Compartment syndrome: Difference between revisions
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== Diagnosis == | == Diagnosis == | ||
=== Work-Up === | |||
*xray to rule out fracture | |||
*Compartment pressure (see below; take serial measurements if needed) | |||
*Total CK, UA ([[rhabdo]]) | |||
*Chemistry ([[hyperkalemia]]) | |||
===[[Compartment Pressure Measurement|Measure Compartment Pressure]]=== | ===[[Compartment Pressure Measurement|Measure Compartment Pressure]]=== | ||
{{Compartment Pressure Interpretation}} | {{Compartment Pressure Interpretation}} | ||
=== Lower Leg Specific Syndromes=== | === Lower Leg Specific Syndromes=== |
Revision as of 18:02, 30 May 2015
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
- Compartment is swollen, firm, tender w/ squeezing
- Usually develops soon after significant trauma
- May be delayed up to 48hr after the event
- 5 P's (pain, paresthesias, pallor, pulselessness, paralysis)
- Classic signs of disruption in arterial flow, not of compartment syndrome
- Only found once arterial flow has stopped (very late finding)
- Pain
- Severe, out of proportion to physical findings
- Worse w/ passive movement (muscle extension > increased volume > increased pressure)
- Often the presenting symptom.
- Paresthesia
- Occurs in sensory distribution of affected nerve
- Paralysis and Pulselessness: late findings
- Classic signs of disruption in arterial flow, not of compartment syndrome
Differential Diagnosis
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
Diagnosis
Work-Up
- xray to rule out fracture
- Compartment pressure (see below; take serial measurements if needed)
- Total CK, UA (rhabdo)
- 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][1]
- ΔPressure < 30 mm Hg is suggestive of compartment syndrome
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, w/ or w/o 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 w/ proximal IP joint slightly flexed
- Pain w/ passive stretch of involved compartmental muscles
- Interosseus: performed w/ MCP joint extended and PIP jionts fully flexed
- Thenar, hypothenar: performed by extension of MCP joint
- Tense swelling of affected compartment
Forearm
- Associated w/ supracondylar fx (peds), distal radius fx (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 fx, cast immobilization, prolonged extremity positioning, snake bites, severe ankle sprains with arterial disruption[2]
- 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 fx 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
Treatment
- 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 pt
- Place affected limb at the level of the heart or slightly dependent
- AVOID ice (will further compromise microcirculation)
- Bivalve or remove cast if present
See Also
Source
- ↑ Elliott, KGB. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003 Jul;85(5):625-32. PDF
- ↑ Haddad, Steven L. Managing risk: Compartment syndromes of the foot. AAOS, 2007. http://www.aaos.org/news/bulletin/janfeb07/clinical1.asp