Compartment syndrome: Difference between revisions
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==Background== | == Background == | ||
*Consider whenever pain and paresthesia occur in an extremity after a fracture | *Consider whenever pain and paresthesia occur in an extremity after a fracture | ||
*Immediate threat is viability of nerve and muscle | *Immediate threat is viability of nerve and muscle | ||
**Later threat is infection, gangrene, rhabdo, and renal failure | **Later threat is infection, gangrene, rhabdo, and renal failure | ||
==Etiology== | ==Pathophysiology== | ||
*Most commonly caused by tibia fracture (anterior compartment) | *Tissue perfusion is difference between diastolic BP and compartment pressure | ||
*Usually develops soon after significant trauma | **As compartment pressure increases, tissue perfusion decreases | ||
**May be delayed up to 48hr after the event | |||
== Etiology == | |||
*Most commonly caused by tibia fracture (anterior compartment) | |||
*Usually develops soon after significant trauma | |||
**May be delayed up to 48hr after the event | |||
*Causes: | *Causes: | ||
#Orthopedic | |||
##Tibial fractures | #Orthopedic | ||
##Forearm fractures | ##Tibial fractures | ||
#Vascular | ##Forearm fractures | ||
##Ischemic-reperfusion injury | #Vascular | ||
##Hemorrhage | ##Ischemic-reperfusion injury | ||
#Iatrogenic | ##Hemorrhage | ||
##Vascular puncture in anticoagulated patients | #Iatrogenic | ||
##IV/intra-arterial drug injection | ##Vascular puncture in anticoagulated patients | ||
##Constrictive casts | ##IV/intra-arterial drug injection | ||
#Soft tissue injury | ##Constrictive casts | ||
##Prolonged limb compression | #Soft tissue injury | ||
##Crush injury | ##Prolonged limb compression | ||
##Crush injury | |||
##Burns | ##Burns | ||
<br> | |||
== Diagnosis == | |||
=== Clinical Findings === | |||
===Clinical Findings=== | |||
*Pain | *Pain | ||
**Severe, out of proportion to physical findings | **Severe, out of proportion to physical findings | ||
**Worse w/ passive movement (this extends the muscle - | **Worse w/ passive movement (this extends the muscle -> incr in volume -> incr pressure) | ||
*Paresthesia | *Paresthesia | ||
**Occurs in sensory distribution of affected nerve | **Occurs in sensory distribution of affected nerve | ||
*Compartment is swollen, firm, tender w/ squeezing | *Compartment is swollen, firm, tender w/ squeezing | ||
*5 P's (pain, paresthesias, pallor, pulselessness, paralysis) | *5 P's (pain, paresthesias, pallor, pulselessness, paralysis) | ||
**Classic signs of disruption in arterial flow, not of compartment syndrome | **Classic signs of disruption in arterial flow, not of compartment syndrome | ||
***Only found once arterial flow has stopped (very late finding) | ***Only found once arterial flow has stopped (very late finding) | ||
=== Compartment Pressure === | |||
*Normal is <10 | |||
*Pressures <30 can be tolerated w/o significant damage | |||
*Exact level of pressure elevation that causes cell death is unclear | |||
*"Delta Pressure" may be better predictor than absolute pressure value | |||
**Diastolic BP - intracompartmental pressure | |||
***Once this value is <30 compartment syndrome is likely | |||
<br> | |||
== Work-Up == | |||
*Compartment pressure (take serial measurements if needed) | |||
*Compartment pressure (take serial measurements if needed) | *Total CK, UA (rhabdo) | ||
*Total CK, UA (rhabdo) | |||
*Chemistry (hyperkalemia) | *Chemistry (hyperkalemia) | ||
==Specific Syndromes== | == Specific Syndromes == | ||
===Lower Leg=== | |||
#Anterior | === Lower Leg === | ||
##Nerve: Deep fibular (peroneal) | |||
###Sensation of 1st webspace | #Anterior | ||
##Muscle: tibialis anterior | ##Nerve: Deep fibular (peroneal) | ||
###Weakness of foot dorsiflexion | ###Sensation of 1st webspace | ||
#Lateral | ##Muscle: tibialis anterior | ||
##Nerve: Superficial fibular (peroneal) nerve | ###Weakness of foot dorsiflexion | ||
###Sensation of lateral aspect of lower leg, dorsum of foot | #Lateral | ||
##Muscle: Peroneus | ##Nerve: Superficial fibular (peroneal) nerve | ||
###Weakness of foot plantarflexion | ###Sensation of lateral aspect of lower leg, dorsum of foot | ||
#Deep posterior | ##Muscle: Peroneus | ||
##Nerve: Posterior tibial nerve | ###Weakness of foot plantarflexion | ||
###Sensation of plantar aspect of foot | #Deep posterior | ||
##Muscle: flexor hallucis/digotirum longus | ##Nerve: Posterior tibial nerve | ||
###Pain with passive extension of the toes | ###Sensation of plantar aspect of foot | ||
#Superficial posterior | ##Muscle: flexor hallucis/digotirum longus | ||
##Nerve: Sural cutaneous nerve | ###Pain with passive extension of the toes | ||
###Sensation of lateral aspect of foot | #Superficial posterior | ||
##Muscle: Gastrocnemius | ##Nerve: Sural cutaneous nerve | ||
###Sensation of lateral aspect of foot | |||
##Muscle: Gastrocnemius | |||
###Weakness of plantarflexion | ###Weakness of plantarflexion | ||
===Hand=== | === Hand === | ||
*Crush injury, w/ or w/o associated fracture | |||
*Involved compartments: thenar, hypothenar, adductor pollicis, and 4 interossei muscles | *Crush injury, w/ or w/o associated fracture | ||
*Diagnosis | *Involved compartments: thenar, hypothenar, adductor pollicis, and 4 interossei muscles | ||
**Clinical, not based on actual compartment pressure | *Diagnosis | ||
**Pain | **Clinical, not based on actual compartment pressure | ||
***Deep, constant, poorly localized, out of proportion to exam | **Pain | ||
**"Intrinsic minus" position at rest | ***Deep, constant, poorly localized, out of proportion to exam | ||
***MCP joint extended w/ proximal IP joint slightly flexed | **"Intrinsic minus" position at rest | ||
**Pain w/ passive stretch of involved compartmental muscles | ***MCP joint extended w/ proximal IP joint slightly flexed | ||
***Interosseus: performed w/ MCP joint extended and PIP jionts fully flexed | **Pain w/ passive stretch of involved compartmental muscles | ||
***Thenar, hypothenar: performed by extension of MCP joint | ***Interosseus: performed w/ MCP joint extended and PIP jionts fully flexed | ||
***Thenar, hypothenar: performed by extension of MCP joint | |||
**Tense swelling of affected compartment | **Tense swelling of affected compartment | ||
===Forearm=== | === Forearm === | ||
*Associated w/ supracondylar fx (peds), distal radius fx (adults) | |||
*Compartments | *Associated w/ supracondylar fx (peds), distal radius fx (adults) | ||
**Dorsal (highest risk) | *Compartments | ||
**Dorsal (highest risk) | |||
**Volar | **Volar | ||
===Other=== | === Other === | ||
*Thigh (quadriceps compartment) | |||
*Buttock (gluteal compartment) | *Thigh (quadriceps compartment) | ||
*Arm (deltoid, biceps compartments) | *Buttock (gluteal compartment) | ||
*Arm (deltoid, biceps compartments) | |||
*Abdominal | *Abdominal | ||
==Treatment== | == Treatment == | ||
#Fasciotomy | |||
##Perform as soon as diagnosis is made by history/physical or by measurement | #Fasciotomy | ||
##Permanent damage results from | ##Perform as soon as diagnosis is made by history/physical or by measurement | ||
#Support the blood pressure in the hypotensive pt | ##Permanent damage results from >8hr of ischemia | ||
#Place affected limb at the level of the heart or slightly dependent | #Support the blood pressure in the hypotensive pt | ||
#AVOID ice (will further compromise microcirculation) | #Place affected limb at the level of the heart or slightly dependent | ||
#AVOID ice (will further compromise microcirculation) | |||
#Bivalve or remove cast if present | #Bivalve or remove cast if present | ||
==Source== | == Source == | ||
*Tintinalli | |||
*Tintinalli | |||
*Rosen's | *Rosen's | ||
[[Category:Ortho]] | [[Category:Ortho]] [[Category:Trauma]] | ||
[[Category:Trauma]] |
Revision as of 22:54, 30 January 2012
Background
- Consider whenever pain and paresthesia occur in an extremity after a fracture
- Immediate threat is viability of nerve and muscle
- Later threat is infection, gangrene, rhabdo, and renal failure
Pathophysiology
- Tissue perfusion is difference between diastolic BP and compartment pressure
- As compartment pressure increases, tissue perfusion decreases
Etiology
- Most commonly caused by tibia fracture (anterior compartment)
- Usually develops soon after significant trauma
- May be delayed up to 48hr after the event
- Causes:
- Orthopedic
- Tibial fractures
- Forearm fractures
- 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
- Burns
Diagnosis
Clinical Findings
- Pain
- Severe, out of proportion to physical findings
- Worse w/ passive movement (this extends the muscle -> incr in volume -> incr pressure)
- Paresthesia
- Occurs in sensory distribution of affected nerve
- Compartment is swollen, firm, tender w/ squeezing
- 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)
- Classic signs of disruption in arterial flow, not of compartment syndrome
Compartment Pressure
- Normal is <10
- Pressures <30 can be tolerated w/o significant damage
- Exact level of pressure elevation that causes cell death is unclear
- "Delta Pressure" may be better predictor than absolute pressure value
- Diastolic BP - intracompartmental pressure
- Once this value is <30 compartment syndrome is likely
- Diastolic BP - intracompartmental pressure
Work-Up
- Compartment pressure (take serial measurements if needed)
- Total CK, UA (rhabdo)
- Chemistry (hyperkalemia)
Specific Syndromes
Lower Leg
- Anterior
- Nerve: Deep fibular (peroneal)
- Sensation of 1st webspace
- Muscle: tibialis anterior
- Weakness of foot dorsiflexion
- Nerve: Deep fibular (peroneal)
- Lateral
- Nerve: Superficial fibular (peroneal) nerve
- Sensation of lateral aspect of lower leg, dorsum of foot
- Muscle: Peroneus
- Weakness of foot plantarflexion
- Nerve: Superficial fibular (peroneal) nerve
- Deep posterior
- Nerve: Posterior tibial nerve
- Sensation of plantar aspect of foot
- Muscle: flexor hallucis/digotirum longus
- Pain with passive extension of the toes
- Nerve: Posterior tibial nerve
- Superficial posterior
- Nerve: Sural cutaneous nerve
- Sensation of lateral aspect of foot
- Muscle: Gastrocnemius
- Weakness of plantarflexion
- Nerve: Sural cutaneous nerve
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
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 the blood pressure in the 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
Source
- Tintinalli
- Rosen's