Case series

Patient 1

An emergency surgical consult was requested for suspected ACS of the right forearm and hand following computed tomography (CT) pulmonary angiography that was performed to exclude pulmonary embolism. The patient, 74-years-old female, was dyspneic at the time of examination and presented with a swollen, painful forearm and hand. The edema was primarily localized to the dorsal aspect of the hand around the venipuncture site. It extended 10 cm proximally up the arm and distally to the distal phalanges of all fingers The fingers of the affected hand were pale, though peripheral sensation and motor skills remained intact, and radial pulses were clearly palpable. Additionally, the patient was unable to move her shoulder, and a painful deformity and hematoma of the right shoulder joint were observed during the surgical examination. It was subsequently revealed that the patient had fallen onto her right arm two days prior. Because she did not seek medical attention or report the trauma during the initial evaluation, assessment of the shoulder joint was omitted. The shoulder injury was clinically distinguished from the forearm extravasation by the absence of symptoms (edema and tenderness) in the distal upper arm and elbow. This unaffected bridge of tissue indicated two isolated pathological processes. The contralateral arm was unaffected, and the patient denied any symptoms regarding it. Initial X-rays of the entire right arm revealed a multifragmentary humeral head fracture and significant accumulation of contrast agent on the dorsal side of the hand and the distal third of the forearm (Fig. 1a and b). Immediate treatment included elevation of the hand at the elbow, application of cold compresses to the hand and forearm, and administration of intravenous corticosteroids and analgesia. The patient was observed for three hours, with neurovascular status checked every 15–30 minutes. After only one hour, the patient reported a regression in pain, the edema became less prominent, and the fingers were less cold and pale. Following three hours of conservative therapy, an MSCT of the shoulder joint was performed. Since the patient no longer exhibited symptoms of ACS and the shoulder fracture was suitable for conservative management, a cast was applied. The patient was then admitted to the internal medicine ward for further treatment of respiratory insufficiency. During follow-up examinations, the edema fully regressed. At the 6-month follow-up, the patient is recovering shoulder function as expected.

Figure 1: (a, b) X-ray of the right hand: Extravasation of contrast media into the soft tissues.

Patient 2

An emergency consult was requested from a plastic surgeon for suspected ACS of the right hand following paravenous infusion of saline solution during a carotid endarterectomy (CEA) performed under general anesthesia. Venipuncture site was on the dorsal side of the hand. The patient, a 69-year-old female, was awake during the examination and reported a sensation of high pressure in her hand. Motor function in all fingers was reduced due to extensive edema spanning the radiocarpal joint and both the dorsal and palmar aspects of the hand. Finger extensors were more severely affected than the flexors. Nevertheless, digital sensation remained intact, and the radial pulse was palpable. Although one liter of saline was infused during the CEA, the exact timing of the extravasation was unknown due to intraoperative sterile drapes; consequently, the volume of paravenously delivered fluid could not be determined. Based on the dorsal localization of the edema and the predominant impairment of the extensor muscles, the motor deficit was considered a result of edema-induced radial nerve compression. However, the partial loss of finger flexor function, combined with mild edema within the carpal tunnel, suggested that concurrent median nerve involvement was also possible. Consequently, decompression incisions on the dorsal aspect of the hand and a carpal tunnel release were performed. Significant amounts of saline were drained from the dorsal incisions, while no fluid was drained from the carpal tunnel. Following the resolution of the edema and the cessation of local anesthesia, the patient reported significant relief, with complete restoration of motor function shortly thereafter. During follow-up, the incisions were sutured, and the patient was discharged third day postoperatively, consistent with the standard recovery protocol for CEA patients.

Patient 3

A 74-year-old woman presented to the emergency department six hours after undergoing CT angiography of the abdomen. The patient reported severe pain and swelling localized to the dorsal aspect of the right hand following contrast administration (Fig. 2). Physical examination revealed hemorrhagic bullae and impaired hand extensor motor function. Notably, fine sensation in all fingers and the radial pulse were completely preserved. A diagnosis of ACS was made, and an emergency fasciotomy was performed. The patient received perioperative broad-spectrum antibiotics and was hospitalized for 5 days. She was discharged with instructions for continued wound care and oral antibiotic therapy. Follow-up examinations confirmed proper wound healing without further complications.

Figure 2: Hand swelling at the site of contrast administration.