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H 10543 Compartment Syndrome

The acute inflammation in the muscle after reestablishing perfusion leads to swelling and a risk for compartment syndrome. The available space for the muscles is limited in the leg and when the increased pressure in the compartments reduces capillary perfusion below the level necessary for tissue viability, nerve injury and muscle necrosis occur. The essential clinical feature of compartment syndrome is pain - often very strong and out of proportion, which is accentuated by passive extension. The muscle is hard and tender when palpated. Unfortunately, nerves within the compartments are also affected, causing disturbance of sensibility and motor function. This makes diagnosis more difficult. Moreover, the patient is often not fully awake or disoriented, but early diagnosis is still important to save the muscle tissue. For that reason measurement of intracompartmental pressure is performed for diagnosis in some hospitals. There are no precise limits that advocate fascioto-my, but 30...

Compartment syndromes

Compartment syndromes have multiple aetiologies, the commonest of which is raised intracompartmental pressure secondary to trauma. The application of tight dressings which goes unrecognized may also exacerbate this condition. The commonest areas where compartment syndromes occur are the volar compartment of the forearm and the anterolateral and lateral compartments of the leg. However, potentially, any closed fascial compartment is prone to the development of a compartment syndrome.

Compartment Syndrome

Compartment syndromes have been more commonly described to affect the arms and legs. Nine compartments have been identified in the foot. Compartment syndrome occurs when an elevation of tissue pressure within one of these nonyielding fascial compartments impedes vascular flow. In the foot, the cause of compartment syndrome is usually a high-energy injury associated with multiple fractures. Crush injuries are more likely to cause compartment syndrome. Compartment syndromes have been reported in association with midfoot fractures and rearfoot fractures, burns, contusions, bleeding disorders, postischemic swelling after arterial injury or thrombosis, venous obstruction, exercise, and prolonged pressure to the affected area. There have also been reports of chronic compartment syndromes due to overuse. Patients typically present with severe acute pain that is worsened on active or passive movement, swelling, paresthesias, and neurovascular deficits. The only reliable method to diagnose...

Abdominal Compartment Syndrome

The normal pressure of the peritoneal cavity is at most atmospheric and varies inversely with intrathoracic pressure during respiration (398). Intra-abdominal pressure (IAP) is elevated when any type of severe abdominal trauma is associated with massive fluid resuscitation, hemoperitoneum, bowel edema, attempted surgical closure of a non-compliant abdominal wall, and use of intra-abdominal packing. Circumferential burn eschar causes extrinsic compression (see Chapter 4, Subheading 5.2.). Increased IAP coexists with increased abdominal girth and obesity. Abdominal compartment syndrome occurs when IAP is associated with organ dysfunction, i.e., reduced cardiorespi-ratory and renal function. Most deaths associated with abdominal compartment syndrome are from sepsis or multiorgan failure.

Positioning the Surgical Patient

The anaesthetised patient is at risk of developing pressure sores in those areas where perfusion may be compromised. Likely sites are the occiput, the sacrum and the heel, all of which must be padded. External pneumatic compression devices applied to the lower limbs both confer a degree of protection from pressure effects and also improve circulation which helps to prevent deep vein thrombosis. No patient should ever be allowed to lie with the legs crossed and where possible an evacuatable mattress should be used. Compartment syndrome, usually related to trauma or arterial surgery, and for which immediate fasciotomy is essential to save life or limb, can be a rare complication of prolonged (four hours or more) lower limb compression in the lithotomy position.

Abdominal and Pelvic Injury

Liver injuries are also common following abdominal trauma. As with spleen injuries, liver injuries due to blunt trauma are frequently managed nonoperatively, as long as concomitant bowel injuries are ruled out. CT scanning, again, is the diagnostic test of choice in stable patients because it allows one to grade the severity of the injury to the liver. Unstable patients with large liver lacerations may sustain large blood loss and transfusion requirements resulting in the lethal triad of hypothermia, acidosis, and coagulopa-thy. In these situations, a damage control laparotomy is frequently done in order to stop any surgical bleeding, stop any ongoing contamination from bowel injuries, and tamponade nonsurgical bleeding with laparotomy packs. The patient is then taken to the ICU for further resuscitation and correction of hypothermia, coagulopathy, and acidosis. The open abdomen also reduces the risk of abdominal compartment syndrome secondary to massive fluid resuscitation.41 A...

Fractures Of Both Forearm Bones

The physical examination of the forearm should include a careful motor and sensory examination of all three major nerves. Radial, median, and ulnar nerve function should be documented. Neurological deficits, though not common, do occur. The presence or absence of pulses and their relationship to the contralateral extremity should be detailed. Both bone fractures of the forearm are a common cause of compartment syndrome. Tense swelling of the forearm may indicate the need for further investigation and possibly an urgent compartment release. The integrity of the skin should also be examined for signs of an open injury.

Bleeding Complications

The emergency physician needs to be aware of major bleeding emergencies that can develop in patients with hemophilia. These patients require emergent factor replacement therapy and management by hemophilia specialists. Air transport to specialized centers should be considered for intracranial, intrathoracic, or intraabdominal bleeding, even if the patient appears stable. Bleeding into the central nervous system (CNS) can occur spontaneously as well as with trauma. Any patient with hemophilia who complains of a new headache or any neurologic symptoms requires immediate factor replacement therapy followed by immediate computed tomographic (CT) scanning of the head. Spontaneous or traumatic bleeding into the neck, retropharynx, or pharynx has a high potential for airway compromise. Such bleeding can be spontaneous or precipitated by successful or unsuccessful placement of external jugular lines or other trauma. These patients require immediate factor replacement and immediate CT scanning...

Assessing Individual Upper Extremity Injuries

Grade 3 injuries have an associated degloving component, vascular interruption, a crushing mechanism of injury, or threat of compartment syndrome. Once an injury is identified, defined, and reduced, it should be splinted in a fashion that will allow reevaluation of the skin, soft tissues, any impending compartment syndrome, and neurological and vascular status. A baseline examination includes assessment of the pulses and capillary refill. Brachial, radial, and ulnar pulses must be examined. Allen's test defines the arterial supply distal to the wrist and tests the integrity of the radial artery-supplied deep palmar arch and the ulnar artery-fed superficial palmar arch. Doppler examination of arterial flow is necessary if pulses are not palpable. Duplex Doppler ultrasound of the deep venous system may be required if there is question of deep venous thrombosis or venous obstruction. If pulses cannot be confidently identified, angiography is imperative. In addition, if pulses are not...

Preventing Additional Posttraumatic Illness

A third common complication of traumatic injury that requires constant vigilance is compartment syndrome. This may occur as an effect of the primary injury, as part of the constellation of polytrauma, or as an iatrogenic injury associated with fracture treatment. Lack of recognition or delayed identification of compartment syndrome is a common cause of litigation related to trauma. Compartment syndrome is caused by the imbalance of arterial and venous flow, with resultant capillary shunting and muscle ischemia. The viability of all tissues within the compartment is at risk when the pressure rises above 30 mmHg or is within 10 to 30 mmHg of the diastolic pressure (for hypertensive or hypotensive patients). Common symptoms and signs of compartment syndrome include pain out of proportion to the injury, pallor, paresthesias, pulselessness, and paralysis however, the earliest and most reliable sign is pain with passive stretch of tendons within the compartment. Diagnosis is confirmed with...

Streptococcal Toxic Shock Syndrome

Commonly than during staphylococcal TSS. The same major and minor criteria used for the diagnosis of staphylococcal TSS can be helpful in identifying patients with STSS. According to a consensus document13 clinical features must include isolation of group A streptococci ( S. pyogenes) and hypoperfusion, as well as evidence of multisystem dysfunction. Because up to 75 percent of cases of STSS have associated soft-tissue infection, a thorough skin examination for the site of infection is warranted. Palpate muscle groups for tenderness, indicating possible myositis or fasciitis, and evaluate for secondary compartment syndrome. Treatment is oxygenation and fluid resuscitation. Because soft-tissue infection plays a large role in STSS, aggressive management of infection is essential. The site of infection should be identified, incised, and drained, and nonviable tissue debrided. Parenteral nafcillin, or oxacillin, or vancomycin, and a first-generation cephalosporin are often given as...

Diagnosis And Management

The presentation of penetrating vascular injury varies widely. Prompt recognition of arterial injury is one of the fundamental goals of management. The presence and volume of the distal pulses in the affected extremity should be noted and compared with the unaffected limb. Ankle-brachial indices (ABIs) should be calculated on the affected and unaffected limbs (method described below). The color, temperature, and capillary refill time are important clinical indicators of more subtle injury to underlying vessels. Examination should also look for signs of compartment syndrome. Capillary refill alone is an unpredictable marker of vascular injury but may be useful in conjunction with other modalities. Only a small minority of patients (fewer than 6 percent) will present with classic hard signs of arterial injury ( IabJe 255-1).

Orthopedic Consultation In The Emergency Department

Some entities or situations that may warrant orthopedic consultation while the patient is still in the emergency department are discussed below. Compartment Syndrome The physiology and potentially catastrophic consequences of compartment syndrome are described later in this chapter. In cases of known or suspected compartment syndrome, orthopedic consultation should be obtained promptly. Emergency surgical intervention may be required to try to avert permanent tissue damage and muscle contracture.

Supracondylar Fractures

The close proximity of the brachial artery to the supracondylar fracture predisposes the artery to contusion, laceration, or entrapment by fractured fragments. Subsequent arterial spasm or compression by splints, casts, or other dressings may further embarrass the arterial blood supply to the muscles of the forearm and to the hand. A resultant forearm compartment syndrome may ensue, with the development within hours of permanent injury and disability to the function of the involved forearm and hand. This is called Volkmann's ischemic contracture and is presaged by (1) pain referred to the proximal forearm upon passive extension of the fingers, (2) stocking-glove anesthesia of the ischemic hand, and (3) rock hard forearm swelling. Skin perfusion is usually normal despite the severe ischemic insult to the entire forearm and hand, and pulses may remain palpable at the wrist despite serious vascular compromise. The clinical suspicion of a potential ischemic compartment syndrome involving...

Fractures of Both Radius and Ulna

Potential complications include reduced ability to supinate and pronate, osteomyelitis, nonunion, malunion, neurovascular injury, and compartment syndrome. Recognizing the development of a compartment syndrome is particularly important to prevent debilitating ischemic contractures of the forearm. The diagnostic findings are palpable induration of the area, pain with passive movement of the fingers, and pain that appears to be disproportionate to the physical findings. The presence of a palpable pulse does not exclude the diagnosis of compartment syndrome. Alterations in sensation and the pulse are late findings. Direct measurements of elevated compartment pressures confirm the diagnosis.

Chapter References

Mubarak SJ, Hargens AR Compartment Syndromes and Volkman's Contracture. Philadelphia, WB Saunders, 1981. 5. Heppenstall RB, Sapega AA, Scott R, et al The compartment syndrome An experimental and clinical study of muscular energy metabolism using phosphorous nuclear magnetic resonance spectroscopy. Clin Orthop 226 138, 1988.

Complications of Pelvic Fractures

The use of the antishock garment is controversial. It may be helpful in controlling bleeding sites by immobilizing fractures and compressing the pelvis. Disadvantages include decreased visibility and access to the abdomen and lower extremities and the risk of compartment syndrome with prolonged application. This garment is generally only recommended for pelvic stabilization in the pre-hospital and ED setting. Early orthopedic consultation should be considered for placement of external fixator device to help control hemorrhage in patients with persistent hemodynamic instability.

Vascular Extravasation and Soft Tissue Toxicity

Intramuscular injection of phenytoin results in localized crystallization of the drug, and hematoma, sterile abscess, and myonecrosis at the injection site. Complications after intravenous infusion have included skin and soft tissue necrosis requiring skin grafting, and compartment syndrome, gangrene, amputation, and death. A syndrome of delayed bluish discoloration of the affected extremity, followed by erythema, edema, vesicles, bullae, and local tissue ischemia, has also been described.13 The propylene glycol diluent, strong alkalinity of the intravenous solution, and crystallization of the drug contribute. Fosphenytoin by contrast, is well tolerated when given IV or iM.

TABLE 2712 Complications of Rhabdomyolysis

The mechanical complications of rhabdomyolysis consist of compartment syndrome and peripheral nerve injury. Compartment syndrome occurs secondary to marked swelling and edema of the involved muscle groups. This swelling will often not occur until after IV hydration. Characteristic signs and symptoms include pain, parasthesias, paralysis, pallor, and pulselessness. Of these, a sensory deficit is the most reliable physical finding. 14 If the intracompartmental pressures exceed 30 to 35 mmHg, fasciotomy is recommended. The associated muscle swelling may also cause pressure on peripheral nerves, resulting in neuronal ischemia and causing parasthesias or paralysis. Nerve injury is often proximal, and multiple nerves may be involved in the same extremity. 15 These peripheral neuropathies usually resolve within a few days or weeks, though, in a minority of patients, they can be permanent.

Acute Soft Tissue Injuries

CRUSH INJURIES AND COMPARTMENT SYNDROME Injuries caused by crush-type mechanisms without associated skin or bone injuries may appear innocuous. These injuries, however, place the foot at risk for the development of compartment syndrome. Compartment syndrome should be suspected when there is pain out of proportion to the injury. Typically, the foot is tensely swollen, and the pain is not relieved by elevation and is increased by passive dorsiflexion of the big toe. Paresthesias may be present, but pedal pulses and capillary refill are often preserved. If compartment syndrome is suspected, intracompartmental pressures must be measured. There are multiple compartments in the foot. The measure of pressure in these small compartments is technically difficult, and orthopedic consultation may be necessary to exclude this diagnosis. Immediate fasciotomy is required once the diagnosis is confirmed.

TABLE 2551 Clinical Manifestations of Extremity Vascular Trauma

Although arterial injury is the most dramatic result of penetrating extremity injury and represents the most immediate life threat, injuries to major nerves are the most likely to lead long-term disability. Fortunately, 70 percent of peripheral nerve injuries noted during the initial examination recover completely within 6 months of the initial injury. A neuromuscular exam of the extremities should indicate both muscular and sensory function ( T.a.b.ie .2.55-2) and check for evidence of compartment syndrome. Patients with suspected nerve, orthopedic, or vascular injury or compartment syndrome should be immediately evaluated by surgical subspecialists.

Immediate complications

Possibility of developing gangrene, necessitating amputation. Other local complications include neural injury from laceration of a nerve or secondary to external compression, for example neurovascular complications in supracondylar fractures of the humerus in children. It is also important to recognize the development of compartment syndrome (see below). This is usually a result of an unrecognized compartment syndrome where there is alternate necrosis of the muscles within a compressed myofascial compartment. Once the muscle tissue is necrotic, it is replaced by scar tissue. As the scar tissue matures it contracts, resulting in joint contractures and deformity across which the muscles act. This is most commonly seen in children after distal humeral fractures wherein the forearm muscles are commonly affected resulting in clawing of the hand, though it may also affect myofascial compartments in the leg, foot and very rarely in the thigh.

Clinical Evaluation

Knee Arthritis Ray

Tissue swelling is essential in cases of massive soft tissue injury in order to avoid missing the diagnosis of compartment syndrome. After reduction, the elbow is assessed for stability as previously described if it is stable, a posterior splint at 90 degrees is applied for 1 week (maximum 10 days). Close observation of the neurovascular status is essential for the first 24-48 h after reduction to assess for possible development of compartment syndrome. After 1 week of immobilization, the splint is discarded and mobilization of the elbow joint begins.

Neurovascular

Hyperextension and stretching of the anterior structures may cause spasm, rupture, or thrombosis of the radial artery. Median nerve injuries (21) can also be associated with dislocation of the elbow because of stretching or intra-articular entrapment. Tension of the nerve across the margin of the epicondylar flare can notch the bone, producing a late radiographic sign known as Matev's sign (22). Extensive soft tissue injury results in excessive swelling around the elbow, which can lead to a compartment syndrome of the forearm and the development of a Volkman's ischemic syndrome. The ulnar nerve is also in danger during elbow dislocations because of valgus stretching (23). Late cubital tunnel symptoms can also occur due to ossification and scarring within the cubital tunnel.

Extremity Injury

Compartment syndrome may be associated with vascular compromise or swelling of the muscle compartments due to crush, contusion, or associated fractures. Signs and symptoms of compartment syndrome include tense muscle compartment, paresthesias, neurologic deficit, paralysis, and diminished pulses or Doppler signals. Diagnosis can be easily confirmed by transducing a compartment pressure with a needle manometer or commercially available device. Compartment pressures exceeding 20-30 mmHg may be sufficient to obstruct capillary flow and produce a compartment syndrome. Treatment is immediate fasciotomy to release the involved muscle compartment. Sequelae of compartment syndrome or crush injury include rhab-domyolysis, hyperkalemia, and renal failure. Therapy is directed at adequate fluid resuscitation, diuresis with mannitol, which may enhance urine flow through its osmotic diuretic effect and also scavenge oxygen free radicals, and alkalinization of urine, which may prevent precipitation...

Orthopaedic Surgery

Much of the orthopaedic surgery in this age group is the result of trauma. A full skeletal survey should be carried out so that other injuries are not missed, particularly head injuries and cervical spine injuries. Blood loss and analgesia requirements should receive particular attention before anaesthesia. After trauma, patients are usually assumed to have a full stomach and should be managed as such with pre-oxygenation and rapid sequence induction techniques. Post operative analgesia for fractures and soft tissue injuries is best provided by regional anaesthesia, although there is some debate about the development of compartment syndrome being masked if there are forearm or lower leg fractures. Elective orthopaedic procedures in children aged five years and over differ little in their anaesthesia requirements from adults.

Soft tissue injury

Soft tissue injury, with or without an associated fracture, results in swelling of the soft tissues and when this occurs within an enclosed fascial compartment, for example, in the lower leg or forearm, a compartment syndrome may occur. This can occur from crushing injury in association with any type of fracture or as a result of a comatose patient lying in an unusual position. As the pressure within the compartment rises, the vascularity of the muscles are compromised and ischaemia and contracture may result. Typical symptoms and signs include pain on passive stretching of involved muscle groups, reduced distal sensation, weakness of involved muscles and intense swelling of the area. This is an urgent condition and a generous fasciotomy is necessary to prevent permanent muscle damage. Where concern exists, tissue pressure can be measured and measurements 35-45 mmHg suggest impairment of vascular supply.

Sensory

Diagnosis of forearm injuries in usually straightforward and based on the physical and radiographic findings. Due to the relatively fixed nature of the ulna, exacting reduction is necessary to retain function. Orthopedic correction is needed for angu-lation of 10 degrees or displacement of 50 of the diameter of the bone. Radius fractures are considered displaced when angulation is 20 degrees or 1 cm of shortening. Complications or all fractures include nonunion and compartment syndrome. Be sure to exclude epiphyseal injuries of the distal radius in children with wrist trauma because the carpal bones are cartilaginous and rarely injured.

Ivdiagnosis Table

Mechanism of injury high-energy vs. low-energy Pain, swelling, and deformity Crepitation at fracture site Neuromuscular examination motor sensory Vascular examination Check for compartment syndrome Check for associated injuries Past medical history, medications allergies Radiological evaluation Most patients upon presentation will have the traditional symptoms of a fracture, such as pain, swelling, deformity, and crepitations. The arm may also be shortened and hypermobile at the site of the fracture. A thorough evaluation of the neurovascular status of the injured extremity is crucial. Motor strength should be tested both proximally and distally to ensure that no injury to the radial, median, or ulnar nerve is missed. The compartments of the arm should also be evaluated to make sure that no compartment syndrome is present. All abrasions and wounds should be probed for the possibility of an open injury, which may warrant the need for emergent surgery.

Pediatric Injuries

Fractures of the foot are rare in children, presumably due to the flexibility of the immature bone and cartilage. Comparison radiographs may be of some benefit in the evaluation of these injuries. Generally, most fractures occur in the metatarsals, and these injuries are usually treated conservatively. Orthopedic consultation can be deferred, with the exception of injuries to the first metatarsal, and complications are usually minimal. Fractures of the calcaneum, talus, tarsals, and phalanges are rare. Injuries to the base of the second metatarsal suggest that a significant injury has occurred, and immediate orthopedic consultation is required. Crush injuries of the pediatric foot should be treated with care compartment syndrome is more common in children than adults, even without fracture.7

Vascular Infections

For limb ischemia, the vascular surgeon should be involved early to decide if surgical intervention or intraarterial thrombolysis is indicated. However, the majority of cases involve distal vessels, and treatment is primarily supportive medical management with heparinization. Limb edema can progress to compartment syndrome or rhabdomyolysis. Fasciotomy may be required for compartment syndrome. For patients who develop rhabdomyolysis, careful monitoring of fluid balance and renal function is required.

Consultation

Orthopedic consultation is required for joint capsule penetration, open fractures, nerve lacerations, lacerations of the EHL, TA, or Achilles tendon, and for suspected compartment syndrome. Hand surgery consultation must be obtained for all flexor tendon lacerations, as well as for extensor tendon lacerations distal to the MCP joint, and should be considered for extensor tendon lacerations proximal to the MCP joint. With peripheral nerve and tendon injuries, it is appropriate for the emergency physician to close the skin and have the patient followed in the consultant's office within the next few days. Injury to the large, named arteries requires vascular surgical consultation.

Emergency Management

The value of aggressive supportive care cannot be overemphasized. Isotonic fluid resuscitation followed by pressor agents is appropriate for hypotension. Antivenom is the best treatment for coagulopathy, but if active bleeding occurs, blood component replacement may be necessary. Another complication of snakebite is compartment syndrome. Increased compartment pressure may occur when venom is injected into a compartment during a bite. This is usually manifest by severe pain, localized to a compartment, that is resistant to narcotic analgesia. The use of fasciotomy is controversial. Recommended management is shown in Table 189-3.

Gunshot Fractures

In gunshot fractures from rifles and large handguns, a greater extent of comminution may be seen. These fractures often have complications because of the soft tissue damage these bullets cause.8 The vascular compromise associated with these comminuted gunshot fractures increases the likelihood of delayed union or nonunion of the fracture. Wound infections are more common in this group. Early fasciotomy to prevent compartment syndrome is important, when needed.