Compartment syndrome: Difference between revisions
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== Background == | ==Background== | ||
*Most commonly caused by tibia fracture (anterior compartment) | *Most commonly caused by tibia fracture (anterior compartment) | ||
{{Compartment Syndrome Indications}} | {{Compartment Syndrome Indications}} | ||
===Pathophysiology=== | ===Pathophysiology=== | ||
| Line 26: | Line 25: | ||
**[[Snake bite]] | **[[Snake bite]] | ||
== Clinical Features == | ==Clinical Features== | ||
===General Symptoms=== | ===General Symptoms=== | ||
*Compartment is swollen, firm, tender | *Compartment is swollen, firm, tender with squeezing | ||
*Usually develops soon after significant trauma | *Usually develops soon after significant trauma | ||
**May be delayed up to 48hr after the event | **May be delayed up to 48hr after the event | ||
====5 P's==== | |||
*Classic signs of disruption in arterial flow, not of compartment syndrome | |||
**Only found once arterial flow has stopped (very late finding) | |||
#Pain (early finding) | |||
#*Severe, out of proportion to physical findings | |||
#*Worse with passive movement (muscle extension > increased volume > increased pressure) | |||
#*Often the presenting symptom. | |||
#Paresthesia (early finding) | |||
#*Occurs in sensory distribution of affected nerve | |||
#Pallor | |||
#Paralysis: late finding | |||
#Pulselessness: late finding | |||
=== Lower Leg Specific Syndromes=== | ===Lower Leg Specific Syndromes=== | ||
*Anterior | |||
**Nerve: deep fibular (peroneal): sensation of 1st webspace | |||
**Muscle: tibialis anterior: foot/ankle dorsiflexion | |||
*Lateral | |||
**Nerve: superficial fibular (peroneal) nerve: sensation of lateral aspect of lower leg, dorsum of foot | |||
**Muscle: peroneus longus and brevis: foot plantarflexion | |||
*Deep posterior | |||
**Nerve: posterior tibial nerve: sensation of plantar aspect of foot | |||
**Muscle: tibialis posterior/flexor hallucis longus/flexor digitorum longus: Pain with passive extension of the toes | |||
*Superficial posterior | |||
**Nerve: sural cutaneous nerve: sensation of lateral aspect of foot | |||
**Muscle: gastrocnemius/soleus/plantaris: weakness of plantar flexion | |||
[[File:lower_leg_compartment.png|thumb|Lower Leg Compartment]] | [[File:lower_leg_compartment.png|thumb|Lower Leg Compartment]] | ||
=== Hand === | ===Hand=== | ||
*Crush injury, | *Crush injury, with or with out associated fracture | ||
*Involved compartments: thenar, hypothenar, adductor pollicis, and 4 interossei muscles | *Involved compartments: thenar, hypothenar, adductor pollicis, and 4 interossei muscles | ||
*Diagnosis | *Diagnosis | ||
| Line 66: | Line 68: | ||
***Deep, constant, poorly localized, out of proportion to exam | ***Deep, constant, poorly localized, out of proportion to exam | ||
**"Intrinsic minus" position at rest | **"Intrinsic minus" position at rest | ||
***MCP joint extended | ***MCP joint extended with proximal IP joint slightly flexed | ||
**Pain | **Pain with passive stretch of involved compartmental muscles | ||
***Interosseus: performed | ***Interosseus: performed with MCP joint extended and PIP jionts fully flexed | ||
***Thenar, hypothenar: performed by extension of MCP joint | ***Thenar, hypothenar: performed by extension of MCP joint | ||
**Tense swelling of affected compartment | **Tense swelling of affected compartment | ||
=== Forearm === | ===Forearm=== | ||
[[File:Forearm_compartments.jpg|thumb|forearm compartments]] | [[File:Forearm_compartments.jpg|thumb|forearm compartments]] | ||
*Associated | *Associated with supracondylar fracture (peds), distal radius fracture (adults) | ||
*Compartments | *Compartments | ||
**Dorsal (highest risk) | **Dorsal (highest risk) | ||
**Volar | **Volar | ||
=== Foot === | ===Foot=== | ||
[[File:Compartments of the Foot.png|thumb|Compartments of the foot]] | [[File:Compartments of the Foot.png|thumb|Compartments of the foot]] | ||
*Number of compartments is controversial, but at least 4, up to 9 | *Number of compartments is controversial, but at least 4, up to 9 | ||
**Medial, lateral, central, interosseous, adductor | **Medial, lateral, central, interosseous, adductor | ||
**Mechanism - crush injuries | **Mechanism - crush injuries | ||
**Other mechanisms - foot surgery, Lisfranc | **Other mechanisms - foot surgery, Lisfranc fracture, cast immobilization, prolonged extremity positioning, snake bites, severe ankle sprains with arterial disruption<ref>Haddad, Steven L. Managing risk: Compartment syndromes of the foot. AAOS, 2007. http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp</ref> | ||
**5-17% of calcaneus fractures result in compartment syndrome | **5-17% of calcaneus fractures result in compartment syndrome | ||
**Diagnosis | **Diagnosis | ||
***Pain out of proprtion | ***Pain out of proprtion | ||
***Pain worse with passive dorsiflexion (stretching intrinsic musculature of foot); concurrent metatarsal | ***Pain worse with passive dorsiflexion (stretching intrinsic musculature of foot); concurrent metatarsal fracture cloud this finding | ||
***Do not rely on absent pulse or complete anesthesia, which are late findings | ***Do not rely on absent pulse or complete anesthesia, which are late findings | ||
***Measure absolute compartment pressures in [http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp insertion sites found here] | ***Measure absolute compartment pressures in [http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp insertion sites found here] | ||
| Line 96: | Line 98: | ||
***Fasciotomy within 24 hrs of injury if pressures > 30 mmHg | ***Fasciotomy within 24 hrs of injury if pressures > 30 mmHg | ||
=== Other === | ===Other=== | ||
*Thigh (quadriceps compartment) | *Thigh (quadriceps compartment) | ||
[[File:Compartments_of_the_Thigh.png|thumb|Compartments of the thigh]] | [[File:Compartments_of_the_Thigh.png|thumb|Compartments of the thigh]] | ||
| Line 104: | Line 106: | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Extremity trauma DDX}} | |||
{{Calf pain DDX}} | {{Calf pain DDX}} | ||
== | ==Evaluation== | ||
=== Work-Up === | ===Work-Up=== | ||
*xray to rule out fracture | *xray to rule out fracture | ||
*Compartment pressure (see below; take serial measurements if needed) | *Compartment pressure (see below; take serial measurements if needed) | ||
*Total CK, UA ([[ | *Total CK, UA ([[rhabdomyolysis]]) | ||
*Chemistry ([[hyperkalemia]]) | *Chemistry ([[hyperkalemia]]) | ||
| Line 116: | Line 119: | ||
{{Compartment Pressure Interpretation}} | {{Compartment Pressure Interpretation}} | ||
== | ==Management== | ||
#Fasciotomy | #Fasciotomy | ||
# | #*Perform as soon as diagnosis is made by history/physical or by measurement | ||
# | #*Permanent damage results from >8hr of ischemia | ||
#Support blood pressure in hypotensive | #*Refer here for technique: http://www.wheelessonline.com/ortho/12806 | ||
#Support blood pressure in hypotensive patient | |||
#Place affected limb at the level of the heart or slightly dependent | #Place affected limb at the level of the heart or slightly dependent | ||
#AVOID ice (will further compromise microcirculation) | #AVOID ice (will further compromise microcirculation) | ||
#Bivalve or remove cast if present | #Bivalve or remove cast if present | ||
#Adequate analgesia | |||
#Management for associated [[rhabdomyolysis]] if present | |||
==See Also== | ==See Also== | ||
*[[Compartment Pressure Measurement]] | *[[Compartment Pressure Measurement]] | ||
*[[Burns]] | *[[Burns]] | ||
*[[Rhabdomyolysis]] | *[[Rhabdomyolysis]] | ||
*[[Fractures (Main)]] | *[[Fractures (Main)]] | ||
*[[Abdominal compartment syndrome]] | |||
==External Links== | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:Orthopedics]] [[Category:Trauma]] | |||
[[Category: | |||
Revision as of 07:01, 13 August 2019
Background
- Most commonly caused by tibia fracture (anterior compartment)
Compartment Syndrome Indications
- Consider whenever pain or paresthesia occurs in an extremity after:
- fracture (most common risk factor) - can occur with open fracture
- crush injury
- immobilization
- snake bites
- burns
- prolonged tourniquet application
- fluid extravasation into a limb
- soft tissue infection
- extreme exertion
- Immediate threat is viability of nerve and muscle; later threat is infection, gangrene, rhabdomyolysis, renal failure
Pathophysiology
- Tissue perfusion is difference between diastolic BP and compartment pressure
- As compartment pressure increases, tissue perfusion decreases
Etiologies
- Orthopedic
- Vascular
- Ischemic-reperfusion injury
- Hemorrhage
- Iatrogenic
- Vascular puncture in anticoagulated patients
- IV/intra-arterial drug injection
- Constrictive casts
- Soft tissue injury
- Prolonged limb compression
- Crush injury
- Burn
- Snake bite
Clinical Features
General Symptoms
- Compartment is swollen, firm, tender with squeezing
- Usually develops soon after significant trauma
- May be delayed up to 48hr after the event
5 P's
- Classic signs of disruption in arterial flow, not of compartment syndrome
- Only found once arterial flow has stopped (very late finding)
- Pain (early finding)
- Severe, out of proportion to physical findings
- Worse with passive movement (muscle extension > increased volume > increased pressure)
- Often the presenting symptom.
- Paresthesia (early finding)
- Occurs in sensory distribution of affected nerve
- Pallor
- Paralysis: late finding
- Pulselessness: late finding
Lower Leg Specific Syndromes
- Anterior
- Nerve: deep fibular (peroneal): sensation of 1st webspace
- Muscle: tibialis anterior: foot/ankle dorsiflexion
- Lateral
- Nerve: superficial fibular (peroneal) nerve: sensation of lateral aspect of lower leg, dorsum of foot
- Muscle: peroneus longus and brevis: foot plantarflexion
- Deep posterior
- Nerve: posterior tibial nerve: sensation of plantar aspect of foot
- Muscle: tibialis posterior/flexor hallucis longus/flexor digitorum longus: Pain with passive extension of the toes
- Superficial posterior
- Nerve: sural cutaneous nerve: sensation of lateral aspect of foot
- Muscle: gastrocnemius/soleus/plantaris: weakness of plantar flexion
Hand
- Crush injury, with or with out associated fracture
- Involved compartments: thenar, hypothenar, adductor pollicis, and 4 interossei muscles
- Diagnosis
- Clinical, not based on actual compartment pressure
- Pain
- Deep, constant, poorly localized, out of proportion to exam
- "Intrinsic minus" position at rest
- MCP joint extended with proximal IP joint slightly flexed
- Pain with passive stretch of involved compartmental muscles
- Interosseus: performed with MCP joint extended and PIP jionts fully flexed
- Thenar, hypothenar: performed by extension of MCP joint
- Tense swelling of affected compartment
Forearm
- Associated with supracondylar fracture (peds), distal radius fracture (adults)
- Compartments
- Dorsal (highest risk)
- Volar
Foot
- Number of compartments is controversial, but at least 4, up to 9
- Medial, lateral, central, interosseous, adductor
- Mechanism - crush injuries
- Other mechanisms - foot surgery, Lisfranc fracture, cast immobilization, prolonged extremity positioning, snake bites, severe ankle sprains with arterial disruption[1]
- 5-17% of calcaneus fractures result in compartment syndrome
- Diagnosis
- Pain out of proprtion
- Pain worse with passive dorsiflexion (stretching intrinsic musculature of foot); concurrent metatarsal fracture cloud this finding
- Do not rely on absent pulse or complete anesthesia, which are late findings
- Measure absolute compartment pressures in insertion sites found here
- Treatment
- Elevate extremity to level of heart (above the heart, and there will be reduction of O2 perfusion)
- SCDs may help decrease interstitial pressure, improve venous return/arterial flow
- Fasciotomy within 24 hrs of injury if pressures > 30 mmHg
Other
- Thigh (quadriceps compartment)
- Buttock (gluteal compartment)
- Arm (deltoid, biceps compartments)
- Abdominal
Differential Diagnosis
Extremity trauma
- Compartment syndrome
- Contusion
- Crush syndrome
- Degloving injury
- Fracture
- Laceration
- Myositis ossificans
- Open joint injury
- Peripheral nerve injury
- Rhabdomyolysis
- Tendon injury
- Vascular injury
Calf pain
- Achilles tendon rupture
- Calcaneal bursitis
- Cellulitis
- Compartment syndrome
- Deep venous thrombosis (DVT)
- Distal leg fractures
- Gastrocnemius strain
- Ruptured popliteal cyst (Bakers cyst)
- Superficial thrombophlebitis
Evaluation
Work-Up
- xray to rule out fracture
- Compartment pressure (see below; take serial measurements if needed)
- Total CK, UA (rhabdomyolysis)
- Chemistry (hyperkalemia)
Measure Compartment Pressure
Interpretation of Compartment Pressure
- Normal is <10 mm Hg
- Pressures <20 mmHg can be tolerated w/o significant damage
- Exact level of pressure elevation that causes cell death is unclear. It was previously thought pressure >30 mmHg was toxic although the "delta pressure" may be better predictor than absolute pressure
ΔPressure = [Diastolic Pressure] – [Compartment Pressure][2]
- ΔPressure < 30 mm Hg is suggestive of compartment syndrome
Management
- Fasciotomy
- Perform as soon as diagnosis is made by history/physical or by measurement
- Permanent damage results from >8hr of ischemia
- Refer here for technique: http://www.wheelessonline.com/ortho/12806
- Support blood pressure in hypotensive patient
- Place affected limb at the level of the heart or slightly dependent
- AVOID ice (will further compromise microcirculation)
- Bivalve or remove cast if present
- Adequate analgesia
- Management for associated rhabdomyolysis if present
See Also
- Compartment Pressure Measurement
- Burns
- Rhabdomyolysis
- Fractures (Main)
- Abdominal compartment syndrome
External Links
References
- ↑ Haddad, Steven L. Managing risk: Compartment syndromes of the foot. AAOS, 2007. http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp
- ↑ Elliott, KGB. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003 Jul;85(5):625-32. PDF