Compartment syndrome: Difference between revisions

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==Pathophysiology==
==Background==
*Increased pressure>impaired perfusion>disruption of cellular metabolism>cytolysis with release of osmotically active contents into compartment>additional fluid drawn into compartment>increased pressure
*Most commonly caused by tibia fracture (anterior compartment)


==Presentation==
{{Compartment Syndrome Indications}}
*Five Ps:
**Pain, paresthesia, pallor, poikilothermia, pulselessness
***Pain, paresthesias are NOT reliable
*Pain at rest or with passive ROM
*Sensory nerves are first to lose conductive ability


==Etiology==
===Pathophysiology===
*Usually develops soon after sig. trauma
*Tissue perfusion is difference between diastolic BP and compartment pressure
**(Particularly involving long bone fractures of the lower leg or forearm)
**As compartment pressure increases, tissue perfusion decreases
*May also occur following minor trauma or from nontraumatic causes:
**Ischemia-reperfusion injury
**Coagulopathy
**Certain  animal envenomations and bites
**Extravasation  of IV fluids
**Injection of recreational drugs
**Prolonged limb compression


==Diagnosis==
===Etiologies===
*Non-invasive tests are NOT reliable
*Orthopedic
*Stryker
**[[Tibial fracture]]
**Normal = 0-8mm Hg
**[[Forearm fracture]]
**Capillary blod flow begins to be compromised at 20mmHg
*Vascular
**Signs/symptoms may develop with pressures above 20mmHg
**Ischemic-reperfusion injury
**Muscles and nerve fibers at risk at >30-40mmHg
**Hemorrhage
**Must interpret in light of SBP
***Can be spontaneous in anticoagulated patients
***Higher pressures may be necessary with systemic hypertension
*Iatrogenic
****May develop at lower pressures in those with hypotension or peripheral vascular disease
**Vascular puncture in anticoagulated patients
**A single nl compartment pressure reading, early in course of disease, does NOT rule out comp sy.
**IV/intra-arterial drug injection
**Serial measurements important when pt risk is mod to high or clinical suspicion exists
**Constrictive casts
*Soft tissue injury
**Prolonged limb compression
**[[Crush injury]]
**[[Burn]]
**[[Snake bite]]
**Expanding hematoma


==Specific Syndromes==
==Clinical Features==
===Forearm (<5%)===
===General Symptoms===
*Supracondylar humerus fracture (children)
*Compartment is swollen, firm, tender with squeezing
*Distal radius fractures (adults)
*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)


*Deep volar
#Pain (early finding)
**At highest risk for comp sy
#*Severe, out of proportion to physical findings
**Contains the digital flexors
#*Worse with passive stretch of distal body part such as toes or fingers (muscle extension > increased volume > increased pressure)
***Includes flexor digitorum profundus (responsible for distal interphalangeal joint flexion) and the flexor pollicis longus (responsible for interphalangeal joint flexion of the thumb)
#*Often the presenting symptom.
#Paresthesia (early finding)
#*Occurs in sensory distribution of affected nerve
#Pallor
#Paralysis: late finding
#Pulselessness: late finding


**Decreased wrist extension
===Lower Leg Specific Syndromes===
*Superficial volar
*Anterior
*Dorsal
**Nerve: deep fibular (peroneal): sensation of 1st webspace
**Contains the digital extensors
**Muscle: tibialis anterior: foot/ankle dorsiflexion
*Lateral
*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]]


===Lower (Leg 2-12% tibia)===
===Hand===
*Anterior
*Crush injury, with or with out associated fracture
**Most common site compartment sy
*Involved compartments: thenar, hypothenar, adductor pollicis, and 4 interossei muscles
**contains the four extensor muscles of the foot, the anterior tibial artery, and the deep peroneal nerve
*Diagnosis
**sx include loss of sensation between the 1st and 2nd toes and weakness of foot dorsiflexion
**Clinical, not based on actual compartment pressure
**late sequelae include foot drop, claw foot, and deep peroneal nerve dysfunction
**Pain
*Lateral
***Deep, constant, poorly localized, out of proportion to exam
**contains muscles for foot eversion and some plantar flexion (ie, peroneus brevis, peroneus longus), the peroneal artery, the superficial peroneal nerve, and the proximal portion of the deep peroneal nerve
**"Intrinsic minus" position at rest
**sx include deep peroneal nerve deficit (weakness in dorsiflexion and inversion of the foot and sensory loss in the web space between the great toe and the adjacent toe)
***MCP joint extended with proximal IP joint slightly flexed
**superficial peroneal nerve also travels through this compartment and supplies sensation to the lower leg and foot
**Pain with passive stretch of involved compartmental muscles
*Deep posterior
***Interosseus: performed with MCP joint extended and PIP jionts fully flexed
**Muscles that aid in foot plantar flexion, as well as the posterior tibial artery, peroneal artery, and the tibial nerve
***Thenar, hypothenar: performed by extension of MCP joint
**sx include plantar hypesthesia, weakness of toe flexion, and pain with passive extension of the toes
**Tense swelling of affected compartment
*Superficial posterior
**Major muscles of plantar flexion (ie, gastrocnemius, soleus)
**No major arteries or nerves in this compartment.
**Least likely to develop ACS in lower leg
**Sx include pain and a palpably tense and tender compartment


==Treatment==
===Forearm===
*Raise limb to level of heart
[[File:Forearm_compartments.jpg|thumb|forearm compartments]]
*AVOID ice (will further compromise microcirculation)
*Associated with supracondylar fracture (peds), distal radius fracture (adults)  
*Bivalve or remove cast if present
*Compartments
*Surgery consult
**Dorsal (highest risk)
*Definitive: Fasciotomy
**Volar
**Goal: <6hr


==Source==
===Foot===
Adapted from KajiQuestions and Donaldson; Perron (ACEP '09)
[[File:Compartments of the Foot.png|thumb|Compartments of the 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<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
**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 [http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp 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


[[Category:Ortho]]
===Lumbar Paraspinal===
[[Category:Trauma]]
*Compartment enclosed on the lateral, dorsal and ventral aspects by thoracolumbar fascia and medial aspect by spinous processes and interspinous ligaments
*Mechanisms
**Direct trauma
**Atraumatic mechanism (Heavy weight lifting)
***Typically males in their 20's and 30's
**Recent surgery causing compromised blood supply
*Characteristics
**Pain of the low back refractory to analgesia
**Radiation of pain to the groin
**Tender and tense lumbar paraspinal muscles
**Loss of normal lumbar lordosis
**Worsening of pain with hip flexion
**Concurrent ileus in some cases
*Diagnosis
**Elevated CK
**Elevated compartment pressures
**Imaging not required
***If imaging is performed, MRI is the test of choice
***MRI will demonstrate enhancement of the paraspinal muscles on T2-weighted images
***CT is less helpful, but can exclude other causes of low-back pain such as fracture
*Treatment is with emergent fasciotomy and with fluid resuscitation for any concurrent rhabdomyolysis <ref>Alexander W. et al. Acute lumbar paraspinal compartment syndrome: a systematic review. ANZ Journal of Surgery. 2018; 88: 854-859.</ref>
[[File:MRI Lumbar Paraspinal Compartment Syndrome.png|thumb|Magnetic resonance imaging (T1-weighted with gadolinium) showing edema and high signal intensity (arrows) in the region of the left multifidus and longissimus muscles.]] 
 
===Other===
*Thigh (quadriceps compartment)
[[File:Compartments_of_the_Thigh.png|thumb|Compartments of the thigh]]
*Buttock (gluteal compartment)
*Arm (deltoid, biceps compartments)
*Abdominal
 
==Differential Diagnosis==
{{Extremity trauma DDX}}
{{Calf pain DDX}}
 
==Evaluation==
===Work-Up===
*X-ray to evaluate for fracture
*[[Compartment pressure measurement]] (take serial measurements if needed)
*Total CK ([[rhabdomyolysis]])
*Chemistry ([[hyperkalemia]])
 
{{Compartment Pressure Interpretation}}
 
==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
 
==Disposition==
*Admit
 
==See Also==
*[[Compartment Pressure Measurement]]
*[[Burns]]
*[[Rhabdomyolysis]]
*[[Fractures (Main)]]
*[[Abdominal compartment syndrome]]
 
==External Links==
 
==References==
<references/>
[[Category:Orthopedics]] [[Category:Trauma]]

Latest revision as of 21:45, 9 April 2020

Background

  • Most commonly caused by tibia fracture (anterior compartment)

Compartment Syndrome Indications

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
      • Can be spontaneous in anticoagulated patients
  • Iatrogenic
    • Vascular puncture in anticoagulated patients
    • IV/intra-arterial drug injection
    • Constrictive casts
  • Soft tissue injury

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)
  1. Pain (early finding)
    • Severe, out of proportion to physical findings
    • Worse with passive stretch of distal body part such as toes or fingers (muscle extension > increased volume > increased pressure)
    • Often the presenting symptom.
  2. Paresthesia (early finding)
    • Occurs in sensory distribution of affected nerve
  3. Pallor
  4. Paralysis: late finding
  5. 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
Lower Leg Compartment

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

forearm compartments
  • Associated with supracondylar fracture (peds), distal radius fracture (adults)
  • Compartments
    • Dorsal (highest risk)
    • Volar

Foot

Compartments of the 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

Lumbar Paraspinal

  • Compartment enclosed on the lateral, dorsal and ventral aspects by thoracolumbar fascia and medial aspect by spinous processes and interspinous ligaments
  • Mechanisms
    • Direct trauma
    • Atraumatic mechanism (Heavy weight lifting)
      • Typically males in their 20's and 30's
    • Recent surgery causing compromised blood supply
  • Characteristics
    • Pain of the low back refractory to analgesia
    • Radiation of pain to the groin
    • Tender and tense lumbar paraspinal muscles
    • Loss of normal lumbar lordosis
    • Worsening of pain with hip flexion
    • Concurrent ileus in some cases
  • Diagnosis
    • Elevated CK
    • Elevated compartment pressures
    • Imaging not required
      • If imaging is performed, MRI is the test of choice
      • MRI will demonstrate enhancement of the paraspinal muscles on T2-weighted images
      • CT is less helpful, but can exclude other causes of low-back pain such as fracture
  • Treatment is with emergent fasciotomy and with fluid resuscitation for any concurrent rhabdomyolysis [2]
Magnetic resonance imaging (T1-weighted with gadolinium) showing edema and high signal intensity (arrows) in the region of the left multifidus and longissimus muscles.

Other

  • Thigh (quadriceps compartment)
Compartments of the thigh
  • Buttock (gluteal compartment)
  • Arm (deltoid, biceps compartments)
  • Abdominal

Differential Diagnosis

Extremity trauma

Calf pain

Evaluation

Work-Up

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][3]

  • ΔPressure < 30 mm Hg is suggestive of compartment syndrome

Management

  1. Fasciotomy
  2. Support blood pressure in hypotensive patient
  3. Place affected limb at the level of the heart or slightly dependent
  4. AVOID ice (will further compromise microcirculation)
  5. Bivalve or remove cast if present
  6. Adequate analgesia
  7. Management for associated rhabdomyolysis if present

Disposition

  • Admit

See Also

External Links

References

  1. ↑ Haddad, Steven L. Managing risk: Compartment syndromes of the foot. AAOS, 2007. http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp
  2. ↑ Alexander W. et al. Acute lumbar paraspinal compartment syndrome: a systematic review. ANZ Journal of Surgery. 2018; 88: 854-859.
  3. ↑ Elliott, KGB. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003 Jul;85(5):625-32. PDF
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