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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?
Intraoperative anterior compartment measurement of 29, with preoperative diastolic pressure 58
Preoperative anterior compartment measurement of 25, with preoperative diastolic pressure of 60
Intraoperative anterior compartment measurement of 25, with intraoperative diastolic pressure of 54
Intraoperative anterior compartment measurement of 28, with intraoperative diastolic pressure of 72
Preoperative anterior compartment measurement of 22, with mean arterial pressure of 70
Select Answer to see Preferred Response
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.
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 29 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.
Kakar S, Firoozabadi R, McKean J, Tornetta P
J Orthop Trauma. 2007 Feb;21(2):99-103. PMID: 17304064 (Link to Abstract)
McQueen MM, Court-Brown CM
J Bone Joint Surg Br. 1996 Jan;78(1):99-104. PMID: 8898137 (Link to Abstract)
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Average 4.0 of 19 Ratings
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?
Decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes
Inability to plantar flex the ankle
Decreased sensation on the dorsum of his foot involving the first webspace
Inability to dorsiflex the ankle
Inability to abduct his toes
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.
Matsen FA 3rd, Winquist RA, Krugmire RB Jr.
J Bone Joint Surg Am. 1980 Mar;62(2):286-91. PMID: 7358759 (Link to Abstract)
Olson SA, Glasgow RR.
J Am Acad Orthop Surg. 2005 Nov;13(7):436-44. PMID: 16272268 (Link to Abstract)
Average 4.0 of 33 Ratings
During a dual incision fasciotomy of the leg, the soleus is elevated from the tibia to allow access to which of the following compartments?
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.
Average 3.0 of 25 Ratings
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?
surgeon's palpation of the leg compartments
paresthesias in her foot
diastolic blood pressure minus intra-compartmental pressure is less than 30 mmHg
diastolic blood pressure minus intra-compartmental pressure is greater than 30 mmHg
intra-compartmental pressure measurement of 25 mmHg
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.
Average 4.0 of 20 Ratings
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?
Immediate four compartment fasciotomy
Fasciotomy of the highest compartment(s)
Removal of the nail and placement of an external fixator
Repeat evaluation in recovery room
Addition of pressors to anesthesia
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.
Average 3.0 of 38 Ratings
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?
40-50 degrees of plantar flexion
10-20 degrees of ankle dorsiflexion
Neutral to 30 degrees of plantar flexion
Neutral to 10 degrees of dorsiflexion
Ankle position has no effect on calf compartment pressure
Agitation, anxiety, and increasing analgesic requirements 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 percent in the anterior compartment and of 33 percent 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.
Weiner G, Styf J, Nakhostine M, Gershuni DH.
J Bone Joint Surg Am. 1994 Oct;76(10):1476-81. PMID: 7929495 (Link to Abstract)
Average 4.0 of 26 Ratings
Which of the following structures is at risk during proximal dissection of a single lateral perifibular approach for compartment syndrome of the leg?
Common peroneal nerve
Superficial peroneal nerve
Deep peroneal nerve
Anterior tibial artery
Lateral inferior genicular artery
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 anteriorly in the distal third of the leg.
The referenced article by Whitesides is a review of compartment syndrome pathology, diagnosis, and treatment.
Whitesides TE, Heckman MM.
J Am Acad Orthop Surg. 1996 Jul;4(4):209-218. PMID: 10795056 (Link to Abstract)
Average 3.0 of 36 Ratings
Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture?
increasing analgesia requirement
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.
Bae DS, Kadiyala RK, Waters PM
J Pediatr Orthop. 2001 Sep-Oct;21(5):680-8. PMID: 11521042 (Link to Abstract)
Average 3.0 of 18 Ratings
Increasing the oxygen gradient for diffusion is the mechanism of action for which of the following methods of treatment of lower extremity trauma?
Hyperbaric oxygen therapy
Negative pressure wound therapy
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.
J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):376-84. PMID: 15615503 (Link to Abstract)
Average 2.0 of 32 Ratings
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 earliest sign or symptom of a developing compartment syndrome of the leg?
pain out of proportion to injury
pale appearance of the foot
loss of the ability to move the toes
decreased sensation in the foot
decreased pulses in the foot
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
Willis RB, Rorabeck CH.
Orthop Clin North Am. 1990 Apr;21(2):401-12. PMID: 2183136 (Link to Abstract)
Average 4.0 of 25 Ratings
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?
Elevate his legs and reevaluate on morning rounds
Adjust his pain medication to accommodate for his increasing pain
Administer a muscle relaxant for leg spasms
Cast removal and measurement of compartment pressures with a standard device
Examine the cast for areas of constriction and reevaluate in the morning
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.
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.
Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson WH.
J Bone Joint Surg Am. 1978 Dec;60(8):1091-5. PMID: 721856 (Link to Abstract)
Matsen FA 3rd, Veith RG.
J Pediatr Orthop. 1981;1(1):33-41. PMID: 7341650 (Link to Abstract)
Average 3.0 of 17 Ratings
All of the following are true statements regarding compartment syndrome in the pediatric patient EXCEPT:
Increasing analgesic requirement is an important indicator for the diagnosis of compartment syndrome in children
Duration of compartment syndrome prior to treatment is the most important variable in determining the outcome
Mechanism of injury is the best predictor of compartment syndrome development
Traditional hallmarks of adult compartment syndrome may be more challenging to detect in pediatric compartment syndrome
Careful patient positioning and the use of prophylactic fasciotomy are methods of preventing compartment syndrome
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.
Four Compartment Fasciotomy with Two Incision Approach, Edward Perez, MD
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This video demonstrates fasciotomies in the lower leg in a cadaver.
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