summary Leg Compartment Syndrome is a devastating lower extremity condition where the osseofascial compartment pressure rises to a level that decreases perfusion to the leg and may lead to irreversible muscle and neurovascular damage. Diagnosis is made with the presence of severe and progressive leg pain that worsens with passive ankle motion. Firmness and decreased compressibility of the compartments is often present. Needle compartment pressures are diagnostic in cases of inconclusive physical exam findings and in sedated patients. Treatment is usually emergent fasciotomies of all 4 compartments. Epidemiology Anatomic location compartment syndrome may occur anywhere that skeletal muscle is surrounded by fascia, but most commonly leg (details below) forearm hand foot thigh buttock shoulder paraspinous muscles Etiology Pathophysiology etiology 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 pathoanatomy cascade of events includes local trauma and soft tissue destruction bleeding and edema increased interstitial pressure vascular occlusion (decreased venous outflow relative to arterial inflow) myoneural ischemia Risk factors diaphyseal fractures young age (highest prevalence in 12-19 year olds) 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 the clinical situation is usually the 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 Imaging Radiographs obtain to rule-out fracture Studies 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 low rates of interobserver reliability have been noted with measurements 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 Diagnosis Clinical based primarily on physical exam in patient with intact mental status Treatment Nonoperative observation indications diastolic differential pressure (delta p) is > 30 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 splinting the ankle between neutral and resting plantar flexion (37 deg) can also decrease intracompartmental pressures 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 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 attempt to restore systemic blood pressure prior to measurement contraindications missed compartment syndrome Special considerations pediatrics children are unable to verbalize feelings if suspicion, then perform compartment pressure measurement under sedation hemophiliacs give Factor VIII replacement before measuring compartment pressures 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
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Leg Compartment Release - Two Incision Approach Orthobullets Team Trauma - Leg Compartment Syndrome Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Leg Compartment Release - Single Incision Approach Orthobullets Team Trauma - Leg Compartment Syndrome
QUESTIONS 1 of 27 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.243) A 25-year-old male sustains the injury depicted in Figure A. He is splinted in the field, but on arrival to the emergency room, he complains of painful "tightness" around the leg and severe uncontrolled pain despite maximum dose narcotics. His pain is exacerbated when the toes and ankle are passively stretched in flexion and extension. What is the most appropriate next step in treatment? QID: 213139 FIGURES: A Type & Select Correct Answer 1 External fixation with serial doppler examinations 1% (16/2290) 2 Intramedullary nailing 0% (9/2290) 3 Open reduction internal fixation using plates and screws 0% (9/2290) 4 Immediate 2-compartment fasciotomies and external fixation 2% (57/2290) 5 Immediate 4-compartment fasciotomies and external fixation 95% (2178/2290) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ18.254) A 24-year-old male is brought to the ED after an MVC. He is found to have a closed comminuted segmental fibula fracture after a prolonged extraction from the vehicle. Several hours after arrival, the patient reports increasing pain and is noted to have an exacerbation of his pain with passive stretching of the ankle. He has a heart rate of 103 and a blood pressure of 141/87. Compartment pressures are obtained and are 27 mmHg in the anterior compartment, 47 mmHg in the lateral compartment, 28 mmHg in the superficial posterior compartment, and 27 mmHg in the deep posterior compartment. Which of the following correctly describes the initial pathophysiology of compartment syndrome and the neurologic deficit that would likely occur in this patient if left untreated? QID: 213150 Type & Select Correct Answer 1 Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the first webspace 4% (77/1784) 2 Decreased arterial inflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes 10% (184/1784) 3 Decreased arterial inflow; inability to dorsiflex his ankle 3% (50/1784) 4 Decreased venous outflow; decreased sensation on the dorsum of his foot involving the first webspace 18% (318/1784) 5 Decreased venous outflow; decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes 63% (1124/1784) N/A Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ15.111.1) You are called to evaluate a 45-year-old male in the ED who was in a motor vehicle accident prior to arrival. EMS reported a prolonged extrication and GCS of 6 on scene, which required a field intubation. He has obvious deformity and crepitus of his left leg, with radiographs seen in Figure A. The ED physician reports an increase in soft tissue swelling and firmness of the leg. You decide to measure the patient's compartments given clinical concern for compartment syndrome. Which of the following is true of intracompartmental pressure measurements? QID: 216658 FIGURES: A Type & Select Correct Answer 1 Interobserver reliability is poor 45% (381/851) 2 Should be obtained remote to the zone of injury 18% (152/851) 3 Should always be obtained to objectively confirm clinical suspicion for compartment syndrome 5% (41/851) 4 Have high specificity for diagnosis of compartment syndrome when absolute pressures exceed 20 mmHg 12% (103/851) 5 Threshold for fasciotomy remains similar intraoperatively 20% (170/851) L 1 Question Complexity Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (SBQ13PE.95.2) An 8-year-old boy is involved in an ATV crash. Xrays were obtained in the trauma bay after being airlifted to your facility, shown in Figures A. On the day of presentation, you perform the treatment shown in the figure B. On postoperative day 1, the patient states his pain is controlled, however, you find that his calf is tense, his foot is cool and has diminished pulses compared to the contralateral extremity. What is the best next step of the options below? QID: 214226 FIGURES: A B Type & Select Correct Answer 1 Remove your fixation and perform repeat reduction 4% (61/1726) 2 Measure leg compartment pressures 52% (899/1726) 3 Request vascular consultation 7% (116/1726) 4 Measure ankle-brachial index (ABI) 33% (561/1726) 5 Duplex ultrasound evaluation 5% (79/1726) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 4388 Type & Select Correct Answer 1 Intraoperative anterior compartment measurement of 29, with preoperative diastolic pressure 58 75% (5484/7341) 2 Preoperative anterior compartment measurement of 25, with preoperative diastolic pressure of 60 7% (483/7341) 3 Intraoperative anterior compartment measurement of 25, with intraoperative diastolic pressure of 54 14% (1011/7341) 4 Intraoperative anterior compartment measurement of 28, with intraoperative diastolic pressure of 72 2% (176/7341) 5 Preoperative anterior compartment measurement of 22, with mean arterial pressure of 70 2% (130/7341) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 3498 Type & Select Correct Answer 1 Decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes 80% (2313/2904) 2 Inability to plantar flex the ankle 1% (37/2904) 3 Decreased sensation on the dorsum of his foot involving the first webspace 11% (330/2904) 4 Inability to dorsiflex the ankle 6% (160/2904) 5 Inability to abduct his toes 2% (52/2904) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 3111 Type & Select Correct Answer 1 Superficial posterior 1% (37/3737) 2 Deep posterior 97% (3643/3737) 3 Lateral 1% (24/3737) 4 Anterior 1% (22/3737) 5 Mobile wad 0% (5/3737) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 531 FIGURES: A B C Type & Select Correct Answer 1 surgeon's palpation of the leg compartments 6% (62/1023) 2 paresthesias in her foot 1% (11/1023) 3 diastolic blood pressure minus intra-compartmental pressure is less than 30 mmHg 79% (812/1023) 4 diastolic blood pressure minus intra-compartmental pressure is greater than 30 mmHg 10% (101/1023) 5 intra-compartmental pressure measurement of 25 mmHg 3% (31/1023) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 556 FIGURES: A Type & Select Correct Answer 1 Immediate four compartment fasciotomy 25% (269/1084) 2 Fasciotomy of the highest compartment(s) 2% (26/1084) 3 Removal of the nail and placement of an external fixator 1% (6/1084) 4 Repeat evaluation in recovery room 68% (734/1084) 5 Addition of pressors to anesthesia 4% (47/1084) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 917 Type & Select Correct Answer 1 Common peroneal nerve 48% (1134/2340) 2 Superficial peroneal nerve 43% (1011/2340) 3 Deep peroneal nerve 6% (144/2340) 4 Anterior tibial artery 1% (24/2340) 5 Lateral inferior genicular artery 1% (20/2340) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 766 Type & Select Correct Answer 1 40-50 degrees of plantar flexion 2% (28/1691) 2 10-20 degrees of ankle dorsiflexion 1% (25/1691) 3 Neutral to 30 degrees of plantar flexion 73% (1230/1691) 4 Neutral to 10 degrees of dorsiflexion 13% (222/1691) 5 Ankle position has no effect on calf compartment pressure 11% (179/1691) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ06.129) Increasing the oxygen gradient for diffusion is the primary mechanism of action for which of the following methods of treatment of lower extremity trauma? QID: 315 Type & Select Correct Answer 1 Open fasciotomy 4% (40/1099) 2 Percutaneous fasciotomy 0% (1/1099) 3 High-dose anti-inflammatories 1% (8/1099) 4 Hyperbaric oxygen therapy 89% (982/1099) 5 Negative pressure wound therapy 6% (66/1099) L 1 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ06.97) Which clinical sign is the most sensitive for the diagnosis of compartment syndrome in a child with a supracondylar humerus fracture? QID: 208 Type & Select Correct Answer 1 pulselessness 1% (24/1953) 2 pallor 1% (12/1953) 3 paresthesia 1% (25/1953) 4 paralysis 1% (10/1953) 5 increasing analgesia requirement 96% (1869/1953) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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 earliest sign or symptom of a developing compartment syndrome of the leg? QID: 1077 Type & Select Correct Answer 1 pain out of proportion to injury 97% (2122/2195) 2 pale appearance of the foot 0% (7/2195) 3 loss of the ability to move the toes 1% (15/2195) 4 decreased sensation in the foot 2% (37/2195) 5 decreased pulses in the foot 0% (7/2195) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (SBQ04PE.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? QID: 2186 FIGURES: A Type & Select Correct Answer 1 Elevate his legs and reevaluate on morning rounds 1% (6/896) 2 Adjust his pain medication to accommodate for his increasing pain 1% (6/896) 3 Administer a muscle relaxant for leg spasms 0% (2/896) 4 Cast removal and measurement of compartment pressures with a standard device 95% (852/896) 5 Examine the cast for areas of constriction and reevaluate in the morning 2% (21/896) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ04.87) All of the following are true statements regarding compartment syndrome in the pediatric patient EXCEPT: QID: 1192 Type & Select Correct Answer 1 Increasing analgesic requirement is an important indicator for the diagnosis of compartment syndrome in children 6% (71/1189) 2 Duration of compartment syndrome prior to treatment is the most important variable in determining the outcome 7% (80/1189) 3 Mechanism of injury is the best predictor of compartment syndrome development 59% (706/1189) 4 Traditional hallmarks of adult compartment syndrome may be more challenging to detect in pediatric compartment syndrome 4% (48/1189) 5 Careful patient positioning and the use of prophylactic fasciotomy are methods of preventing compartment syndrome 23% (274/1189) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
All Videos (6) Podcasts (2) 2019 Orthopaedic Trauma & Fracture Care: Pushing the Envelope Compartment Syndrome: What More Do We Know - Andy Schmidt, MD (OTFC 2019, 5.2) Trauma - Leg Compartment Syndrome A 3/27/2019 2585 views 4.7 (6) Login to View Community Videos Login to View Community Videos California Orthopaedic Association Annual Meeting - 2018 Acute Limb Trauma - External Fixation and Fasciotomy Techniques - Saam Morshed, MD (COA 2018 , 2.1) Trauma - Leg Compartment Syndrome A 8/27/2018 2367 views 4.6 (25) Login to View Community Videos Login to View Community Videos Four Compartment Fasciotomy with Two Incision Approach, Edward Perez, MD Derek W. Moore Trauma - Leg Compartment Syndrome A 10/22/2016 2242 views 4.8 (14) Trauma | Leg Compartment Syndrome Trauma - Leg Compartment Syndrome Listen Now 17:30 min 10/16/2019 1629 plays 4.7 (7) Question SessionâȘLeg Compartment Syndrome & Adult Dysplasia of the Hip Orthobullets Team Trauma - Leg Compartment Syndrome Listen Now 31:55 min 11/8/2019 120 plays 0.0 (0) See More See Less