WALANT technique for acute compartment syndrome of the arm in a COVID-19 patient: A case report

Introduction

Compartment syndrome is a surgical emergency caused by elevated pressure within a closed fascial compartment, leading to compromised tissue perfusion and the potential for irreversible damage if not treated promptly. This report presents a rare case of upper limb compartment syndrome in a COVID-19 patient on anticoagulation therapy following multiple failed venipuncture attempts. This work has been reported in line with the SCARE criteria.

Case presentation

A 67-year-old man with hypertension, diabetes, and congenital hydrocephalus was admitted for COVID-19 pneumonia. He required anticoagulation therapy with Enoxaparin due to his high risk for thromboembolic events. Following multiple failed attempts to secure venous access in the right upper limb, the patient developed severe pain, swelling, and numbness in the limb. Clinical examination revealed pallor, paresthesia, and pulselessness, raising suspicion of compartment syndrome. Ultrasonography confirmed the absence of radial and ulnar arterial flow, with evidence of significant muscular edema and hematoma formation in the anterior compartment of the arm.

Due to the patient's pulmonary compromise and elevated risk for general anesthesia, the decision was made to perform a fasciotomy under the WALANT (Wide Awake Local Anesthesia No Tourniquet) technique. Following the procedure, pulses were restored after evacuation of a deep hematoma compressing the humeral artery, with immediate improvement in hand perfusion. The patient was transferred back to the infectious diseases department for continued COVID-19 management, and the postoperative course was uneventful. At 6-month follow-up, the patient had fully recovered mobility of the shoulder, elbow, wrist, and fingers.

Discussion

This case underscores the rare development of upper limb compartment syndrome in a patient on anticoagulation therapy for COVID-19, likely due to venipuncture-related trauma. It highlights the challenges of diagnosing and managing compartment syndrome in critically ill patients, and demonstrates the utility of the WALANT technique in performing fasciotomy in high-risk patients. Early recognition and timely intervention were crucial in ensuring the patient's full functional recovery.

Conclusion

Compartment syndrome should be considered in patients on anticoagulation therapy, particularly those with multiple venipuncture attempts. The WALANT technique provides a viable surgical option for fasciotomy in critically ill patients.