questions 8

Compartment Syndrome

Topic updated on 08/14/17 10:53pm

  • A 21-year-old, previously healthy male presents for evaluation of a painful right leg approximately 5 hours after his leg got caught between closing subway doors. He reports that he did not have significant 10/10 pain until 30 minutes ago, when the pain became excruciating. Physical exam reveals pain with dorsiflexion of his left foot and tenderness in his calf. Posterior tibial and dorsalis pedis pulses are present bilaterally. The surgical service is consulted immediately for urgent fasciotomy of his left foot.
  • Definition
    • increased interstitial pressure in an anatomical compartment (forearm, calf) where muscle and tissue are bound by fascia and bone with little room for expansion
    • interstitial pressure exceeds capillary perfusion pressure
      • muscle necrosis in 4-6 hours
      • eventual nerve necrosis
  • Causes
    • fracture
    • crush injury
    • ischemia-reperfusion injury (e.g., post-embolectomy of peripheral vessel)
    • constrictive dressing (circumferential cast, poor surgical positioning)
    • circumferential burn
  • Most common sites
    • legs
    • forearms
Presentation - the 6 P's
  • History
    • Pain out of proportion to injury
      • first and most important/specific symptom
      • pain with active contraction of compartment
  • Physical exam
    • Pain 
      • most important/specific sign
      • increased pain with passive stretch
    • Pallor
      • from lack of blood flow
      • late finding
    • Paresthesia
      • "pins and needles" sensation
    • Paralysis 
      • late finding
    • Pulselessness
      • late finding
    • Pressure
      • tense compartment with increased pressure and decreased/absent pulses
      • note that a tense compartment/absent pulses is NOT needed to make the diagnosis
  • Compartment syndrome is a clinical diagnosis
    • based on history and physical exam
  • Compartment pressure monitoring can be helpful if patient is child and/or is unconscious
    • considered positive for compartment syndrome when
      • absolute pressure  30 mmHg
      • Δ pressure  30 mmHg
        • Δ pressure = diastolic pressure - compartment pressure
      • normal = 0 mmHg
  • Best next step: emergency fasciotomy post  
    • indications   
      • anytime there is a suspicion or confirmed by compartmenet pressures.
      • untreated compartment syndrome leads to permanent nerve damage and muscle necrosis (Volkmann contracture)  


Qbank (2 Questions)

(M3.OR.39) A 24-year-old male presents to the emergency department as a trauma code shortly after a motorcycle accident. According to the report, the patient was thrown from his motorcycle when a car suddenly braked in front of him, and his leg was caught under the wheel of the vehicle. On primary survey, his airway is intact, he is complaining of severe leg pain, and his blood pressure is stable. He was helmeted, and his injuries appear to be isolated to the left lower extremity. When you move to the secondary survey, you note severe left lower extremity edema, and the patient screams and writhes in pain upon palpation of the distal pulses. You observe diffuse road rash but no open lacerations. His peripheral pulses are palpable and strong. Radiograph of his left lower extremity is shown in Figure A. What is the next best step in management? Topic Review Topic
FIGURES: A          

1. Admission for observation and pain control
2. Closed reduction and splinting
3. Percutaneous pinning and casting
4. Multi-compartment fasciotomy
5. Physical and occupational therapy

(M2.OR.59) A 25-year-old male presents to the ED after sustaining a left leg injury while playing soccer. Plain film demonstrates closed fracture of the tibia. Vital signs are stable, and the orthopedic service is consulted. While waiting in the ED, the patient reports worsening pain and numbness in the left leg. On physical exam, the left lower leg feels firm, and passive plantar flexion of the left foot elicits severe pain. The patient is unable to dorsiflex his left foot. Which of the following is the most appropriate next step?
Topic Review Topic

1. CT of left lower extremity
2. Doppler ultrasonography of left lower extremity
3. Blood work
4. Compartment release
5. Manometry

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