.

[19] M. Pérez-Abad, D. Noriego Muñoz, Á. Ferreres Claramunt, M. Del Valle Jou, and A. Rodríguez-Baeza, “The Loads Developed by Epicondylar and Epitrochlear Muscles Across the Elbow Joint. A Dynamic Simulated Model,” Journal of Biomechanics 145 (2022): 111356, https://doi.org/10.1016/j.jbiomech.2022.111356.

[20] C. Salas, J. Brantley, D. Mercer, J. Gross, K. L. Scott, and E. Mikola, “Mini All-Suture Anchors for Repairing the Central Slip of the Extensor Tendon at the Proximal Interphalangeal Joint: A Biomechanical Investigation,” Journal of Hand Surgery 49, no. 10 (2024): 1042.e1-1042.e6, https://doi.org/10.1016/j.jhsa.2023.01.005.

[21] Y. Tamaki, T. Goto, J. Iwase, et al., “Relationship Between Iliopsoas Muscle Surface Pressure and Implant Alignment After Total Hip Arthroplasty: A Cadaveric Study,” Scientific Reports 13, no. 1 (2023): 3492, https://doi.org/10.1038/s41598-023-30734-5.

[22] R. O. Davenport, C. S. Locke, B. K. Gundlach, et al., “Bone Morphology and Vascular Supply of Pedicled Distal Radius Bone Using Nano-Computed Tomography,” Hand 19, no. 5 (2024): 734-741, https://doi.org/10.1177/15589447221150500.

[23] “How to Measure Compartment Pressure in a Forearm—Injuries; Poisoning—Merck Manual Professional Edition,”https://www.merckmanuals.com/professional/injuries-poisoning/how-to-do-other-orthopedic-procedures/how-to-measure-compartment-pressure-in-a-forearm#Contraindications_v49751522.

[24] A. D. Duckworth, S. E. Mitchell, S. G. Molyneux, T. O. White, C. M. Court-Brown, and M. M. McQueen, “Acute Compartment Syndrome of the Forearm,” Journal of Bone and Joint Surgery 94, no. 10 (2012): e63, https://doi.org/10.2106/JBJS.K.00837.

[25] E. Ko, Y. J. Song, K. Choe, Y. Park, S. Yang, and C. H. Lim, “The Effects of Intravenous Fluid Viscosity on the Accuracy of Intravenous Infusion Flow Regulators,” Journal of Korean Medical Science 37, no. 9 (2022): e71, https://doi.org/10.3346/jkms.2022.37.e71.

[26] V. Kumbár, J. Strnková, Š. Nedomová, and J. Buchar, “Fluid Dynamics of Liquid Egg Products,” Journal of Biological Physics 41, no. 3 (2015): 303-311, https://doi.org/10.1007/s10867-015-9380-5.

[27] P. G. Wright, “The Variation of Viscosity With Temperature,” Physics Education 12, no. 5 (1977): 323-325, https://doi.org/10.1088/0031-9120/12/5/012.

[28] D. H. Lalonde and A. Wong, “Dosage of Local Anesthesia in Wide Awake Hand Surgery,” Journal of Hand Surgery 38, no. 10 (2013): 2025-2028, https://doi.org/10.1016/j.jhsa.2013.07.017.

[29] J. S. Kurtzman, J. I. Etcheson, and S. M. Koehler, “Wide-Awake Local Anesthesia With no Tourniquet: An Updated Review,” Plastic and Reconstructive Surgery-Global Open 9, no. 3 (2021): e3507, https://doi.org/10.1097/GOX.0000000000003507.

[30] C. Cen, D. He, A. Cao, Y. Xie, C. Hu, and Y. Cao, “Elastic Stable Intramedullary Nails Compared to Locking Compression Plates for Treating Unstable Distal Ulnar Fractures in Adults: A Prospective Comparative Study,” Journal of Orthopaedic Surgery and Research 20, no. 1 (2025): 267, https://doi.org/10.1186/s13018-025-05646-x.

[31] A.-S. Ravery, G. Villatte, J. Dartus, S. Descamps, S. Boisgard, and R. Erivan, “Reasons for Delays to Orthopaedic and Trauma Surgery: A Retrospective Five-Year Cohort,” Orthopaedics & Traumatology, Surgery & Research 109, no. 4 (2023): 103535, https://doi.org/10.1016/j.otsr.2022.103535.

[32] F. Coccolini, M. Improta, E. Picetti, et al., “Timing of Surgical Intervention for Compartment Syndrome in Different Body Region: Systematic Review of the Literature,” World Journal of Emergency Surgery: WJES 15, no. 1 (2020): 60, https://doi.org/10.1186/s13017-020-00339-8.

[33] F. Han, Z. J. Daruwalla, L. Shen, and V. P. Kumar, “A Prospective Study of Surgical Outcomes and Quality of Life in Severe Foot Trauma and Associated Compartment Syndrome After Fasciotomy,” Journal of Foot and Ankle Surgery 54, no. 3 (2015): 417-423, https://doi.org/10.1053/j.jfas.2014.09.015.

[34] S. G. Maliha, O. Cohen, A. Jacoby, and S. Sharma, “A Cost and Efficiency Analysis of the WALANT Technique for the Management of Trigger Finger in a Procedure Room of a Major City Hospital,” Plastic and Reconstructive Surgery-Global Open 7, no. 11 (2019): e2509, https://doi.org/10.1097/GOX.0000000000002509.

[35] G. DeKeyser, E. Bunzel, D. O'Neill, S. Nork, J. Haller, and D. Barei, “Single-Incision Fasciotomy Decreases Infection Risk Compared With Dual-Incision Fasciotomy in Treatment of Tibial Plateau Fractures With Acute Compartment Syndrome,” Journal of Orthopaedic Trauma 37, no. 10 (2023): 519-524, https://doi.org/10.1097/BOT.0000000000002644.

[36] E. Choke, R. Sayers, and M. Born, “Compartment Syndromes,” in Mechanisms of Vascular Disease: A Reference Book for Vascular Specialists, ed. R. Fitridge and M. Thompson (University of Adelaide Press, 2011).

RIGHTS & PERMISSIONS

2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.