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.