Iatrogenic compartment syndrome from hypertonic saline injection in Bier block

A case study of an iatrogenic forearm compartment syndrome is presented. The patient underwent intravenous regional anesthesia (Bier's block) for an attempted closed reduction of a Bennett's fracture. Hypertonic saline (23.4%) was inadvertently used as a lidocaine diluent for the Bier's block, and after tourniquet release, the patient developed signs and symptoms of an acute compartment syndrome. An emergent fasciotomy was required. A review of the theoretical pathogenesis of compartment syndrome resulting from intravenous injection of hypertonic saline is presented. While vein sclerosis from i.v. hypertonic saline may play a role in the development of a compartment syndrome, we speculate that the major factor was an increase in the extracellular tissue fluid volume resulting from osmotic equilibrium after the tourniquet was released. The need for meticulous attention to details when performing this technique is emphasized.