Reconstruction of COVID-19–Related Compartment Syndrome With Massive Soft Tissue Necrosis

Christopher Bibbo, DO, FACS, FAAOS, FACFAS


Wounds. 2021;33(4):99-105. 

In This Article

Case Report

A 35-year-old male rehabilitation nurse presented to the emergency department with a fever, shortness of breath, and a cough; the patient's condition rapidly deteriorated and intubation was required. Computerized tomography of the chest revealed a ground-glass appearance in all lung fields, consistent with COVID-19 respiratory disease. Subsequent COVID test results were positive for COVID-19.

At 2 weeks post intubation, standard hematologic laboratory values (platelet, disseminated intravascular coagulation panel, prothrombin time/partial thromboplastin time) were consistent with consumptive coagulopathy. The patient developed massive soft tissue edema of the right arm. Skin ecchymoses over the forearm developed, quickly followed by clear, then hemorrhagic, skin bullae and semirigid flexion deformity of the right wrist and fingers. The arm continued to become even more edematous, with larger blue hemorrhagic blisters and skin necrosis; serial serum creatine phosphokinase (CPK) levels were persistently elevated (2944 U/L rising to a peak of 9633 U/L [normal male range, 39–308 U/L]). Nutritional indices were suboptimal (serum albumin, 2.9 g/dL [range, 3.4–5 g/dL]; serum total protein, 5.4 g/dL [range, 6.4–8.2 g/dL]). Acute renal failure ensued, and the patient required hemodialysis.

Consultation with the general musculoskeletal service was ordered, but a thorough musculoskeletal examination was not possible because the patient was intubated and obtunded. Therefore, a diagnosis of compartment syndrome was uncertain. However, due to the persistently high CPK levels, additional subspecialty consultation with the reconstructive orthopaedic-plastic surgery service was ordered, yielding a delayed diagnosis of capillary leak syndrome and hemorrhagic/thrombotic coagulopathy. This resulted in compartment syndrome of the right arm. Emergent surgical intervention was performed to prevent loss of the upper extremity.


At surgery, medium-sized and smallsized venous thrombosis and massive third-spacing of fluid was evident, resulting in the necrosis of the superficial volar compartment muscles and the median nerve. The radial and ulnar arteries remained patent, and the ulnar nerve was viable. The arm required an extended volar fasciotomy crossing the antecubital fossa onto the distal brachium, and anterior over the dorsal forearm (Figure 1). Operative cultures grew Klebsiella aerogenes, and parental culture/sensitivity-specific antibiotics were initiated.

Figure 1.

Arm after index compartment release. Note the progression to ischemic muscle.

At repeat irrigation and debridement, there was continued necrosis involving the deep volar compartment (Figure 2). After secondary debridement, both the radius and ulna were exposed (Figure 3); only the flexor carpi ulnaris (FCU), brachioradialis (BR), radial and ulnar arteries, and ulnar nerve remained. The stumps of flexor digitorum longus (FDL), flexor digitorum profundus (FDP), and flexor pollicis longus (FPL) were salvaged at the wrist crease. A negative pressure dressing with fluid ingress/egress function was applied in the operating room.

Postoperatively, serial CPK levels measured daily trended downward over 2 weeks but never normalized; however, the patient still required hemodialysis and remained intubated. The patient's pulmonary and mental status improved, and he was ultimately extubated. A bedside examination demonstrated intact sensation and intrinsic motor function to the distribution of the radial and ulnar nerves. Wrist flexion was 4-/5 (Medical Research Counsel Scale Manual Muscle Testing Scale) with activity of the FCU. Wrist and finger extension and BR functions remained. Finger flexion (deep and superficial; FDP), radial wrist flexion, and thumb flexion functions (FPL) were absent. Thenar eminence function also was absent. Thus, hand grasp via finger flexion and thumb flexion/pinch, thenar function, and partial wrist flexion were lost.

Figure 2.

Arm during second debridement with massive muscle necrosis and necrosis of the medial nerve.

Figure 3.

Appearance after second debridement. Superficial and deep finger and thumb flexors have been excised, as well as the median nerve. The radius and ulna are exposed, resulting in a barren volar forearm. The intact flexor carpi radialis is seen at the border of the radius.

Because the stumps of the FDP and FPL were salvaged at the level of the volar wrist crease, tendon transfers remained an option to restore hand grasp. To restore finger flexion, the extensor carpi radialis longus (ECRL) tendon was transferred to the combined tendons of the FDP (Figure 4A, 4B). To restore thumb flexion-pinch, the BR was transferred to the stump of the FPL tendon (Figure 4C). A human decellularized dermal allograft with vascular-like channels (DermaPure; Tissue Regenix) was utilized to reinforce the tendon transfers (Figure 5). To achieve soft tissue coverage of the tendon transfer reconstruction and the volar forearm soft tissue defect, an adipofasciocutanious abdominal thoracoepigastric tube flap was elevated, maintaining a wide proximal skin bridge (Figure 6A, 6B). The forearm was banked under the flap, completely covering the tendon transfers and volar soft tissue defect (Figure 6C). The dorsal fasciotomy brachial wounds were skin grafted. Decellularized dermis also was used to repair an incidental defect of the transversalis abdominal fascia discovered at flap elevation.

Figure 4.

(A) Harvest of ECRL; (B) transfer of ECRL to FDP with decellularized dermis reinforcement; and (C) transfer of BR to the stump of the FPL tendon with decellularized dermis to reinforce.
ECRL: extensor carpi radialis longus; FDP: flexor digitorum profundus; BR: brachioradialis; FPL: flexor pollicis longus

Figure 5.

Completed double tendon transfers with decellularized dermis wrapped for reinforcement; decellularized dermis also used to prevent bowstringing of the FCR tendon.
FCR: flexor carpi radialis

Figure 6.

(A) Approach to raising the thoracoepigastric abdominal flap; (B) inset of forearm under abdominal flap; and (C) final appearance after banking of arm and skin grafting dorsal forearm and anterior brachium.

The forearm was banked under the abdominal flap for 3 weeks, after which division of the flap skin bridge commenced. Partial skin division was performed, maintaining a smaller tubed skin bridge (Figure 7). One week later, the residual skin bridge was divided, and the forearm elevated from the abdominal wall. The orthoptic abdominal adipofasciocutaneous tissue was completely inset onto the native volar margins of the forearm (Figure 8A–8C). The abdominal wall was closed (Figure 8D). After repair of the abdominal wall fascial defect with the decellularized dermal allograft, the umbilicus was reassigned to a midline position.

Figure 7.

Subtotal release of arm from tube flap and partial abdominal closure. Note residual small flap tube preserved due to slow dermal bleeding.

Figure 8.

(A) Final release from residual flap tube; (B) complete release showing flap donor site was revised to properly reassign the umbilicus; (C) final abdominal closure; and (D) close-up of flap inset onto forearm.

After both arm banking and flap inset, the patient's shoulder, elbow, finger, and thumb motion resumed immediately; a tendon transfer rehabilitation and retraining program was also initiated. Hand therapy was continued throughout the postoperative course.

At 6 weeks postoperatively, there was complete healing of the flap and skin grafts (Figure 9A). At the 3-month follow-up, the patient had full shoulder and elbow motion. The initial stages of self-directed thumb-index pinch and finger flexion were demonstrated (Figure 9B). Sensation to the distribution of the ulnar and radial nerve remained intact, with 3 mm static 2-point discrimination to the distribution of the ulnar and radial nerves.

Figure 9.

(A) Appearance at 12 weeks with full healing; and (B) finger flexion to 45° and early thumb flexion.