Compartment Syndrome: UNDER PRESSURE

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    Compartment Syndrome: UNDER PRESSURE

    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.
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