By Jason M. Rovak, MD

My night was ruined at 11:30 PM when I got the call from a local freestanding ER with a 28-year-old female who sustained a crush injury to her right hand while she was working at UPS. She had no fractures, a small laceration, but was sucking down equine doses of pain medicine and they were “concerned about a compartment syndrome.”

“Oh, yes, please. I would love nothing more than to take care of your ‘certainly not a compartment syndrome’ patient in the middle of the night. Please transfer her immediately.”

Per standard protocol, it took 3 hours for the patient to make it less than 10 miles to the ER at which I take call. At 2:30 AM I received a call that “my patient was here” and had moved on from equine doses to whale doses of pain medicine. I was able to review her completely unremarkable X-rays on my phone and promptly drove to the ER in a phenomenal mood.

The patient was a young female who had crushed her hand between two heavy UPS package carts. The crush was to the radial aspect of her hand. There was a bit of edema on the radial side of her hand. She held her hand in a normal flexion cascade. The entire hand was soft. She had less than 2 second capillary refill and dopplerable arterial signals in the pads of all digits. Intact light touch sensation in the thumb, long, index, and small, with subjective numbness in the index finger, primarily on the ulnar side. She had a small burst laceration on the ulnar aspect of the index finger at the proximal phalanx level, just distal to the index-long web space. She reported 12 out of 10 pain. Passive movement of the radial digits caused significant pain.

Given the fact that her entire hand was soft, she had normal blood flow to the digits, there were no fractures, and only a small laceration, my clinical suspicion for a compartment syndrome was extremely low. Her only concerning finding was her subjective pain level. I wasn’t sure what to make of her pain with passive intrinsic stretch given the completely benign findings otherwise. I’ve never found compartment pressure testing in the hand to be helpful.

I explained to the patient that her only real finding is her pain level and it would behoove her to give me a realistic assessment of her pain. If it is as bad as she describes I’ll have to fillet her hand open to relieve the pressure, and is that really what she wants?

“Do whatever you have to do!”

Grrr. I pictured myself rounding on this woman for the next week with her continued severe pain and stiff fingers, likely poor outcome, and decided that, with her pain level, it was on me to prove that she didn’t have a compartment syndrome. I called the OR and booked the emergency sham surgery I was about to perform.

Her swelling and pain were isolated to the radial aspect of the hand so I elected to address the 1st dorsal interossous, index/long interossei, explore the ulnar digital nerve to the index, volar instrinsics, and leave the ulnar aspect of the hand unscathed.

Under bier block anesthesia, I started with the dorsal incision and released the compartments dorsally. In a huge shock, they looked completely normal. No hematoma, no bulging after the fascia was open. Volar dissection revealed a completely intact ulnar digital nerve, which was not surprising since it was a burst laceration. I extended the laceration proximally using standard Brunner incisions.

To my surprise, the index lumbrical looked a bit pale. The tourniquet was up, but there was definitely a color difference compared to the other exposed musculature. I incised the fascia overlying the lumbrical, which immediately bulged out and, despite the bier block, pinked up.

Fairly incredulous, I asked the scrub who was helping me that evening if that actually happened. Was I making it up? No, that happened. He saw it too.

I loosely closed the skin since the hand was soft, there was no hematoma, and the pathology was isolated to the index lumbrical.

I hung out for a while and examined her in PACU after she was awake enough to communicate. Her hand, while sore, felt much better than it did preoperatively.

It was now about 5 AM and I had enough time to get home and shower before morning clinic. Per protocol, I got pulled over on the way home, but managed to look pathetic enough to avoid a ticket. I examined the patient on the floor before starting clinic and she continued to report improvement. Her narcotic requirements had decreased to standard human postoperative levels.

She was discharged on postoperative day 2 and recovered well.

So: Apparently isolated index lumbrical compartment syndrome is a thing.

I wish I could chalk this up to my diety-like diagnostic skills. My course of action stemmed more from a conversation I had with one of my partners when I started practice. If you’re ever questioning what you should do, imagine your choice being recited in a court room and consider how it sounds. “Dr. Rovak, you had a patient who sustained a crush injury between two heavy objects requiring substantial amounts of pain medicine to barely control her pain, and you decided to observe?”

Obviously, as physicians we need to make decisions based on clinical acumen and not fear of litigation. That said, it’s also easy to write off a patient’s complaints as exaggerated, especially at two in the morning.

Unfortunately, there’s probably not a great overarching message to this story and it is more of a “this one time, at band camp” story aka “case report” since obviously index lumbrical compartment syndrome is rare enough that I have never heard of it, much less seen it. I told everyone I knew about this case right afterward, and they were purely torqued off that I had just given them one more thing to worry about in the middle of the night.