Compartment Syndrome of Hand Following Extravasation of Intravenous Contrast

INTRODUCTION

Contrast medium extravasation occurs when contrast medium deposits outside the blood vessel during the injection phase of scanning. It’s a frequent injection-related issue with CT, X-ray, and magnetic resonance (MRI). This type of issue occurs in 0.25%–0.9% of all injection therapies.^[1] The literature describes an array of causes for hand compartment syndrome. The most prevalent causes of hand compartment syndrome are forearm and distal radius fractures, burns, crush injuries, penetrating trauma, constrictive dressings or casts, infections, bleeding disorders, extravasation of medicines or intravenous fluids, reperfusion injury, and vascular injury are among the other established causes.^[2] Extravasation of contrast compounds is a prevalent and serious issue during CT scans. Symptoms are often modest. In rare instances of significant volume extravasation, consequences might be highly dangerous.^[3] Traditionally, compartment syndrome was usually established clinically. Medical experts frequently highlight the six “P’s” of compartment syndrome: pain, pallor, pulselessness, paraesthesia, paralysis, and poikothermia.^[4] Early identification and fasciotomy to alleviate compartment pressure is crucial to avoid permanent injury. Untreated compartment syndrome causes elevated pressure, vascular impairment, and diminished perfusion.^[5]

CASE REPORT

A 59-year-old woman presented with complaints of severe abdominal pain on and off since 2 months, insidious and progressive in nature, and for which she was taking tablet cyclopam [Si opus sit (SOS)], and symptoms were relieved after taking medication. She is a known case of Hypertension since 5 years on the tablet amlodipine 5 mg once daily in morning, type 2-Dabetes Mellitus since 8 years; she was on the tablet metformin 500 mg with glimepiride 2 mg and voglibose 0.3 mg twice daily in the morning and at night and the tablet vildagliptin 50 mg with metformin 500 mg once daily in morning, and Hypothyroidism since 8 years on tablet thyroxine 100 mcg once daily in the morning. No history of any allergic reactions was elicited. She was advised for contrast-enhanced computed tomography (CECT) abdomen for evaluation of severe unexplained abdominal pain. And at the start of the injection patient experienced mild pain, swelling, and irritation in the hand [Figure 1]. Contrast was discontinued, and an ice pack was applied. Contrast was given on the other hand, and the patient tolerated the scanning. Later the patient started developing blisters and bullous lesions on the left hand (wrist, thumb, and knuckles region), as seen in [Figure 2]. She returned to hospital, and on examination tense swelling, redness, reduced pulsations and fluid-filled bullous lesion were seen on her left hand. She was diagnosed with compartment syndrome secondary to extravasation of contrast medium. The patient was immediately admitted for an emergency fasciotomy. Dorsal incisions over the left hand were done as shown in [Figure 3]. The operative findings were oedematous fluid in sub-cutaneous plane, oedema of the deep muscle compartment of the forearm. After day 7 of surgery, oedema reduced; 15 days following surgery wound was healthy [Figures 4a and b, respectively]. The patient was discharged in a stable condition and advised to follow up after 1 week.

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Figure 1:

Mild swelling and pain.

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Figure 2:

Bullous after four hours of contrast.

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Figure 3:

Dorsal incisions of left hand.

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Figure 4:

(a) Healing wound. (b) After 15 days of surgery.

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DISCUSSION

Compartment syndrome is a set of symptoms caused by increased tissue pressure within a confined space, affecting circulation and function of the components.^[6] When employing automatic infusers, substantial volumes of contrast can sometimes be extravasated, which might have serious repercussions, especially if extravasation happens in the hand. Extravasation of contrast is a potential problem of contrast-enhanced imaging. Most extravasations cause minor oedema or erythema, although skin necrosis, ulceration, and compartment syndrome may develop with extravasation of substantial volumes of contrast.^[7] Contrast extravasation has been classified into three severity phases: Mild extravasation injury causes discomfort and swelling that can be alleviated with simple methods like an ice pack and hand elevation. Moderate extravasation injury can cause significant symptoms such as erythema, blistering, discomfort, swelling, and injuries that do not require further treatment. All indications and symptoms fade within 2 weeks. Rarely, Severe extravasation injuries result in compartment syndrome, skin necrosis, or blisters.^[1]

In this case, blister and bullous lesions started appearing after 4 hours of injection, as shown in Figure 2. This patient presented with most symptoms, such as swelling, erythema, and skin irritation, and compartment syndrome developed soon. Hence, these indications can be classified as a severe form of contrast extravasation.^[1]

The best treatment technique is currently unknown, but elevation of the afflicted limb, ice or heated packs, and hyaluronidase injection are commonly used. Hyaluronidase is an enzyme that dissolves interstitial barriers in connective tissue by destroying the interstitial polysaccharide connections that usually hold cells together. This increases the clearance of extravasated material by the lymphatics and capillaries. Hyaluronidase is widely recognised as a safe and effective treatment for the extravasation of a wide range of drugs. When skin blistering occurs, it is advisable to apply silver sulfadiazine and Intrasyte gel to the affected area. More invasive treatments include saline irrigation followed by suction, local vitamin and enzyme administration, negative pressure therapy, and liposuction with saline/hyaluronidase washout. If compartment syndrome is suspected, a fasciotomy must be performed immediately.^[8]

In this case, it was diagnosed with compartment syndrome, and immediate fasciotomy was performed. And most of the literature says that immediate and quick action within 6 hours is needed to consider initiating fasciotomy when compartment syndrome is noticed.^[7] In our case fasciotomy was performed immediately after developing bullous. Post-operative daily sterile dressing was done regularly, and on day 7 of surgery, swelling was alleviated, and the wound was healing and healthy. On day 15, the surgery wound was almost healed and healthy. The patient could mobilise her hand and was discharged with advice for follow-up after 1 week.

CONCLUSION

Contrast-induced extravasation is serious, and it is preventable. Our experience with this case shows that the wrong technique of placement of the IV cannula can induce the contrast to leak in the skin and soft tissue, leading to severe complications such as compartment syndrome and necrosis of the affected part. Our understanding with this case shows that early diagnosis and fasciotomy can save the hand’s function and prevent the necrosis and amputation of the hand. Fasciotomy should be preferably performed within the first 6 hours of contrast media injection to prevent further neurovascular complications.