Compartment syndrome: Difference between revisions
No edit summary
Line 1: Line 1:
==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
*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


==Presentation==
==Etiology==
*Five Ps:
*Most commonly caused by tibia fracture (anterior compartment)
**Pain, paresthesia, pallor, poikilothermia, pulselessness
*Usually develops soon after significant trauma
***Pain, paresthesias are NOT reliable
**May be delayed up to 48hr after the event
*Pain at rest or with passive ROM
*Causes:
*Sensory nerves are first to lose conductive ability
#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


==Etiology==
*Usually develops soon after sig. trauma
**(Particularly involving long bone fractures of the lower leg or forearm)
*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==
==Diagnosis==
*Non-invasive tests are NOT reliable
===Clinical Findings===
*Stryker
*Pain
**Normal = 0-8mm Hg
**Severe, out of proportion to physical findings
**Capillary blod flow begins to be compromised at 20mmHg
**Worse w/ passive movement (this extends the muscle -> incr in volume -> incr pressure)
**Signs/symptoms may develop with pressures above 20mmHg
*Paresthesia
**Muscles and nerve fibers at risk at >30-40mmHg
**Occurs in sensory distribution of affected nerve
**Must interpret in light of SBP
*Compartment is swollen, firm, tender w/ squeezing
***Higher pressures may be necessary with systemic hypertension
*5 P's (pain, paresthesias, pallor, pulselessness, paralysis)
****May develop at lower pressures in those with hypotension or peripheral vascular disease
**Classic signs of disruption in arterial flow, not of compartment syndrome
**A single nl compartment pressure reading, early in course of disease, does NOT rule out comp sy.
***Only found once arterial flow has stopped (very late finding)
**Serial measurements important when pt risk is mod to high or clinical suspicion exists
===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
 
 
==Work-Up==
*Compartment pressure (take serial measurements if needed)
*Total CK, UA (rhabdo)
*Chemistry (hyperkalemia)


==Specific Syndromes==
==Specific Syndromes==
===Lower Leg===
*Compartments
#Anterior
##Nerve: Deep fibular (peroneal)
###Sensation of 1st webspace
##Muscle: tibialis anterior
###Weakness of foot dorsiflexion
#Lateral
##Nerve: Superficial fibular (peroneal) nerve
###Sensation of lateral aspect of lower leg, dorsum of foot
##Muscle: Peroneus
###Weakness of foot plantarflexion
#Deep posterior
##Nerve: Posterior tibial nerve
###Sensation of plantar aspect of foot
##Muscle: flexor hallucis/digotirum longus
###Pain with passive extension of the toes
#Superficial posterior
##Nerve: Sural cutaneous nerve
###Sensation of lateral aspect of foot
##Muscle: Gastrocnemius
###Weakness of plantarflexion
===Hand===
===Hand===
*Crush injury, w/ or w/o associated fracture
*Crush injury, w/ or w/o associated fracture
Line 48: Line 91:
**Tense swelling of affected compartment
**Tense swelling of affected compartment


===Forearm (<5%)===
===Forearm===
*Compartments
**Dorsal
**Volar
**Mobile wad
 
 
 
 
*Supracondylar humerus fracture (children)
*Supracondylar humerus fracture (children)
*Distal radius fractures (adults)
*Distal radius fractures (adults)
Line 61: Line 112:
*Lateral
*Lateral


===Lower (Leg 2-12% tibia)===
 
*Anterior
**Most common site compartment sy
**contains the four extensor muscles of the foot, the anterior tibial artery, and the deep peroneal nerve
**sx include loss of sensation between the 1st and 2nd toes and weakness of foot dorsiflexion
**late sequelae include foot drop, claw foot, and deep peroneal nerve dysfunction
*Lateral
**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
**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)
**superficial peroneal nerve also travels through this compartment and supplies sensation to the lower leg and foot
*Deep posterior
**Muscles that aid in foot plantar flexion, as well as the posterior tibial artery, peroneal artery, and the tibial nerve
**sx include plantar hypesthesia, weakness of toe flexion, and pain with passive extension of the toes
*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==
==Treatment==
*Raise limb to level of heart
#Fasciotomy
*AVOID ice (will further compromise microcirculation)
##Perform as soon as diagnosis is made by history/physical or by measurement
*Bivalve or remove cast if present
##Permanent damage results from >8hr of ischemia
*Surgery consult
#Support the blood pressure in the hypotensive pt
*Definitive: Fasciotomy
#Place affected limb at the level of the heart or slightly dependent
**Goal: <6hr
#AVOID ice (will further compromise microcirculation)
#Bivalve or remove cast if present


==Source==
==Source==
Adapted from KajiQuestions and Donaldson; Perron (ACEP '09)
*Tintinalli
*Rosen's


[[Category:Ortho]]
[[Category:Ortho]]
[[Category:Trauma]]
[[Category:Trauma]]

Revision as of 05:38, 27 September 2011

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:
  1. Orthopedic
    1. Tibial fractures
    2. Forearm fractures
  2. Vascular
    1. Ischemic-reperfusion injury
    2. Hemorrhage
  3. Iatrogenic
    1. Vascular puncture in anticoagulated patients
    2. IV/intra-arterial drug injection
    3. Constrictive casts
  4. Soft tissue injury
    1. Prolonged limb compression
    2. Crush injury
    3. 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)

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


Work-Up

  • Compartment pressure (take serial measurements if needed)
  • Total CK, UA (rhabdo)
  • Chemistry (hyperkalemia)

Specific Syndromes

Lower Leg

  • Compartments
  1. Anterior
    1. Nerve: Deep fibular (peroneal)
      1. Sensation of 1st webspace
    2. Muscle: tibialis anterior
      1. Weakness of foot dorsiflexion
  2. Lateral
    1. Nerve: Superficial fibular (peroneal) nerve
      1. Sensation of lateral aspect of lower leg, dorsum of foot
    2. Muscle: Peroneus
      1. Weakness of foot plantarflexion
  3. Deep posterior
    1. Nerve: Posterior tibial nerve
      1. Sensation of plantar aspect of foot
    2. Muscle: flexor hallucis/digotirum longus
      1. Pain with passive extension of the toes
  4. Superficial posterior
    1. Nerve: Sural cutaneous nerve
      1. Sensation of lateral aspect of foot
    2. Muscle: Gastrocnemius
      1. Weakness of plantarflexion

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

  • Compartments
    • Dorsal
    • Volar
    • Mobile wad



  • Supracondylar humerus fracture (children)
  • Distal radius fractures (adults)
  • Deep volar
    • At highest risk for comp sy
    • Contains the digital flexors
      • Includes flexor digitorum profundus (responsible for distal interphalangeal joint flexion) and the flexor pollicis longus (responsible for interphalangeal joint flexion of the thumb)
    • Decreased wrist extension
  • Superficial volar
  • Dorsal
    • Contains the digital extensors
  • Lateral


Treatment

  1. Fasciotomy
    1. Perform as soon as diagnosis is made by history/physical or by measurement
    2. Permanent damage results from >8hr of ischemia
  2. Support the blood pressure in the hypotensive pt
  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

Source

  • Tintinalli
  • Rosen's
Retrieved from "https://www.wikem.org/w/index.php?title=Compartment_syndrome&oldid=5884"