A 29-year-old woman comes to the emergency department after spilling hot coffee on her left forearm. Medications include a daily oral contraceptive, and the patient has no other medical issues. Evaluation shows a full-thickness burn, and she is discharged with analgesics, topical antibiotics, and wound care instructions. Three days later, the patient returns due to worsening pain and swelling of the left hand. She describes the pain in her hand as severe and aching. Repeat examination shows previous burn injury healing with a circumferential eschar formation. Her left hand is tense and tender. Which of the following is the most likely cause of this patient's condition?

Question

A 29-year-old woman comes to the emergency department after spilling hot coffee on her left forearm.  Medications include a daily oral contraceptive, and the patient has no other medical issues.  Evaluation shows a full-thickness burn, and she is discharged with analgesics, topical antibiotics, and wound care instructions.  Three days later, the patient returns due to worsening pain and swelling of the left hand.  She describes the pain in her hand as severe and aching.  Repeat examination shows previous burn injury healing with a circumferential eschar formation.  Her left hand is tense and tender.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d934_b64d_bc81_dfde423d80d2_MD0003_00 Acute compartment syndrome (ACS) occurs when excessive fluid accumulation in a confined compartment of the body (eg, upper leg, lower leg, upper arm, forearm, hand, foot, abdomen) causes an increase in compartment pressure to the point that blood flow is severely impaired. Pain out of proportion to clinical findings is often the first presenting symptom, and worsening pain may be elicited with passive stretch of the affected muscle compartment. Tissue tension, pallor, and decreased sensation may also be present. If elevated compartment pressure is allowed to persist, tissue ischemia and eventual tissue death will occur. The eschar that results from a circumferential, full-thickness (third degree) burn often leads to constriction of venous and lymphatic drainage, fluid accumulation, and resulting distal ACS. Overall, clinical findings for ACS can be unreliable, and a high clinical suspicion should be maintained in patients with significant injuries to the extremities, especially the distal extremities. Serial compartment pressure monitoring is useful in determining the need for definitive operative management, which consists of compartment decompression by fasciotomy or, in the case of circumferential burns, escharotomy. (Choices A and C) Subcutaneous bacterial invasion may lead to cellulitis or, in the case of Clostridium perfringens, gas gangrene with myonecrosis. However, cellulitis is typically characterized by skin warmth and gas gangrene is characterized by crepitus. (Choice B) Inflammatory arthritis (eg, rheumatoid arthritis) is characterized by pain and swelling often involving the bilateral metacarpal phalangeal joints. Unilateral swelling of the left hand following a forearm burn is not consistent with inflammatory arthritis. (Choice E) Venous thrombosis of the upper extremity can lead to pain and swelling of the hand, and burn trauma may increase the risk of venous thrombosis development. However, the combination of swelling, tissue tension, and severe pain in the setting of a circumferential, full-thickness burn with an eschar is more consistent with ACS. Educational objective: Circumferential, full-thickness (third degree) burns can result in eschar formation that restricts venous and lymphatic drainage, leading to acute compartment syndrome. References: Acute compartment syndrome in lower extremity musculoskeletal trauma. (http://www.ncbi.nlm.nih.gov/pubmed/16272268) Escharotomy and fasciotomy of the burned upper extremity. (http://www.ncbi.nlm.nih.gov/pubmed/10791164) The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/23595064)

A 29-Year-Old Woman Comes to the Emergency Department After Spilling