A 75-year-old woman with a strong family history of ischemic heart disease presented to the casualty department with typical left-sided chest pain. She had underlying diabetes mellitus, hypertension, dyslipidemia, and chronic kidney disease. Diagnosis revealed a non-ST elevation myocardial infarction (NSTEMI), with a troponin I level of 1374 ng/L. The patient received loading doses of aspirin, clopidogrel, and subcutaneous low molecular weight heparin.

Preprocedural blood investigations indicated normal levels of hemoglobin, platelets, and coagulation screening. A coronary angiogram was performed via an uncomplicated right radial artery puncture using a 6-French sheath. Intraoperative anticoagulation was achieved with an intra-arterial bolus of 2000 IU of heparin at the beginning of the procedure. The angiogram revealed double-vessel disease with critical calcific stenosis of the right coronary artery. The cardiologist proceeded with urgent percutaneous coronary intervention, including stenting of the right coronary artery.

Four hours postprocedure, a referral was made to the orthopaedic team upon noting gross swelling of the right forearm. Further history provided by the patient revealed that swelling over the right forearm had begun slowly and progressively after the procedure. The patient complained of increasing pain, which disturbed her sleep, and reported numbness in the fingers. Upon examination, gross swelling was observed over the volar aspect of the right forearm, with striking tense swelling over the distal half. Multiple bullous eruptions were noted over the volar aspect of the right forearm (Fig. 1). There was no active bleeding from the puncture site of the right radial artery at the wrist. The ulnar artery was palpable with strong volume; however, the radial artery could not be appreciated due to the gross swelling. A bedside Doppler ultrasound scan revealed a biphasic signal of the ulnar artery and a monophasic signal of the radial artery. Sensation was reduced over the fingertips, although oxygen saturation in all fingers ranged from 96 to 98%, with a negative passive stretch test. The signs and symptoms experienced by the patient were suggestive of compartment syndrome of the right forearm.

Pre-operative clinical picture of the right upper limb showing signs of acute compartment syndrome

After explaining the patient's condition to her and her family, she was taken to the operating theatre for emergency fasciotomy release of the right forearm, along with prophylactic right carpal tunnel release. Intraoperatively, upon opening the fascia over the volar forearm, muscle bulging from the volar and mobile wad compartments was observed. Gushing of hematoma was seen upon releasing the superficial and deep compartments of the right forearm. The muscles over these compartments were contused but viable. Both radial and ulnar pulses were strong and comparable after evacuating the hematoma. The surgeon opted to approximate the wound using the shoelace technique with a vessel loop (Fig. 2). Two months postoperatively, the wound healed well with no functional deficit.

Postoperative clinical picture showing the shoelace technique used over the right forearm fasciotomy wound

An 80-year-old man with comorbidities of diabetes mellitus, hypertension, and dyslipidemia presented with severe angina pectoris upon exertion. His electrocardiogram showed sinus rhythm with no ST changes; however, troponin I levels were elevated at 142,200 ng/L, indicative of NSTEMI. He was initiated on subcutaneous heparin, oral aspirin, and clopidogrel for treatment.

The baseline blood tests revealed a prolonged activated partial thromboplastin time (APTT) of 76.2 s, with normal prothrombin time (PT) and International Normalized Ratio (INR) values of 16.3 s and 1.29, respectively. The full blood count was normal, with a hemoglobin level of 11.8 g/dL. Transradial coronary angiography was performed one day after admission, revealing three-vessel coronary artery disease. An intra-arterial bolus of 3000 IU of heparin was administered at the beginning of the procedure. The radial artery sheath was removed immediately after the completion of the intervention, and hemostasis was achieved by applying a compression dressing.

On the first day postprocedure while under cardio care, a referral was made to the orthopaedic team due to suspicion of impending compartment syndrome of the right forearm. Early assessment revealed mild swelling over the right hand and ipsilateral forearm, with all compartments otherwise feeling soft. Since there were no other signs or symptoms suggestive of compartment syndrome, the patient was advised to elevate the right forearm using an arm sling connected to a drip stand, and the swelling was carefully monitored.

Unfortunately, on the following day after our assessment, we observed worsening swelling of the right hand and forearm, accompanied by the formation of blisters and bruises over the forearm (Fig. 3). The compartments of the forearm were tense, while those of the hand remained soft. A passive stretch test was positive. Both radial and ulnar pulses were palpable with good volume. The range of motion of the small joints of the fingers, wrist, and elbow was restricted due to the swelling. At this point, a diagnosis of acute compartment syndrome was made, and the patient was promptly taken to the operating theatre for urgent volar and extensor compartment forearm fasciotomy, along with prophylactic carpal tunnel release under general anesthesia. Intraoperative findings revealed muscle bulging upon entering the forearm compartments, accompanied by abundant hematoma. However, the muscles were otherwise viable with good contractility.

Grossly swollen right forearm with extensive bruising and blistering

After the procedure, a deranged coagulation profile led to oozing from the wound. However, as there was no active arterial bleeding, a compression dressing was applied. Unfortunately, the patient's hemoglobin level dropped slowly to 6.6 g/dL, exacerbating his heart condition. Despite resuscitative efforts and attempts to correct the coagulopathy, the patient experienced cardiorespiratory arrest one day after the procedure and passed away due to heart failure from ischemic heart disease.