Updated: 10/22/2016

Leg Compartment Syndrome

Topic
Review Topic
0
0
Questions
23
0
0
Evidence
15
0
0
Videos
6
Techniques
2
https://upload.orthobullets.com/topic/1001/images/technique.jpg
https://upload.orthobullets.com/topic/1001/images/compartments.jpg
Introduction
  • Devastating condition where an osseofascial compartment pressure rises to a level that decreases perfusion
    • may lead to irreversible muscle and nerve damage
  • Epidemiology
    • 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
  • 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 > 
        • myoneural ischemia
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
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
      • 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
    • 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
 

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Technique Guides (2)
Questions (23)
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(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? Review Topic

QID: 2186
FIGURES:
1

Elevate his legs and reevaluate on morning rounds

1%

(2/389)

2

Adjust his pain medication to accommodate for his increasing pain

1%

(3/389)

3

Administer a muscle relaxant for leg spasms

1%

(2/389)

4

Cast removal and measurement of compartment pressures with a standard device

93%

(362/389)

5

Examine the cast for areas of constriction and reevaluate in the morning

4%

(14/389)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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(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? Review Topic

QID: 4388
1

Intraoperative anterior compartment measurement of 29, with preoperative diastolic pressure 58

77%

(4485/5860)

2

Preoperative anterior compartment measurement of 25, with preoperative diastolic pressure of 60

6%

(357/5860)

3

Intraoperative anterior compartment measurement of 25, with intraoperative diastolic pressure of 54

12%

(723/5860)

4

Intraoperative anterior compartment measurement of 28, with intraoperative diastolic pressure of 72

2%

(143/5860)

5

Preoperative anterior compartment measurement of 22, with mean arterial pressure of 70

2%

(109/5860)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ06.129) Increasing the oxygen gradient for diffusion is the mechanism of action for which of the following methods of treatment of lower extremity trauma? Review Topic

QID: 315
1

Open fasciotomy

4%

(20/553)

2

Percutaneous fasciotomy

0%

(0/553)

3

High-dose anti-inflammatories

1%

(5/553)

4

Hyperbaric oxygen therapy

91%

(501/553)

5

Negative pressure wound therapy

5%

(26/553)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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? Review Topic

QID: 917
1

Common peroneal nerve

47%

(835/1786)

2

Superficial peroneal nerve

45%

(799/1786)

3

Deep peroneal nerve

6%

(114/1786)

4

Anterior tibial artery

1%

(19/1786)

5

Lateral inferior genicular artery

1%

(14/1786)

ML 4

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PREFERRED RESPONSE 1

(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? Review Topic

QID: 3111
1

Superficial posterior

1%

(24/2850)

2

Deep posterior

98%

(2790/2850)

3

Lateral

0%

(14/2850)

4

Anterior

1%

(15/2850)

5

Mobile wad

0%

(2/2850)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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? Review Topic

QID: 531
FIGURES:
1

surgeon's palpation of the leg compartments

6%

(30/485)

2

paresthesias in her foot

1%

(4/485)

3

diastolic blood pressure minus intra-compartmental pressure is less than 30 mmHg

76%

(370/485)

4

diastolic blood pressure minus intra-compartmental pressure is greater than 30 mmHg

12%

(57/485)

5

intra-compartmental pressure measurement of 25 mmHg

4%

(21/485)

ML 2

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 556
FIGURES:
1

Immediate four compartment fasciotomy

26%

(130/506)

2

Fasciotomy of the highest compartment(s)

2%

(8/506)

3

Removal of the nail and placement of an external fixator

0%

(0/506)

4

Repeat evaluation in recovery room

69%

(348/506)

5

Addition of pressors to anesthesia

4%

(19/506)

ML 2

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PREFERRED RESPONSE 4

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

QID: 1192
1

Increasing analgesic requirement is an important indicator for the diagnosis of compartment syndrome in children

4%

(20/558)

2

Duration of compartment syndrome prior to treatment is the most important variable in determining the outcome

8%

(42/558)

3

Mechanism of injury is the best predictor of compartment syndrome development

63%

(351/558)

4

Traditional hallmarks of adult compartment syndrome may be more challenging to detect in pediatric compartment syndrome

4%

(25/558)

5

Careful patient positioning and the use of prophylactic fasciotomy are methods of preventing compartment syndrome

20%

(113/558)

ML 3

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 3498
1

Decreased sensation on the dorsum of his foot involving the hallux, 3rd, and 4th toes

81%

(1830/2268)

2

Inability to plantar flex the ankle

1%

(21/2268)

3

Decreased sensation on the dorsum of his foot involving the first webspace

11%

(252/2268)

4

Inability to dorsiflex the ankle

5%

(117/2268)

5

Inability to abduct his toes

2%

(39/2268)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 1077
1

pain out of proportion to injury

97%

(1616/1670)

2

pale appearance of the foot

0%

(6/1670)

3

loss of the ability to move the toes

1%

(13/1670)

4

decreased sensation in the foot

1%

(24/1670)

5

decreased pulses in the foot

0%

(6/1670)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 766
1

40-50 degrees of plantar flexion

2%

(14/739)

2

10-20 degrees of ankle dorsiflexion

1%

(7/739)

3

Neutral to 30 degrees of plantar flexion

73%

(542/739)

4

Neutral to 10 degrees of dorsiflexion

12%

(87/739)

5

Ankle position has no effect on calf compartment pressure

12%

(86/739)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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

QID: 208
1

pulselessness

1%

(11/1249)

2

pallor

1%

(7/1249)

3

paresthesia

1%

(15/1249)

4

paralysis

0%

(6/1249)

5

increasing analgesia requirement

96%

(1203/1249)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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