Leg Compartment Syndrome

Author: Mark Karadsheh

Topic updated on 04/04/13 7:11pm

Introduction

Devastating condition where an osseofascial compartment pressure rises to a level that decreases perfusion
May lead to irreversible muscle and nerve damage
May occur anywhere that skeletal muscle is surrounded by fascia, but most commonly
- leg (details below)
- forearm
- hand
- foot
- thigh
- buttock
- shoulder
- paraspinous muscles
Pathophysiology
- local trauma and soft tissue destruction> bleeding and edema > increased interstitial pressure > vascular occlusion > myoneural ischemia
Causes
- trauma
  - fractures (69% of cases)
  - crush injuries
  - contusions
  - gunshot wounds
- tight casts, dressings, or external wrappings
- extravasation of IV infusion
- burns
- postischemic swelling
- bleeding disorders
- arterial injury

Anatomy

4 compartments of the leg
- anterior compartment
  - function
    - dorsiflexion of foot and ankle
  - muscles
    - tibialis anterior
    - extensor hallucis longus
    - extensor digitorum longus
    - peroneus tertius
- lateral compartment
  - function
    - plantarflexion and eversion of foot
  - muscles
    - peroneus longus
    - peroneus brevis
  - isolated lateral compartment syndrome would only affect superficial peroneal nerve
- deep posterior compartment
  - function
    - plantarflexion and inversion of foot
  - muscles
    - tibialis posterior
    - flexor digitorum longus
    - flexor hallucis longus
- superficial posterior compartment
  - function
    - mainly plantarflexion of foot and ankle
  - muscles
    - gastrocnemius
    - soleus
    - plantaris

Presentation

Symptoms
- pain out of proportion to clinical situation is usually first symptom
  - may be absent in cases of nerve damage
  - pain is difficult to assess in a polytrauma patient and impossible to assess in a sedated patient
  - difficult to assess in children (unable to verbalize)
Physical exam
- pain w/ passive stretch
  - is most sensitive finding prior to onset of ischemia
- paresthesia and hypoesthesia
  - indicative of nerve ischemia in affected compartment
- paralysis
  - late finding
  - full recovery is rare in this case
- palpable swelling
- peripheral pulses absent
  - late finding
  - amputation usually inevitable in this case

Evaluation

Diagnosis
- based primarily on physical exam in patient with intact mental status
Radiographs
- obtain to rule-out fracture
Compartment pressure measurements
- indications
  - polytrauma patients
  - patient not alert/unreliable
  - inconclusive physical exam findings
- relative contraindication
  - unequivocally positive clinical findings should prompt emergent operative intervention without need for compartment measurements
- technique
  - should be performed within 5cm of fracture site
  - anterior compartment
    - entry point
      - 1cm lateral to anterior border of tibia within 5cm of fracture site if possible
    - needle should be perpendicular to skin
  - deep posterior compartment
    - entry point
      - just posterior to the medial border of tibia
    - advance needle perpendicular to skin towards fibula
  - lateral compartment
    - entry point
      - just anterior to the posterior border of fibula
  - superficial posterior
    - entry point
      - middle of calf within 5 cm of fracture site if possible

Treatment

Nonoperative
- observation
  - indications
    - delta p > 30, and
    - presentation not consistent with compartment syndrome
- bi-valving the cast and loosening circumferential dressings
  - indications
    - initial treatment for swelling or pain that is NOT compartment syndrome
- hyperbaric oxygen therapy
  - works by increasing the oxygen diffusion gradient
Operative
- emergent fasciotomy of all four compartments
  - indications
    - clinical presentation consistent with compartment syndrome
    - compartment pressures with absolute value of 30-45 mm Hg
    - compartment pressures within 30 mm Hg of diastolic blood pressure (delta p)
      - intraoperatively, diastolic blood pressure may be decreased from anesthesia
        
        must compare intra-operative measurement to pre-operative diastolic pressure
  - contraindications
    - missed compartment syndrome
Special considerations
- pedriatrics
  - children are unable to verbalize feelings
    - if suspicion, then perform compartment pressure measurement under sedation
- hemophiliacs
  - give Factor VIII replacement before measuring compartment pressures

Surgical Techniques

Emergent fasciotomy of all four compartments
- dual medial-lateral incision
  - approach
    - two 15-18cm vertical incisions separated by 8cm skin bridge
      - anterolateral incision
      - posteromedial incision
  - technique
    - anterolateral incision
      - identify and protect the superficial peroneal nerve
      - fasciotomy of anterior compartment performed 1cm in front of intermuscular septum
      - fasciotomy of lateral compartment performed 1cm behind intermuscular septum
    - posteromedial incision
      - protect saphenous vein and nerve
      - incise superficial posterior compartment
      - detach soleal bridge from back of tibia to adequately decompress deep posterior compartment
  - post-operative
    - dressing changes followed by delayed primary closure or skin grafting at 3-7 days post decompression
  - pros
    - easy to perform
    - excellent exposure
  - cons
    - requires two incisions
- single lateral incision
  - approach
    - single lateral incision from head of fibula to ankle along line of fibula
  - technique
    - identify superficial peroneal nerve
    - perform anterior compartment fasciotomy 1cm anterior to the intermuscular septum
    - perform lateral compartment fasciotomy 1cm posterior to the intermuscular septum
    - identify and perform fasciotomy on superficial posterior compartment
    - enter interval between superficial posterior and lateral compartment
    - reach deep posterior compartment by following interosseous membrane from the posterior aspect of fibula and releasing compartment from this membrane
      - common peroneal nerve at risk with proximal dissection
  - pros
    - single incision
  - cons
    - decreased exposure

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Qbank (11 Questions)

TAG

(SBQ04.1) A 6-year-old boy with progressive bilateral genu varum undergoes the surgeries shown in Figure A. On postoperative rounds later that day, the patient appears sedated after several doses of pain medication. His toes are pink with brisk capillary refill however, passive motion of his toes causes pain. Among the answer choices listed, what is the best management strategy for this child? Topic

Review Topic

FIGURES: A

1. Elevate his legs and reevaluate on morning rounds
2. Adjust his pain medication to accommodate for his increasing pain
3. Administer a muscle relaxant for leg spasms
4. Measure intracompartmental pressures with a standard device
5. Examine the cast for areas of constriction and reevaluate in the morning

PREFERRED RESPONSE ▶

DISCUSSION: Intracompartmental pressure measurements should be performed when pain with passive motion of the toes is found in young patients with insufficient clinical data to establish a definitive diagnosis of compartment syndrome. The child in this clinical vignette has Blount’s disease which was treated with bilateral tibial osteotomies, a procedure commonly associated with compartment syndrome.

Pain with passive stretch is the most sensitive clinical sign of elevated compartment pressures prior to the onset of ischemia in compartment syndrome. Pain is difficult to assess in children at baseline, therefore, a high level of suspicion should exist and compartment pressure monitoring should be performed in unreliable patients.

Mubarak et al. reported on a series of 27 patients subjected to intracompartmental pressure monitoring for a clinical suspicion of acute compartment syndrome. The wick catheter technique was employed not only to aid in the diagnosis of compartment syndrome at an early stage but also to indicate the effectiveness of the decompressions when used intraoperatively during fasciotomies.

Matsen et al. reported on 24 children with compartment syndrome following injuries and surgery. The most common etiologies identified were fractures, vascular injuries, and tibial osteotomies. Compartment pressure measurements were helpful in establishing the diagnosis of compartment syndrome in young patients and in those with neurologic or vascular injuries with ambiguous clinical findings.

Figure A reveals an AP radiograph of bilateral knees status post valgus-producing tibial osteotomies and epiphysiolyses of the medial tibial physes in a 6-year-old male with Blount’s disease.

Incorrect Answers:
Answers 1 and 5 are wrong because immediate action should be taken to establish a definitive diagnosis and treat accordingly when a clinical suspicion of compartment syndrome arises.
Answers 2 and 3 are incorrect because administering medications that can cause sedation will exacerbate the patient’s present state of drowsiness, confuse the clinical picture, and make the diagnosis of compartment syndrome even more difficult to establish.

Illustrations: V

REFERENCES:

1. Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson WH. Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg Am. 1978 Dec;60(8):1091-5. PMID:721856 (Link to Abstract)

2. Matsen FA 3rd, Veith RG. Compartmental syndromes in children. J Pediatr Orthop. 1981;1(1):33-41. PMID:7341650 (Link to Abstract)

Question Authors:

Deborah Allen MD, john froelich MD, Ben Taylor MD,

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TAG

(OBQ12.28) A 35-year-old male sustains a closed tibial shaft fracture after falling from 12 feet. Which of the following measurements would be concerning for an evolving compartment syndrome? Topic

Review Topic

1. Preoperative anterior compartment measurement of 29, with diastolic pressure 58
2. Preoperative anterior compartment measurement of 25, with diastolic pressure of 60
3. Intraoperative anterior compartment measurement of 25, with intraoperative diastolic pressure of 54
4. Intraoperative anterior compartment measurement of 28, with intraoperative diastolic pressure of 72
5. Preoperative anterior compartment measurement of 22, with mean arterial pressure of 70

PREFERRED RESPONSE ▶

DISCUSSION: A delta P (diastolic blood pressure minus compartment pressure measurement)of < 30 mmHg is an indication for fasciotomies with the caveat that the diastolic pressure is measured either pre- or postoperatively.

Given the poor outcomes associated with missed compartment syndromes, it is important to obtain both clinical and objective data when determining if a patient needs fasciotomies. Determining if a patient needs fasciotomies in the operating room while a patient is under anesthesia is complicated by the fact that obtaining a clinical exam is impossible, and that the diastolic blood pressure may be falsely decreased compared to normal pre- or postoperative measurements. Currently, it is recommended that intraoperative compartment pressures be compared to preoperative diastolic blood pressures, with delta p < 30 indicating the need for fasciotomies.

Kakar et al. review the preoperative, intraoperative, and postoperative diastolic blood pressure (DBP) in 242 patients with a tibia fracture treated operatively. They found the mean DBP was 18 points lower in the operating room compared to the preoperative measurement. In addition, they found the difference between preoperative and postoperative diastolic blood pressures to be within 2 points, indicating the decrease seen intraoperatively is likely a spurious value induced by anesthetic.

McQueen and Court-Brown prospectively review 116 patients with tibia fractures that had continuous monitoring of their anterior compartment for 24 hours. They found that using an absolute pressure of 30 mmHg would have resulted in 50 patients (43%) treated with unnecessary fasciotomies. They conclude using a differential pressure of 30 mmHg is a more reliable indicator of compartment syndrome.

Incorrect Answers:
Answer 2: a delta p of 35 is not an indication for fasciotomies in the setting of a benign clinical exam.
Answer 3: a delta p of 25 when calculated with the intraoperative diastolic blood pressure is not an indication for fasciotomies. This value should be obtained from preoperative diastolic blood pressure measurements.
Answer 4: a delta p of 44 is not an indication for fasciotomies.
Answer 5: mean arterial pressure is not used for calculation of delta p.

REFERENCES:

1. Kakar S, Firoozabadi R, McKean J, Tornetta P III. Diastolic blood pressure in patients with tibia fractures under anaesthesia: implications for the diagnosis of compartment syndrome. J Orthop Trauma. 2007 Feb;21(2):99-103. PMID:17304064 (Link to Abstract)

2. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br. 1996 Jan;78(1):99-104. PMID:8898137 (Link to Abstract)

Question Authors:

Mark Karadsheh MD, Ben Taylor MD, Jan Szatkowski MD,

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TAG

(OBQ11.75) A 28-year-old male sustains a midshaft fibula fracture after being kicked during a karate tournament and develops compartment syndrome isolated to the lateral compartment of his leg. If left untreated, which of the following sensory or motor deficits would be expected? Topic

Review Topic

1. Decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes
2. Inability to plantar flex the ankle
3. Decreased sensation on the dorsum of his foot involving the first webspace
4. Inability to dorsiflex the ankle
5. Inability to abduct his toes

PREFERRED RESPONSE ▶

DISCUSSION: The clinical vignette describes a scenario of isolated compartment syndrome in the lateral compartment of the leg. The only nervous structure residing in the lateral compartment is the superficial peroneal nerve. In compartment syndrome of the lateral leg compartment, failure of prompt surgical fasciotomy would present as a sensory deficit of the superficial peroneal nerve presenting as numbness on the dorsum of his foot involving the hallux, 3rd, and 4th toes, as seen in Illustration A.

Matsen et al discuss the poor results which can be a cause of late diagnosis and surgical decompression. They recommended compartment monitoring in equivocal cases as well as release of all four leg compartments when facing leg compartment syndrome. A diagram of a two-incision fasciotomy is shown in Illustration B.

Olson et al provide a review of compartment syndrome for the lower extremity. They discuss a variety of injuries and medical conditions may initiate acute compartment syndrome, including fractures, bleeding disorders, and other trauma. Although the diagnosis is primarily a clinical one, they also recommend supplementation with compartment pressure measurements in equivocal cases.

Illustrations: A

REFERENCES:

1. Matsen FA 3rd, Winquist RA, Krugmire RB Jr. Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am. 1980 Mar;62(2):286-91. PMID:7358759 (Link to Abstract)

2. Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg. 2005 Nov;13(7):436-44. PMID:16272268 (Link to Abstract)

Question Authors:

David Abbasi MD, Ben Taylor MD, Jan Szatkowski MD, Edward Perez M.D.,

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TAG

(OBQ10.23) During a dual incision fasciotomy of the leg, the soleus is elevated from the tibia to allow access to which of the following compartments? Topic

Review Topic

1. Superficial posterior
2. Deep posterior
3. Lateral
4. Anterior
5. Mobile wad

PREFERRED RESPONSE ▶

DISCUSSION: The soleus is elevated/released from the posterior tibia during the medial approach to allow access to the deep posterior compartment. Release of this compartment cannot be done without proper elevation of the soleus. The superficial posterior compartment mass is primarily located in the proximal half of the leg, while the deep posterior musculature is located in the distal 2/3 of the leg.

Illustration A depicts the musculature and septums compartmentalizing the lower leg. The transverse intermuscular septum separates the deep from the superficial posterior compartments.

Illustrations: A

REFERENCES:

1. Schepsis AA, Watson FJ, Creevy W. Surgical treatment of overuse injuries of the lower extremity. In: El Attrache NS, Harner CD, Mirzayan R, Sekiya JK, eds. Surgical Techniques in Sports Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:621-640.

2. Amendola A, Twaddle BC. Compartment syndromes. In: Browner BD, Jupiter JB, Levine AM, Trafton G, eds. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries, 3rd ed. Philadelphia, PA: WB Saunders; 2009:359.

Question Authors:

Ben Taylor MD, Michael Hughes MD,

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TAG

(OBQ08.145) A 35-year-old female presents to the emergency room after a motor vehicle collision where her leg was pinned under the car for over 30 minutes. A clinical photo and radiographs are shown. Which of the following is the most accurate way to diagnose compartment syndrome? Topic

Review Topic

FIGURES: A

1. surgeon's palpation of the leg compartments
2. parathesias in her foot
3. diastolic blood pressure minus intra-compartmental pressure is less than 30 mmHg
4. diastolic blood pressure minus intra-compartmental pressure is greater than 30 mmHg
5. intra-compartmental pressure measurement of 25 mmHg

PREFERRED RESPONSE ▶

DISCUSSION: The clinical picture is consistent with compartment syndrome. The most accurate way to make the diagnosis is to measure the difference between the diastolic blood pressure and intracompartmental pressure (delta p).

In a prospective study of 116 patients with tibial diaphyseal fractures, McQueen et al found that the use of a differential pressure of 30 mmHg as a threshold for fasciotomy led to no missed cases of acute compartment syndrome. They recommended that a fasciotomy should be performed if the differential pressure level drops to under 30 mmHg.

The cited study by Kakar et al found the intraoperative DBP is significantly lower than the preoperative DBP in patient undergoing IM nailing for tibia shaft fractures. Therefore, they emphasize that the surgeon should recognize that intraoperative DeltaP may be lower than DeltaP once the patient is awakened in deciding whether to perform a fasciotomy versus awaken the patient and perform serial examinations and or compartment pressure measurements.

An absolute intra-compartmental value greater than 30 to 45mmHg can also be used to make the diagnosis of compartment syndrome, but is more controversial than the delta p according to Kakar and Amendola.

REFERENCES:

1. Amendola N. Compartment syndromes, in: Skeletal Trauma, Phila, PA, WB Saunders 2003, pp 293-319

2. Kakar S, Firoozabadi R, McKean J, Tornetta P 3rd. Diastolic blood pressure in patients with tibia fractures under anaesthesia: implications for the diagnosis of compartment syndrome. J Orthop Trauma. 2007 Feb;21(2):99-103. PMID:17304064 (Link to Abstract)

3. McQueen MM, Court-Brown CM: Compartment monitoring in tibial fractures: The pressure threshold for Decompression. J Bone Joint Surg Br 1996; 78: 99-104 PMID:8898137 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Ben Taylor MD, John Badylak MD,

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TAG

(OBQ08.170) A 32-year-old male sustains the injury seen in Figure A. His blood pressure preoperatively was 132/84. After closed reduction and placement of an intramedullary nail, his intraoperative leg compartment pressures are measured, with the highest being 28 mmHg. His blood pressure at this time is 84/57. What is the next appropriate step? Topic

Review Topic

FIGURES: A

1. Immediate four compartment fasciotomy
2. Fasciotomy of the highest compartment(s)
3. Acute shortening of the tibia with exchange of nail as needed
4. Repeat evaluation and compartment pressure evaluation in recovery room
5. Addition of pressors to anesthesia

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows a mildly comminuted tibia fracture, which is a fracture highly associated with compartment syndrome. However, in this scenario, the delta p (difference between compartmental pressures and diastolic pressure) is greater than 30 preoperatively, with a decrease to less than 30 intraoperatively, due to the hypotension associated with anesthesia.

The referenced article by Kakar et al notes that the delta p may be spuriously low intraoperatively, and with tibial nailing, it is safe to assume the delta p will return to a higher level postoperatively. They recommended continued monitoring in the postoperative period with clinical examination and measurements as needed.

The McQueen referenced article showed that the delta p is more important than absolute pressures, as an absolute threshold of 30mmHg would have led to unnecessary fasciotomies in 43% of their cohort.

REFERENCES:

1. Amendola A, Twaddle BC: Compartment Syndromes, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 293-319

2. Kakar S, Firoozabadi R, McKean J, Tornetta P 3rd. Diastolic blood pressure in patients with tibia fractures under anesthesia: Implications for the diagnosis of compartment syndrome. J Orthop Trauma 2007, 21:99-103 PMID:17304064 (Link to Abstract)

3. McQueen MM, Court-Brown CM: Compartment monitoring in tibial fractures: The pressure threshold for Decompression. J Bone Joint Surg Br 1996; 78: 99-104 PMID:8898137 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD, Jan Szatkowski MD, Edward Perez M.D.,

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(OBQ07.105) A 10-year-old girl is treated for a tibia/fibula fracture with a long leg cast. The on-call resident is called to evaluate the patient for increasing pain medicine requirements and tingling in her foot. Examination of the cast reveals that the ankle has been immobilized in 10 degrees of dorsiflexion. What ankle position results in the safest compartment pressures in a casted lower leg? Topic

Review Topic

1. 40-50 degrees of plantar flexion
2. 10-20 degrees of ankle dorsiflexion
3. Neutral to 30 degrees of plantar flexion
4. Neutral to 10 degrees of dorsiflexion
5. Ankle position has no effect on calf compartment pressure

PREFERRED RESPONSE ▶

DISCUSSION: Agitation, anxiety, and increasing analgesic requirments are the "3 A's" of pediatric compartment syndrome.

Weiner et al measured intramuscular compartment pressure in the anterior and deep posterior compartments of the leg in seven healthy adults who had long leg casts placed. They found that in a casted leg the intramuscular pressure in the anterior compartment was lowest with the ankle in neutral, and the deep posterior compartments was lowest when the ankle joint was in the resting position to approximately 37 degrees of plantar flexion. Based on this, they concluded that the safest ankle casting position regarding compartment pressure is between 0 and 37 degrees of plantar flexion. After the cast was bivalved, they noted a significant decrease in intramuscular pressure of 47 per cent in the anterior compartment and of 33 per cent in the deep posterior compartment. Constrictive casts and abberant ankle positioning can exacerbate pain/symptoms. Loosening of the cast by bivalving, spreading, and cutting underlying stockinette/softroll should always be the first step in management of possible compartment syndrome.

REFERENCES:

1. Weiner G, Styf J, Nakhostine M, Gershuni DH. Effect of ankle position and a plaster cast on intramuscular pressure in the human leg. J Bone Joint Surg Am. 1994 Oct;76(10):1476-81. PMID:7929495 (Link to Abstract)

2. Browner BD. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. Philadelphia, Pa: WB Saunders Co; 1998.

Question Authors:

Joshua Blomberg MD, Derek Moore, Ben Taylor MD,

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TAG

(OBQ07.256) Which of the following structures is at risk during proximal dissection of a single lateral perifibular approach for compartment syndrome of the leg? Topic

Review Topic

1. Common peroneal nerve
2. Superficial peroneal nerve
3. Deep peroneal nerve
4. Anterior tibial artery
5. Lateral inferior genicular artery

PREFERRED RESPONSE ▶

DISCUSSION: The perifibular approach is carried out through a straight lateral incision beginning just posterior and parallel to the fibula from the fibular head to the tip of the lateral malleolus. At the proximal end of the incision, the common peroneal nerve must be identified and protected. Elevation of the soleus off the posterior fibula ensures proper deep compartment release. The anterior edge of the incision is then retracted to expose the anterior and lateral compartments, and at this point, care must be taken to avoid the superficial peroneal nerve as it exits the fascia of the lateral compartment and runs anterior in the distal third of the leg. The referenced article by Whitesides is a review of compartment syndrome pathology, diagnosis, and treatment.

REFERENCES:

1. Whitesides TE, Heckman MM. Acute Compartment Syndrome: Update on Diagnosis and Treatment. J Am Acad Orthop Surg. 1996 Jul;4(4):209-218. PMID:10795056 (Link to Abstract)

Question Authors:

Ben Taylor MD, Jan Szatkowski MD,

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TAG

(OBQ06.97) Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture? Topic

Review Topic

1. pulselessness
2. palor
3. paresthesia
4. paralysis
5. increasing analgesia requirement

PREFERRED RESPONSE ▶

DISCUSSION: Although pain, pallor, paresthesia, paralysis, and pulselessness are all possible signs and symptoms of compartment syndrome in children with fractures, studies have shown increasing analgesia requirement is more sensitive.

Bae et al reviewed thirty-six cases of compartment syndrome in 33 pediatric patients. Approximately 75% of these patients developed compartment syndrome in the setting of fracture. "They found pain, pallor, paresthesia, paralysis, and pulselessness were relatively unreliable signs and symptoms of compartment syndrome in these children. An increasing analgesia requirement in combination with other clinical signs, was a more sensitive indicator of compartment syndrome."

Whitesides et al summarizes the diagnosis and treatment of acute compartment syndrome. They emphasize the need for early diagnosis, as "muscles tolerate 4 hours of ischemia well, but by 6 hours the result is uncertain; after 8 hours, the damage is irreversible." They recommend fasciotomy be performed when tissue pressure rises past 20 mm Hg below diastolic pressure.

REFERENCES:

1. Whitesides TE, Heckman MM: Acute compartment syndrome: Update on diagnosis and treatment. J Am Acad Orthop Surg 1996;4:209-218. PMID:10795056 (Link to Abstract)

2. Bae DS, Kadiyala RK, Waters PM: Acute compartment syndrome in children: Contemporary diagnosis, treatment, and outcome. J Pediatr Orthop 2001;21:680-688. PMID:11521042 (Link to Abstract)

Question Authors:

Derek Moore, Derek Moore, Patrick McCulloch MD,

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TAG

(OBQ06.129) Increasing the oxygen gradient for diffusion is the mechanism of action for what method of treatment for compartment syndrome? Topic

Review Topic

1. Open fasciotomy
2. Percutaneous fasciotomy
3. High-dose anti-inflammatories
4. Hyperbaric oxygen therapy
5. Negative pressure wound therapy

PREFERRED RESPONSE ▶

DISCUSSION: Hyperbaric oxygen therapy (HBO) allows patients to breathe 100% oxygen in a chamber under conditions of increased barometric pressure. This tremendous partial pressure of oxygen supports gas diffusion for a much greater distance than under normal conditions, thus delivering oxygen to relatively ischemic and hypoxic tissues. Trauma-related indications for HBO therapy include carbon monoxide intoxication, gas gangrene, crush injury, compartment syndrome, necrotizing fasciitis, treatment of chronic osteomyelitis, support of grafts and flaps, and burns. Contraindications relate to issues of gas exchange, oxygen sensitivity, and technical safety. The cited reference is a useful review article of hyperbaric oxygen therapy in extremity trauma.

REFERENCES:

1. Greensmith JE. Hyperbaric oxygen therapy in extremity trauma. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):376-84 PMID:15615503 (Link to Abstract)

Question Authors:

Ben Taylor MD,

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(OBQ05.191) An 11-year-old child has a tibia-fibula fracture following a fall from a swing. The fracture is reduced and placed in a long leg splint in the emergency room. What is considered the most important symptom of a developing compartment syndrome of the leg? Topic

Review Topic

1. pain out of proportion to injury
2. pale appearance of the foot
3. loss of the ability to move the toes
4. decreased sensation in the foot
5. decreased pulses in the foot

PREFERRED RESPONSE ▶

DISCUSSION: The Willis reference states “the single most important symptom of impending compartment syndrome is pain out of proportion to the injury." This symptom requires a conscious patient. Most children requiring a reduction for a displaced upper or lower extremity fracture will become comfortable soon after the reduction has been completed. Children requiring frequent analgesia or complaining loudly about pain should be examined very carefully for possible compartment syndrome.” The key wording in this question is “earliest indicator”. Pulselessness, paralysis, pallor, and parasthesias are all late indicators.

The Willis article also lists the most reliable signs of a developing compartment syndrome as severe pain with passive stretching of the involved compartment, pain with palpation of the involved compartment, sensory disturbances

REFERENCES:

1. Willis RB, Rorabeck CH. Treatment of compartment syndrome in children. Orthop Clin North Am. 1990 Apr;21(2):401-12. Review. PMID:2183136 (Link to Abstract)

Question Authors:

Derek Moore, Ben Taylor MD, Jan Szatkowski MD,

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(OBQ04.87) All of the following are true statements regarding compartment syndrome in the pediatric patient EXCEPT: Topic

Review Topic

1. Increasing analgesic requirement is an important indicator for the diagnosis of compartment syndrome in children
2. Duration of compartment syndrome prior to treatment is the most important variable in determining the outcome
3. Mechanism of injury is the best predictor of compartment syndrome development
4. Traditional hallmarks of adult compartment syndrome may be unreliable in the diagnosis of pediatric compartment syndrome
5. Careful patient positioning and the use of prophylactic fasciotomy are methods of preventing compartment syndrome

PREFERRED RESPONSE ▶

DISCUSSION: Compartment syndrome can often be difficult to diagnosis in the pediatric patient. Mechanism of injury is not the best predictor of compartment syndrome development or diagnosis in pediatric patients. It is important to note that functional outcome following compartment syndrome in patients is inversely related to the duration of elevated tissue pressures before surgical fasciotomy.

Level 4 evidence by Bae et al reviewed 33 children with compartment syndrome. They found that all 10 compartment syndrome patients that had access to nurse or patient controlled analgesia (PCAs), during their initial evaluation, demonstrated an increasing requirement for pain medication.

Matsen et al reviewed 24 children with compartment syndrome with the most common causes being fracture, vascular injury, and tibial osteotomy. The study concluded that is imperative that a compartment syndrome be identified and treated as promptly as possible.

REFERENCES:

1. Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop. 2001 Sep-Oct;21(5):680-8. PMID:11521042 (Link to Abstract)

2. Matsen FA 3rd, Veith RG. Compartmental syndromes in children. J Pediatr Orthop. 1981;1(1):33-41. PMID:7341650 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD, Dave Marcu MD,

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ABOS II: Compartment Syndrome Leg

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Evidence & References Show References

Level of Evidence 2 (Prospective Cohort Study)

McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br. 1996 Jan;78(1):99-104. PMID:8898137 (Link to Abstract)
Weiner G, Styf J, Nakhostine M, Gershuni DH. Effect of ankle position and a plaster cast on intramuscular pressure in the human leg. J Bone Joint Surg Am. 1994 Oct;76(10):1476-81. PMID:7929495 (Link to Abstract)

Level of Evidence 4 (Case Series)

Kakar S, Firoozabadi R, McKean J, Tornetta P III. Diastolic blood pressure in patients with tibia fractures under anaesthesia: implications for the diagnosis of compartment syndrome. J Orthop Trauma. 2007 Feb;21(2):99-103. PMID:17304064 (Link to Abstract)
Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop. 2001 Sep-Oct;21(5):680-8. PMID:11521042 (Link to Abstract)
Matsen FA 3rd, Veith RG. Compartmental syndromes in children. J Pediatr Orthop. 1981;1(1):33-41. PMID:7341650 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Whitesides TE, Heckman MM. Acute Compartment Syndrome: Update on Diagnosis and Treatment. J Am Acad Orthop Surg. 1996 Jul;4(4):209-218. PMID:10795056 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Amendola A, Twaddle BC. Compartment syndromes. In: Browner BD, Jupiter JB, Levine AM, Trafton G, eds. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries, 3rd ed. Philadelphia, PA: WB Saunders; 2009:359.
Browner BD. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. Philadelphia, Pa: WB Saunders Co; 1998.
Schepsis AA, Watson FJ, Creevy W. Surgical treatment of overuse injuries of the lower extremity. In: El Attrache NS, Harner CD, Mirzayan R, Sekiya JK, eds. Surgical Techniques in Sports Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:621-640.

Undefined

Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg. 2005 Nov;13(7):436-44. PMID:16272268 (Link to Abstract)
Amendola A, Twaddle BC: Compartment Syndromes, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 293-319
Amendola N. Compartment syndromes, in: Skeletal Trauma, Phila, PA, WB Saunders 2003, pp 293-319
Bae DS, Kadiyala RK, Waters PM: Acute compartment syndrome in children: Contemporary diagnosis, treatment, and outcome. J Pediatr Orthop 2001;21:680-688. PMID:11521042 (Link to Abstract)
Greensmith JE. Hyperbaric oxygen therapy in extremity trauma. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):376-84 PMID:15615503 (Link to Abstract)
Kakar S, Firoozabadi R, McKean J, Tornetta P 3rd. Diastolic blood pressure in patients with tibia fractures under anaesthesia: implications for the diagnosis of compartment syndrome. J Orthop Trauma. 2007 Feb;21(2):99-103. PMID:17304064 (Link to Abstract)
Kakar S, Firoozabadi R, McKean J, Tornetta P 3rd. Diastolic blood pressure in patients with tibia fractures under anesthesia: Implications for the diagnosis of compartment syndrome. J Orthop Trauma 2007, 21:99-103 PMID:17304064 (Link to Abstract)
Matsen FA 3rd, Winquist RA, Krugmire RB Jr. Diagnosis and management of compartmental syndromes. J Bone Joint Surg Am. 1980 Mar;62(2):286-91. PMID:7358759 (Link to Abstract)
McQueen MM, Court-Brown CM: Compartment monitoring in tibial fractures: The pressure threshold for Decompression. J Bone Joint Surg Br 1996; 78: 99-104 PMID:8898137 (Link to Abstract)
Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson WH. Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg Am. 1978 Dec;60(8):1091-5. PMID:721856 (Link to Abstract)
Whitesides TE, Heckman MM: Acute compartment syndrome: Update on diagnosis and treatment. J Am Acad Orthop Surg 1996;4:209-218. PMID:10795056 (Link to Abstract)
Willis RB, Rorabeck CH. Treatment of compartment syndrome in children. Orthop Clin North Am. 1990 Apr;21(2):401-12. Review. PMID:2183136 (Link to Abstract)

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Leg Compartment Syndrome

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