Dr. David Forsh’s review yesterday of compartment syndrome made me realize how rarely we see this life-threatening diagnosis.
So what do we need to know?
What’s the etiology of compartment syndrome?
- Majority cases 2/2 Fractures (75%); the rest are soft tissue injuries from causes such as: snake bites, seizures, burns, tourniquets,…
- People with coagulopathy such as those on anticoagulation have a higher risk for compartment syndrome
- The main fracture sites associated w/ compartment syndrome: (1) Tibia Fractures (diaphyseal region) (2) Distal Radius Fractures
- May also see with open fractures!
Who/When do we usually see this in?
- Young, Restless Men usually 2-4d after injury
How do patients present? Clinical diagnosis is hard because patients usually present with 1 of these signs and the rest when it is “too late”
- 6ps: PAIN, Pallor, Pulselessness, Paresthesias, Paralysis, Perishingly cold/Pudgy calf
- Pain is the earliest sign/ Pain w/ passive stretching/Pain out of proportion
- Pudgy calf aka Swelling many patients will have swelling and a “tense” calf but this is not a very sensitive or specific clinical finding
- Paresthesias in the legs may be seen initially around the 1st metatarsal dorsal webspace b/c that is where the deep peroneal n. ends and more susceptible to injury w/ swelling; 4hrs=damage; around 8-12hrs you see nerve damage
- Pallor, Paralysis, Perishingly Cold, Pulselessness=BAD!
What ancillary tests do we use to diagnose this?
- Stryker Needle to measure compartment pressure
- Normal compartment pressure <10mmHg
- >30-40mmHg may result in ischemic necrosis
- Formula: ∆ pressure = diastolic blood pressure (DBP) — intracompartment pressure (ICP)
- ∆P of ≤ 30 mmHg–>OR
- You want to measure pressure in the anterior and posterior compartments (click link for Video)
- Can also use A line setup, other methods…
Management
- Remove all constrictive clothing or jewelry
- elevate limb to level of heart
- apply traction if indicated
- Ideal time to fasciotomy: 6-12hrs approx 68% of patients will have good outcomes within this timeframe; outside this timeframe may not want to do fasciotomy based on risks/benefits (patient may have contracture w/o fasciotomy but they may have worse outcomes w/ fasciotomy)
Controversial Topics:
Do nerve blocks mask compartment syndrome? Dr. Forsh says “No! Ischemic pain breaks through the nerve block and therefore you have a higher suspicion for compartment syndrome if patient is in pain. But don’t use dense blocks.” What does the literature say? There is a mixed consensus with some studies finding possible delays in management of compartment syndrome 2/2 nerve block. Often these are nerve blocks that are too dense. Therefore if used there needs to be a thorough discussion with anesthesia about the type and amount of anesthetic used.
RECAP:
- Look for compartment syndrome in patients with fractures especially in the distal radius, diaphyseal of the tibia, or open fractures
- Be weary of patients on anticoagulants as they are at increased risk for compartment syndrome 2/2 bleeding
- Look for pain out of proportion, pain w/ passive stretching, parethesias in the 1st metatarsal dorsal webspace, all other signs late…
- Stryker measurement of pressure: DBP — ICP=∆ pressure <30mmHg–>Needs OR
- Remove constrictive clothing/jewelry, elevate limb, GET PATIENT TO OR!
Sources:
- Dr. David Forsh Orthopedic Emergencies Lecture at Sinai 10/12/2016.
- McQueen, M. & Duckworth, AD. Diagnosis of Acute Compartment Syndrome. http://www.boneandjoint.org.uk/content/diagnosis-acute-compartment-syndrome
- Compartment Syndrome. http://lifeinthefastlane.com/ortho-library/compartment-syndrome/
- Inaba,K. & Swadron, S. Compartment Syndrome. Nov 2011. https://www.emrap.org/episode/november2011/compartment?link=episode-guide
- Garner, M. R., Taylor, S. A., Gausden, E., & Lyden, J. P. (2014). Compartment syndrome: diagnosis, management, and unique concerns in the twenty-first century. HSS Journal®, 10(2), 143-152.
