Compartments of the hand.
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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Emergency Operations of Sudden Water Pollution Accidents",doi:null,correctionPDFUrl:"https://cdn.intechopen.com/pdfs/64890.pdf",downloadPdfUrl:"/chapter/pdf-download/64890",previewPdfUrl:"/chapter/pdf-preview/64890",totalDownloads:null,totalCrossrefCites:null,bibtexUrl:"/chapter/bibtex/64890",risUrl:"/chapter/ris/64890",chapter:{id:"64626",slug:"emergency-operations-of-sudden-water-pollution-accidents",signatures:"Jin Quan, Lingzhong Kong, Xiaohui Lei and Mingna Wang",dateSubmitted:null,dateReviewed:"October 15th 2018",datePrePublished:"December 1st 2018",datePublished:"December 19th 2018",book:{id:"8874",title:"Emergency Operation Technologies for Sudden Water Pollution Accidents in the Middle Route of South-to-North Water Diversion Project",subtitle:null,fullTitle:"Emergency Operation Technologies for Sudden Water Pollution Accidents in the Middle Route of South-to-North Water Diversion Project",slug:"emergency-operation-technologies-for-sudden-water-pollution-accidents-in-the-middle-route-of-south-to-north-water-diversion-project",publishedDate:"December 19th 2018",bookSignature:"Xiaohui Lei",coverURL:"https://cdn.intechopen.com/books/images_new/8874.jpg",licenceType:"CC BY-NC 4.0",editedByType:"Edited by",editors:[{id:"282118",title:"Dr.",name:"Xiaohui",middleName:null,surname:"Lei",slug:"xiaohui-lei",fullName:"Xiaohui Lei"}],productType:{id:"4",title:"Compact",chapterContentType:"compact",authoredCaption:"Authored by"}},authors:[{id:"280923",title:"Dr.",name:"Lingzhong",middleName:null,surname:"Kong",fullName:"Lingzhong Kong",slug:"lingzhong-kong",email:"lzkong@126.com",position:null,institution:null}]}},chapter:{id:"64626",slug:"emergency-operations-of-sudden-water-pollution-accidents",signatures:"Jin Quan, Lingzhong Kong, Xiaohui Lei and Mingna Wang",dateSubmitted:null,dateReviewed:"October 15th 2018",datePrePublished:"December 1st 2018",datePublished:"December 19th 2018",book:{id:"8874",title:"Emergency Operation Technologies for Sudden Water Pollution Accidents in the Middle Route of South-to-North Water Diversion Project",subtitle:null,fullTitle:"Emergency Operation Technologies for Sudden Water Pollution Accidents in the Middle Route of South-to-North Water Diversion Project",slug:"emergency-operation-technologies-for-sudden-water-pollution-accidents-in-the-middle-route-of-south-to-north-water-diversion-project",publishedDate:"December 19th 2018",bookSignature:"Xiaohui Lei",coverURL:"https://cdn.intechopen.com/books/images_new/8874.jpg",licenceType:"CC BY-NC 4.0",editedByType:"Edited by",editors:[{id:"282118",title:"Dr.",name:"Xiaohui",middleName:null,surname:"Lei",slug:"xiaohui-lei",fullName:"Xiaohui Lei"}],productType:{id:"4",title:"Compact",chapterContentType:"compact",authoredCaption:"Authored by"}},authors:[{id:"280923",title:"Dr.",name:"Lingzhong",middleName:null,surname:"Kong",fullName:"Lingzhong Kong",slug:"lingzhong-kong",email:"lzkong@126.com",position:null,institution:null}]},book:{id:"8874",title:"Emergency Operation Technologies for Sudden Water Pollution Accidents in the Middle Route of South-to-North Water Diversion Project",subtitle:null,fullTitle:"Emergency Operation Technologies for Sudden Water Pollution Accidents in the Middle Route of South-to-North Water Diversion Project",slug:"emergency-operation-technologies-for-sudden-water-pollution-accidents-in-the-middle-route-of-south-to-north-water-diversion-project",publishedDate:"December 19th 2018",bookSignature:"Xiaohui Lei",coverURL:"https://cdn.intechopen.com/books/images_new/8874.jpg",licenceType:"CC BY-NC 4.0",editedByType:"Edited by",editors:[{id:"282118",title:"Dr.",name:"Xiaohui",middleName:null,surname:"Lei",slug:"xiaohui-lei",fullName:"Xiaohui Lei"}],productType:{id:"4",title:"Compact",chapterContentType:"compact",authoredCaption:"Authored by"}}},ofsBook:{item:{type:"book",id:"9589",leadTitle:null,title:"Depigmentation as a Disease or Therapeutic Goal",subtitle:null,reviewType:"peer-reviewed",abstract:"
\r\n\tDepigmentation disorders may be congenital or acquired. Congenital diseases of depigmentation include oculocutaneous albinism, piebaldism, Waardenburg syndrome, tuberous sclerosis, nevus depigmentosus and cutaneous mosaicism. Acquired diseases of depigmentation include vitiligo, hypomelanosis secondary to cutaneous inflammation, infectious hypomelanosis, chemical or pharmacologic hypomelanosis, hypomelanosis from physical agents, and miscellaneous. Vitiligo is a very common acquired depigmentation disorder where melanocytes that produce melanin pigment of the skin are destroyed. It can occur systematically and affect whole body or locally/segmentally affecting parts of the body. For the treatment of vitiligo, various medical, surgical and photo therapies are in use, and several emerging new treatments are under investigation.
\r\n\r\n\tThese disorders can profoundly affect patient's quality of life. To improve facial blemishes, many people resort to laser treatments, chemical peels and cosmetics, thus markets for depigmenting lasers and cosmeceuticals are also increasing rapidly. This book aims to cover topics in diseases of depigmentation and therapeutic depigmentation.
",isbn:"978-1-83969-012-9",printIsbn:"978-1-83969-011-2",pdfIsbn:"978-1-83969-013-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"3e1efdb1fc8c403c402da09b242496c6",bookSignature:"Dr. Tae-Heung Kim",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9589.jpg",keywords:"Congenital Depigmentation, Albinism, Piebaldism, Dyschromatosis Hereditaria, Vitiligo, Pathogenesis, Phototherapy, Excimer Laser, Excimer Light, Surgical Treatments, Postinflammatory Hypopigmentation, Pityriasis Alba",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 9th 2020",dateEndSecondStepPublish:"November 23rd 2020",dateEndThirdStepPublish:"January 22nd 2021",dateEndFourthStepPublish:"April 12th 2021",dateEndFifthStepPublish:"June 11th 2021",remainingDaysToSecondStep:"2 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Kim graduated from and acquired a doctoral degree (Ph.D.) at Seoul National University College of Medicine. He is an active member of many international and domestic societies and a former President of the Korean Society for Vitiligo.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"121353",title:"Dr.",name:"Tae-Heung",middleName:null,surname:"Kim",slug:"tae-heung-kim",fullName:"Tae-Heung Kim",profilePictureURL:"https://mts.intechopen.com/storage/users/121353/images/system/121353.png",biography:"Dr. Tae-Heung Kim graduated from and acquired a doctoral degree (PhD) at Seoul National University College of Medicine. He completed an internship and dermatology residency at Seoul National University Hospital.\r\nHe moved to the Department of Dermatology, Gyeongsang National University, and was then promoted to Professor and Chairman of Dermatology.\r\nIn 1996, he did a research sabbatical for two years at the Department of Immunology, University of Texas MD Anderson Cancer Center.\r\nIn 2003, he started private practice as Director of the White-Line Skin Clinic and Research Center, Changwon, Kyungnam.\r\nHe is an active member of many international and domestic societies, and was the President of the Korean Society for Vitiligo (2016–2018).",institutionString:"White-Line Skin Clinic & Research Center",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"184402",firstName:"Romina",lastName:"Rovan",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/184402/images/4747_n.jpg",email:"romina.r@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"70921",title:"Installation of Vegetable Based Roof Gardens in Schools From Recyclable Materials: A Study",doi:"10.5772/intechopen.90721",slug:"installation-of-vegetable-based-roof-gardens-in-schools-from-recyclable-materials-a-study",body:'\nIn view of the constant evolutions that technology imposes on agriculture and food production, especially in family farming associated with climatic phenomena, the uncertainties of an economically, socially, politically and technologically correct agriculture, as well as the absence of agricultural practices in the experience of young people in rural communities, raises a concern on the future of world agriculture and food production [1], with similar concerns occurring in Brazil.
\nIn Nigeria, the idea that agricultural activity, especially in rural areas, is undervalued and provides few benefits for its practitioners [2], prevails on the part of young people.
\nAnjos and Caldas [3] cite that there is a very negative view populating the imagery of rural youths, a fact that, ultimately, reproduces the dominant stigma that rural spaces represent the place of “non-development”, of the archaic, of the traditional.
\nAccording to Guthman [4] for the production of food, students, in the exercise of citizenship or as future agricultural workers, will be better able to understand the debates and controversies that underlie the production, creation and marketing of agricultural products, recognizing the limits and possibilities of models, both of intensive production and alternative models, these little valued and disseminated (family farming, agroforestry production, etc.), as well as recognizing the various aspects (environmental, scientific, political, economic, cultural, etc.) present in the different models of food production and understand the different tools of flexible teaching and learning, based on permaculture, that the gardens School (Gardens) can offer.
\nOne of the alternatives to raise the perception about activities in the agricultural environment and the care of the environment is the use of a school garden, which can serve as a source of food and didactic activities, offering advantages to the communities involved, such as obtaining quality food at low cost and involvement in food and health programs developed by schools [5], contributing also to the knowledge of the 3 R’s (reduce, reuse and recycle), integration of the community school in the performance of socio-environmental activities, encouraging the consumption of organic foods, providing students with experiences of agroecological practices for food production, so that they can be transmitted to their relatives and, consequently, apply them to home or community gardens [6].
\nIn this context, the research aims to reflect on the environmental issues and the action of the gardens in urban/school spaces, taking allowance from the garden as a methodological instrument the interdisciplinary practices of activities related to agriculture family.
\nThe literature review presented below contains a synthesis of the latest studies on the production of vegetable gardens in urban areas, highlighting the production of vegetable gardens in schools. The methods used were studies of free area in school spaces of three schools of early childhood education, investigation of the needs and desires of the school community and researches on types and forms for plant production in urban areas and employability of recyclable materials in its construction. The software Auto Card, a tool for architectural drawings, enabling the creation of gardens for each space studied was used.
\nFor the preparation of the gardens passive recycling materials may be used, through characterization of solid residues, materials that has been discarded by the local population, without appropriate destination for the environment, for example,
Tires: used in the garden site
Pet bottles: it is used to demarcate the Mandala (vegetable garden en circle) garden site and store rainwater for irrigation through the drip.
Paper: fertilizer and base of the flowerbeds.
Organic residues of food production in school: fertilizer.
Gray water from the production of school feeding: irrigation and fertilization.
Demolition wood: to assemble the structure of the vegetable gardens.
Urban agriculture is an activity that has been growing in Brazil and worldwide, according to FAO—Food and Agriculture Organization of the United Nations. This activity refers to the use of surfaces located in urban areas or in their respective peripheries for agricultural production and the creation of small animals intended for own consumption or for sale in local markets.
\nSome of the concepts about urban agriculture in general address their relationship with localization. For Dimoud and Nikolopoulou [7], the definition of urban agriculture refers to the location of the spaces within and around cities or urban areas. Therefore, the intra area refers to all spaces within cities that may have some type of agricultural activity, which can be individual or collective, in addition to being located in private or public areas such as squares or idle areas.
\nWong [8] stated that the concept of urban agriculture goes beyond what is defined by the area of localization, which is therefore an interaction between the ecological and urban economic system, not being reduced only to the urban location.
\nDimoud and Nikolopoulou [7] stated that this integration is made possible by the fact that urban agriculture has a set of activities (cultivation, breeding, fishing, etc.) that develop in the interior (Intraurban) or in the periphery (periurban) of the cities.
\nThe development of urban or periurban agriculture is directly linked to the demographic and economic growth of cities, contributing to the reconfiguration of urban spaces through land use, population structures, social practices, among other factors.
\nThe advantages of urban agriculture, includes the local development through the rational use of spaces, food security, formation of microclimates, maintenance of biodiversity, water drainage, harvesting of rain water, decreased temperature and income generation. Most common examples of urban agriculture are the community gardens that are most often installed in urban idle areas, which may be public or private, intended for cultivations of vegetables, medicinal plants, legumes, fruits and other foods, providing food for families living near these areas, or seedling production [9].
\nUrban gardens have differentiated configurations, where they almost always correspond to the boundary of the area where you want to deploy it.
\nOne of the configurations observed in the use of urban gardens is the greenhouses. These are protected agricultural environments where the plastics are used as cladding materials for covering the greenhouse framework, used in the protection of crops, facing the climatic adversities. Agricultural greenhouses are used to create climatic environments suitable for plants, protecting them from poor environmental conditions such as frost, hail, and other weather. They are used for food production, cultivation of ornamental plants, flowers and medicinal plants [10].
\nRosenzweig et al. [11] stated that the cultivation in protected environment brings with it numerous advantages such as: harvest in the periods between harvest, faster production cycle due to favorable environment conditions, increase in production, control of the environment promoting the development and production of plants, greater control of pests and diseases that may occur in the protected environment, better use of available resources, reduced risks and increased market competitiveness by the producer.
\nAccording to Wong [8], besides urban gardens, vertical farms have numerous advantages such as production of several crops throughout the year, zero loss of crops related to possible adverse weather conditions, reduction of transaction costs, production without pesticide use, herbicides and fertilizers, optimization of water resources, greater control of food security and social and esthetic gain in large urban centers.
\nIn the educational context, adopting other forms of production and consumption that is more sustainable is fundamental to resignify time, space and social relations of the students.
\nIt is noteworthy that for school garden its size is not important, but the diversity of plants used matters. The main idea is to manage, in a balanced way, the soil and other natural resources through a work harmonized with nature and, as the garden will be located in the premises of a school, the construction and management can be used as an activity of enrichment of classroom learning [12].
\nThe study proposes the elaboration for the construction of school gardens that meet children and adolescents for the experience of agricultural and environmental practices for plant and animal production. Vegetable gardens, vertical gardens in pet bottles and gardens in ceilings with the use of pallets are preferred in which vegetables and fruits adapted to the region, are to be cultivated. Proper management options are required, besides use of constructive materials of low cost. Community and rural producers in the region may supply the seedlings and may be involved in the production system.
\nThere are enormous benefits of composting in the school community, and most important among them is the possibility of students to start administering and using the leftover food produced in their family environment. In addition are the inevitable learning process related to ethics, personal responsibility and environmental citizenship, giving them a specific action to help their local community and society as a whole. The landscape effect that the materials recyclable and plants can provide, has been shown in Figure 1.
\nProposal of an agropedagogical space of recyclable materials.
With the short space, it was proposed to build units of vertical vegetable gardens using pet bottles that can be collected by students at their homes, vegetable gardens with tires and a central site that is already existing in space. For the cultivation of species that do not have good productive results receiving solar incidence, a recycle wood pergola of solid waste from civil construction—RSC, was designed where vines will be cultivated, for example, passion fruit.
\nVegetable gardens serve as pedagogical space for teaching learning, almost all care is performed by the students, as seen in Figures 2 and 3.
\nPlanting with technical guidance.
Vegetable bed with the use of tires.
Thus, the garden inserted in the school environment can be a living laboratory that enables the development of several pedagogical activities in environmental and food education, uniting theory and practice in a contextualized way, assisting in the teaching process, learning and promoting collective and cooperative work among the social agents involved [5].
\nIt is worth noticing that this space will serve to perform different trainings that may be offered to the community, enabling knowledge about the breeding of birds, including the sanitary management, the preparation of the ration in the property, records and notes, the use of poultry manure for crop fertilization, production of vegetables and legumes and climatic studies, etc.
\nIn the field study, one of the schools had the space in a covered area with roof in slab, and thus pallets were used for the construction of beds, in order to protect the floor of the covering and use a material that would possibly have its destination in the dumps.
\nAnother proposal was on lajeed roofs, and again use of pallets was suggested (Figure 4). The pallets may be purchased in trade as recycled material, and used as the basis for transporting construction products, machinery, and other high-weight products.
\nGardens on roofs utilizing pallets.
In addition to providing a better nutrition to school students, it also ensured a greater awareness about the natural assets and valorous vision about the agricultural activities so present in their midst. The lack of encouragement to the young in the field generates the non-continuity of properties and the growing demographic, economic and cultural emptying of regions of predominance of family farming [3, 13]. According to Adeokun [1], all the efforts of the stakeholders for sustainable child development is valid, and this research continues to be a formidable way to rationalize alternatives and practices of agriculture in the school life.
\nProjects of this nature are of great relevance to transform some esthetic concepts such as the use of green spaces, actions geared towards environmental education, possibility of exploitation of reusable resources could be debated, used and transformed artistically in a vertical garden, which continues to be cared for by all students and school staff, as documented in the study of Oliveira et al. [6].
\nWith pedagogical practices appropriate to the work, elaboration and development of the school garden in public schools, it is observed that there is also encouragement to the various forms of learning and understanding, enabling the acquisition of new knowledge, where all, through research and practice can exert a dynamic activity, which favors the teaching of science, enabling the encouragement of research and discussion of topics as a food environment, waste, cooperative work, behavior and make possible the development of the teaching-learning method, through practice, in addition to awakening social values such as participation, sense of responsibility, interpersonal relationship and awareness of the metastatic issues in the period in which we live.
\nWith the study carried out, it was possible to construct different types of gardens for different spaces, bringing to the school spaces the plant production and the productive knowledge for children in urban areas, in the guidelines of (1) sustainability in the ecological, economic, social, cultural, political and ethical dimensions; (2) agricultural production bringing well-being and guaranteeing productivity; (3) construction with low cost and use of recyclable materials and adopting the method in educational spaces.
\nCompartment syndrome is defined as an elevated pressure of an anatomical compartment up to a level where the tissue blood perfusion is impeded. Acute compartment syndrome (ACS) of the hand is rare, as compared to other areas of the human body, but the consequences are detrimental if treated suboptimally. Severe functional disability of the hand, due to muscles’ contractures, is the inevitable result of a neglected compartment syndrome. Diagnosis of this urgent situation is challenging and it is based mainly on the clinical examination [1, 2, 3].
In case there is any doubt towards the diagnosis of ACS or for insensate patients, intracompartmental pressure measurement is used to aid the evaluation [4]. Good knowledge of the special anatomy of the hand is necessary, in order to manage compartment syndrome appropriately. Disproportionate pain, severe swelling and a relevant mechanism should raise a strong suspicion of a compartment syndrome [5]. Once the diagnosis of an ACS is made, treatment should be implemented promptly. Intervention varies from simple actions, such as splitting a tight cast, to a surgical decompression [2]. Correct timing of fasciotomies is of paramount importance, in order to achieve a good functional outcome [6].
This chapter aims to present the current concepts regarding hand compartment syndrome. Special features of the hand compartments’ anatomy are reported. Pathophysiology is described briefly, as it is analyzed in extension in other parts of this book. Etiology, diagnosis, treatment and complications are mentioned as well, emphasizing towards the proper technique of fasciotomies.
Hand contains basically ten myofascial compartments: the adductor pollicis compartment, four dorsal interossei and three palmar interossei compartments, the thenar and the hypothenar compartment. The thenar compartment includes the Abductor Pollicis Brevis (AbPB), the Flexor Pollicis Brevis (FPB) and the Opponens Pollicis (OP) muscles. They are innervated by the recurrent motor branch of the median nerve, apart from the deep head of the FPB, which is innervated by the deep branch of the ulnar nerve [2]. The hypothenar compartment includes the Opponens Digiti Minimi (ODM), the Abductor Digiti Minimi (AbDM) and Flexor Digiti Minimi (FDM) muscles. They are all innervated by branches of the ulnar nerve (Figure 1). Although located basically in the wrist, the carpal tunnel is frequently mentioned as a compartment of the hand. Cleland and Grayson ligaments also compartmentalize digital space. All compartments of the hand along with their muscles and nerves are presented on the Table 1 [2, 4, 7]. It is highlighted here that the compartments of the hand contain predominantly motor nerves. Intracompartmental sensory nerves of the hand are only the digital nerves and the median nerve inside the carpal tunnel. This characteristic anatomy is reflected to the clinical image of the compartment syndrome of the hand [4, 5, 8].
Hand compartments cross sectional anatomy. (from: Reichman EF. Compartment syndrome of the hand: A little thought about diagnosis. Case rep Emerg med. 2016;2016 [5]).
Compartment | Muscles | Nerves | Incision |
---|---|---|---|
Adductor Pollicis | Adductor Pollicis | Sensory: None Motor: Branches of the ulnar nerve | Dorsal over the second metacarpal (radial aspect) |
Interossei compartments | 4 dorsal interossei, 3 palmar interossei | Sensory: None Motor: Branches of the ulnar nerve | Two Dorsal incsions over the second and fourth metacarpal |
Thenar | AbPB, OP, FPB | Sensory: None Motor: Recurrent motor branch of the median nerve, apart from the deep head of the FBP (ulnar nerve) | Radial aspect of the first metacarpal |
Hypothenar | AbDM, FDM, ODM | Sensory: None Motor: Ulnar nerve | Ulnar aspect of the fifth metacarpal |
Carpal tunnel | None (FPL, 4 FDS, 4 FDP tendons/not muscles) | Sensory: Median nerve Motor: Recurrent motor branch of the median nerve | Midpalmar incision |
Digital | None (digital tendons/not muscles) | Sensory: digital nerves Motor: None | Lateral midaxial incision |
Compartments of the hand.
AbPB: abductor pollicis brevis, OP: opponens pollicis, FPB: flexor pollicis brevis, AbDM: abductor digiti minimi, FDM: flexor digiti minimi, ODM: opponens digiti minimi, FPL: flexor pollicis longus, FDS: flexor digitorum superficialis, FDP: flexor digitorum profoundis.
Several variations of the hand compartments have been described. Difelice et al. [7] found that in 52% of the hands, the thenar space is separated in two discrete compartments. In 76% of the hands the hypothenar demonstrated at least two compartments. The second, third and fourth interossei group demonstrated different dorsal and volar compartment in the 48%, 67% and 38% of the hands respectively. The fasciotomies used for the treatment of hand ACS are designed based on this anatomic model. Whether further subcompartmentalization of the thenar and hypothenar area has any clinical significance is controversial. Gyuton et al. [9] found through a cadaveric study that fascia between dorsal and volar interrossei muscles subsides at pressures as low as 15 mmHg, putting its clinical relevance in question.
The pathophysiology of acute compartment syndrome is based on Matsen’s arteriovenous gradient theory. According to this model, interstitial edema increases the local venous pressure (Pv). Local blood flow (LBF) equals to arteriovenous pressure difference (Pa - Pv), divided by vascular resistance (R). Thus, the increase of the local venous pressure decreases local blood flow. Tissue ischemia increases small vessels permeability as well as extravascular osmolality, leading to a further fluid extravasation and subsequent more interstitial edema. Viscious cycle is continued through the former mechanism. Local and systemic inflammatory response is exacerbated by the release of cytokines, as a result of impaired tissue blood supply [4, 10].
Muscle damage due to compartment syndrome occurs prior to nerve impairment and it is reversible for the first 4 hours. The time frame after which muscle necrosis is occurred is still controversial, with a reported range among studies between 8 to 12 hours [2, 4, 11]. Experimental studies of canine model showed permanent tissue necrosis and nerve conduction arrest with interstitial pressures of more than 40 mmHg for at least 8 hours [12].
Intracompartmental pressure increases by either extrinsic or intrinsic causes or combination of both. Tight dressings or casts represent extrinsic factors, via external pressure application to the compartments of the hand [13].
Intrinsic causes of hand compartment syndrome are:
Trauma: fractures, soft tissue injury, crush syndrome (Figure 2),
Burns,
High pressure injection injuries (Figure 3),
Iatrogenic: arterial injury, reperfusion surgery, intravenous material extravasation (Figure 4),
Infection: abscess, septic tenosynovitis, necrotizing fasciitis,
Bites (snake, insect),
Anticoagulation medications,
Hand crush syndrome. Compartment syndrome due to extensive soft tissue injury and concomitant third and fourth metacarpal fractures, after prolonged compression of the hand by a heavy object.
Index finger compartment syndrome (delayed presentation), due to high pressure injection injury, complicated with septic tenosynovitis.
Hand compartment syndrome due to extravasation contrast material. Hand is sitting in intrinsic minus position. Excessive swelling and skin blisters are noticed (from: Stavrakakis IM et al. hand compartment syndrome as a result of intravenous contrast extravasation. Oxf med case rep. 2018;2018(12):omy098 [8]).
Patient’s history, clinical image and physical examination are the keystones for the diagnosis of acute compartment syndrome [2]. Localized swelling and disproportionate pain, unresponsive to analgesics, along with a relative mechanism of injury should raise the suspicion of ACS [2, 4, 13]. As mentioned in the anatomy section, sensory nerves of the hand are located outside the compartments, with the exception of the median and digital nerves. Hence, tingling and paresthesia are not always present, unless the carpal tunnel or digits are involved [4, 5].
Serial clinical examination is of paramount importance, in order to detect ACS early. On inspection, severe swelling is noticed. Blisters might also be visible. The hand is sitting in intrinsic minus position, i.e. the metacarpophalangeal joints (MCPJs) are in extension and the interphalangeal joints (IPJs) are in slight flexion (Figure 4) [1, 4, 8]. Digital palpation reveals great tension of the hand. Pain on passive stretching of the intracompartmental muscles is an early sign of impaired blood perfusion. Specifically for the hand, each compartment should be stretched individually. The interossei compartments are stretched by passively abducting and adducting the digits and at the same time keeping the MCPJs in flexion and the IPJs in extension (bring the hand from the intrinsic minus position to the intrinsic plus position - “intrinsic stretch test”). The lumbricals are stretched by passively extending the MCPJ and flexing the proximal IPJ. The adductor pollicis is checked by passively abducting the thumb. Passive adduction of the thumb is used to test the thenar compartment and finally the hypothenar compartment is evaluated by passive adduction and extension of the small finger [2, 13]. In case the five P’s of tissue ischemia are already present (pain, pallor, pulselessness, paresthesia and paralysis), then the diagnosis is considered delayed and irreversible muscle damage is very likely. Clinical examination has high specificity as well as high negative predictive value, meaning that it can exclude ACS better than confirming it [15].
In case there is any doubt regarding the diagnosis of ACS after clinical examination, or for unconscious patients, more subjective tools for evaluation should be used. Intracompartmental pressure measurement (ICP) is considered to be the main adjunct to the diagnosis. It is generally accepted that a pressure difference (ΔP) between the diastolic blood pressure (Pd) and the compartmental pressure (Pc) less than 30 mmHg necessitates surgical decompression (ΔP = Pd – Pc < 30 mmHg). This difference is more reliable than an absolute intracompartmental pressure of more than 30 mmHg [15, 16]. Several modalities of measuring the pressure of the compartments have been described, such as the infusion Whiteside apparatus, the slit catheter technique and the handheld intracompartmental pressure monitoring [13]. Straight catheters have the least accuracy as compared to the slit catheter and side port needle. It is also reported that the Whiteside apparatus overestimates the intracompartmental pressure, which can potentially lead to an unnecessary fasciotomy [2, 15]. Current trend is towards a continuous pressure measurement, which is probably more reliable than a single one, as the latter approach is associated with a high false positive rate [17, 18]. As there are cases of silent compartment syndrome described in the literature, i.e. severe swelling with no excruciating pain, whenever there is a slight suspicion of ACS, ICP measurement should be performed [18].
Regardless of the apparatus used, it is crucial that a correct technique of pressure measurement is performed. General guidelines include perpendicular insertion of the needle on the skin [2], within 5 cm of the fracture site, but not in direct cοntact with the fracture [15, 16]. Particularly for the hand, each compartment’s pressure should be measured individually. The hand should rest at the level of the heart. For the thenar and hypothenar compartment the needle is inserted at the border of glabrous and nonglabrous skin. The adductor pollicis muscle is entered ulnarly to the first metacarpal. The interossei compartments are entered between the index-long, long-ring and ring-small finger metacarpal, 1 cm proximal to the metacarpal heads, superficial at first for the dorsal interrosei muscle and then 0,5 to 1 cm deeper for the volar interrosei. Needle insertion over the midpalmar lesion is also used for carpal tunnel pressure measurement (Figure 5) [2, 4].
Portals of intracompartmental pressure measurement of the hand.
Given the fact that clinical examination and intracompartmental pressure measurements have their own limitations, recent research is directed towards hemodynamic and metabolic parameters in an effort to achieve a more accurate diagnosis of ACS. These parameters include: a. Monitoring local oxygenation (via intramuscular partial oxygen pressure, oxygen saturation measurement or near infrared spectroscopy), b. monitoring local perfusion (via pulsed phased - locked loop ultrasound, photoplethysmography, laser Doppler flowmetry and scintigraphy), c. local metabolic analysis (intramuscular glucose monitoring, intramuscular pH monitoring) and d. serum biomarkers (white blood cell count, erythrocyte sedimentation rate, C - reative protein and creatinine kinase). However there is still no evidence of superiority over intracompartmental pressure measurement and there is still long way to go until they can be used safely in clinical practise [16].
Chronic exertional compartment syndrome is defined as a muscle dysfunction because of ICP rising due to excessive activity. Only few cases of chronic compartment syndrome located in the hand have been described in the literature and the most commonly affected compartments are the adductor pollicis, the first dorsal interosseous, the thenar and hypothenar compartments [19].
Muscles can tolerate a condition of reduced vascular supply for a time period of no more than 6 to 8 hours. Regarding the limbs there is evidence supporting that the time threshold after which necrosis occurs, is 8 hours [6]. There are though case series reporting a good outcome from fasciotomies which were performed within 12 hours [11]. Impeded compartment syndrome should be recognized early, in order to avoid loss of limb function. Once the diagnosis is made, every effort should be done to decrease the intracompartmental pressure. Conservative treatment includes simple releasing of dressings or splitting a tight cast. The hand should be elevated at the level of the heart, but not above it, in order to preserve the arteriovenous gradient. Oxygen supplementation, intravenous hydration and mannitol adminstration are additional adjuvants to operative treatment [10]. Surgical decompression through fasciotomies is the mainstay of treatment, if acute compartment syndrome is suspected [3, 13].
Faciotomies of the hand are performed through four skin incision. a. Two dorsal incisions over the second and the fourth metacarpal are recommended for decompression of the interossei’s and adductor pollicis’ compartments. Blunt dissection is carried out deeper through the fascia between the 1st dorsal interossei and the adductor pollicis and between the dorsal and palmar interossei muscles. b. One incision radial to the first metacarpal between the glabrous and nonglabrous skin for the thenar decompression. c. One incision ulnar to the fifth metacarpal for the hypothenar release. d. Carpal tunnel, although not a true compartment, it should be released through the traditional midpalmar longitudinal incision (Figure 6) [2, 3, 4]. e. If digits are involved, Cleland and Grayson ligaments are released through midaxial lateral incision, 4 cm long centered over the proximal interphallangeal joint (PIPJ), taking care of the neurovascular bundle. Dominant sensory nerves should be avoided, indicating a radial incision for the thumb and the small finger and ulnar incision for the index, middle and ring fingers [2, 13]. In delayed cases though, especially if they are complicated with infection, a volar Brunner incision is suggested (Figure 7). After the procedure, the wounds are generally left opened and the hand is splinted in a safe position of function. In case of severe skin damage (burns), which precludes the splint application, the metacarpophallangeal (MTPJ) joints are pinned in flexion and the PIPJs in extension (intrinsic plus position) [2, 4]. The wounds are inspected every 2 to 3 days and a second debridement is suggested, if signs of infection or necrosis are identified. As soon as edema subsides and circulation is restored, the wounds can either be closed primarily or they can receive a split thickness graft. Priority is given to the coverage of tendons and nerves. Physiotherapy is initiated as early as possible [2, 10]. Proposed treatment algorithm of acute hand compartment syndrome is presented on the Table 2.
Hand fasciotomies. Two dorsal incisions over the second and fourth metacarpal are used to decompress the adductor pollicis and interossei compartments. One incision radial and palmar to the first metacarpal for the thenar compartment. One incision ulnar to the fifth metacarpal for the hypothenar compartment. One midpalmar incision for carpal tunnel release. (from: Stavrakakis IM et al. hand compartment syndrome as a result of intravenous contrast extravasation. Oxf med case rep. 2018;2018(12):omy098 [8]).
Surgical decompression of index finger’s compartment syndrome, due to high pressure injection injury, complicated with septic tenosynovitis of the patient of the Figure 3. Proper debridement required a volar Brunner incision instead of a lateral one, which is normally used for digital compartment syndrome.
Algorithm of hand ACS management. ΔP: pressure difference, BPd: diastolic blood pressure, ICP: intracompartmental pressure.
A good functional outcome can be expected after ACS, if surgical release is performed early. In case of a neglected compartment syndrome, it is widely accepted that delayed fasciotomies (more than 24 hours since initial presentation), are no beneficial to the patient, and they actually carry a risk of serious complications, such as infection, septicemia and amputation. Fasciotomies are also associated with stiffness, pain, cosmetic problems, nerve injury and chronic venous insufficiency [15, 16]. If the hand compartment syndrome is not managed properly, permanent loss of function is inevitable. Muscle contractures are developed and the hand sits in intrinsic minus position, with the MCPJs in extension and the PIPJs in flexion. Intrinsic plus contraction though is possible, if lumbricals muscles are predominantly affected. The first web space is contracted as well [2, 20].
Hand ischaemic contractures includes three groups. Group 1: All interrosei and thenar muscles are involved (typical Volkmann contracture). Group 2: thenar or interossei muscles are involved. Deformity concerns the thumb or the fingers. Group 3: one or more fingers are affected. Established intrinsic muscles contractures are treated with appropriate operative releases. The first web space is released and the tendons of the interossei muscles are released at the level of the metacarpal necks. Fibrotic tissue is removed. Detailed description of these operations are beyond the scope of this chapter [20, 21].
Hand compartment syndrome is an urgent condition which demands early recognition and treatment, otherwise it results to a permanent loss of function. Several controversies regarding diagnosis and management still exist in the contemporary literature. Future research should target on how a more accurate and early diagnosis can be achieved and the time frame beyond which fasciotomy is not beneficial to the patient. Fasciotomies of the hand are the cornerstone of treatment, and if they are performed early, they guarantee a good functional outcome. The surgeon should demonstrate a low threshold towards surgical release if compartment syndrome is suspected. Knowledge of the special anatomical features of the hand is necessary, in order for the physician to offer to the patient a sufficient treatment.
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