Compartment syndrome: Difference between revisions

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==Background==
==Background==
*Consider whenever pain and paresthesia occur in an extremity after a fracture
*Most commonly caused by tibia fracture (anterior compartment)
*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==
{{Compartment Syndrome Indications}}
*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


===Pathophysiology===
*Tissue perfusion is difference between diastolic BP and compartment pressure
**As compartment pressure increases, tissue perfusion decreases


==Diagnosis==
===Etiologies===
===Clinical Findings===
*Orthopedic
*Pain
**[[Tibial fracture]]
**Severe, out of proportion to physical findings
**[[Forearm fracture]]
**Worse w/ passive movement (this extends the muscle -> incr in volume -> incr pressure)
*Vascular
*Paresthesia
**Ischemic-reperfusion injury
**Occurs in sensory distribution of affected nerve
**Hemorrhage
*Compartment is swollen, firm, tender w/ squeezing
***Can be spontaneous in anticoagulated patients
*5 P's (pain, paresthesias, pallor, pulselessness, paralysis)
*Iatrogenic
**Classic signs of disruption in arterial flow, not of compartment syndrome
**Vascular puncture in anticoagulated patients
***Only found once arterial flow has stopped (very late finding)
**IV/intra-arterial drug injection
===Compartment Pressure===
**Constrictive casts
*Normal is <10
*Soft tissue injury
*Pressures <30 can be tolerated w/o significant damage
**Prolonged limb compression
*Exact level of pressure elevation that causes cell death is unclear
**[[Crush injury]]
*"Delta Pressure" may be better predictor than absolute pressure value
**[[Burn]]
**Diastolic BP - intracompartmental pressure
**[[Snake bite]]
***Once this value is <30 compartment syndrome is likely
**Expanding hematoma


==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


==Work-Up==
====5 P's====
*Compartment pressure (take serial measurements if needed)
*Classic signs of disruption in arterial flow, not of compartment syndrome
*Total CK, UA (rhabdo)
**Only found once arterial flow has stopped (very late finding)
*Chemistry (hyperkalemia)


==Specific Syndromes==
#Pain (early finding)
===Lower Leg===
#*Severe, out of proportion to physical findings
#Anterior
#*Worse with passive stretch of distal body part such as toes or fingers (muscle extension > increased volume > increased pressure)
##Nerve: Deep fibular (peroneal)
#*Often the presenting symptom.
###Sensation of 1st webspace
#Paresthesia (early finding)
##Muscle: tibialis anterior
#*Occurs in sensory distribution of affected nerve
###Weakness of foot dorsiflexion
#Pallor
#Lateral
#Paralysis: late finding
##Nerve: Superficial fibular (peroneal) nerve
#Pulselessness: late finding
###Sensation of lateral aspect of lower leg, dorsum of foot
 
##Muscle: Peroneus
===Lower Leg Specific Syndromes===
###Weakness of foot plantarflexion
*Anterior  
#Deep posterior
**Nerve: deep fibular (peroneal): sensation of 1st webspace  
##Nerve: Posterior tibial nerve
**Muscle: tibialis anterior: foot/ankle dorsiflexion  
###Sensation of plantar aspect of foot
*Lateral  
##Muscle: flexor hallucis/digotirum longus
**Nerve: superficial fibular (peroneal) nerve: sensation of lateral aspect of lower leg, dorsum of foot  
###Pain with passive extension of the toes
**Muscle: peroneus longus and brevis: foot plantarflexion  
#Superficial posterior
*Deep posterior  
##Nerve: Sural cutaneous nerve
**Nerve: posterior tibial nerve: sensation of plantar aspect of foot  
###Sensation of lateral aspect of foot
**Muscle: tibialis posterior/flexor hallucis longus/flexor digitorum longus: Pain with passive extension of the toes  
##Muscle: Gastrocnemius
*Superficial posterior  
###Weakness of plantarflexion
**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]]


===Hand===
===Hand===
*Crush injury, w/ or w/o associated fracture
*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  
**Clinical, not based on actual compartment pressure
**Clinical, not based on actual compartment pressure  
**Pain
**Pain  
***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 w/ proximal IP joint slightly flexed
***MCP joint extended with proximal IP joint slightly flexed  
**Pain w/ passive stretch of involved compartmental muscles
**Pain with passive stretch of involved compartmental muscles  
***Interosseus: performed w/ MCP joint extended and PIP jionts fully flexed
***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===
*Associated w/ supracondylar fx (peds), distal radius fx (adults)
[[File:Forearm_compartments.jpg|thumb|forearm compartments]]
*Compartments
*Associated with supracondylar fracture (peds), distal radius fracture (adults)  
**Dorsal (highest risk)
*Compartments  
**Dorsal (highest risk)  
**Volar
**Volar
===Foot===
[[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
===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 <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===
===Other===
*Thigh (quadriceps compartment)
*Thigh (quadriceps compartment)  
*Buttock (gluteal compartment)
[[File:Compartments_of_the_Thigh.png|thumb|Compartments of the thigh]]
*Arm (deltoid, biceps compartments)
*Buttock (gluteal compartment)  
*Arm (deltoid, biceps compartments)  
*Abdominal
*Abdominal


==Treatment==
==Differential Diagnosis==
#Fasciotomy
{{Extremity trauma DDX}}
##Perform as soon as diagnosis is made by history/physical or by measurement
{{Calf pain DDX}}
##Permanent damage results from >8hr of ischemia
 
#Support the blood pressure in the hypotensive pt
==Evaluation==
#Place affected limb at the level of the heart or slightly dependent
===Work-Up===
#AVOID ice (will further compromise microcirculation)
*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
#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]]


==Source==
==External Links==
*Tintinalli
*Rosen's


[[Category:Ortho]]
==References==
[[Category:Trauma]]
<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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