Bilateral acute exertional compartment syndrome of the forearms in a sport climber: a case report

Abstract

Introduction: Acute exertional compartment syndrome (AECS) of the forearm is rare, and bilateral cases are reported only sporadically. In sport climbers, the far more familiar entity is chronic exertional compartment syndrome (CECS) of the forearm, for which fasciotomy is elective. That mismatch in expected time pressure, paired with sparse upper-extremity AECS literature, drives delayed diagnosis and avoidable functional loss. Case Presentation: A previously healthy man in his early thirties presented with bilateral forearm tightness, swelling, median and ulnar paresthesia, and inability to make a fist after a single high-volume climbing day combining outdoor multi-pitch effort with extended hangboard and campus-board training. Examination showed bilateral volar swelling, cyanotic discoloration, and reduced two-point discrimination with intact distal pulses. Serum creatine kinase peaked at 31,420 units/L, and forearm magnetic resonance imaging demonstrated diffuse volar compartment T2 hyperintensity. Right-sided compartment pressures (volar 58 and 62 mmHg, dorsal 38 mmHg, mobile wad 42 mmHg) prompted emergent two-incision fasciotomy. The contralateral forearm progressed clinically and was decompressed on hospital day 2. Both wounds underwent delayed primary closure. At six months the QuickDASH score was 14, and at three years the patient had returned to recreational climbing near his pre-injury level. Discussion: Forearm AECS in athletes is uncommon and easily mistaken for chronic exertional compartment syndrome in the climbing population. The constellation of hours-acute symptom onset, marked rhabdomyolysis, and progressing neurologic deficit distinguished AECS from CECS in our patient and triggered emergent compartmental pressure measurement. Bilateral cases can present asynchronously; contralateral surveillance was the practical refinement that permitted timely staged decompression. Conclusion: Bilateral forearm AECS in a sport climber is easily anchored to CECS. Recognition rests on the constellation of hours-acute onset, marked rhabdomyolysis, and progressing neurologic deficit, with contralateral surveillance for asynchronous bilateral progression. Decompression within the six-hour window can preserve near-baseline function.