DIAGNOSING ACUTE COMPARTMENT SYNDROME

Compartment syndrome is a serious complication of fractures of the tibial shaft and its clinical presentation and evaluation have been well documented (Holden 1975; Kikuchi, Hasue and Watanabe 1978). The most important diagnostic feature is the presence of inappropriate pain even after stabilisation of the fracture by a cast or by external or internal fixation. Pain is made worse by passive stretching of the muscles involved and there is an associated sensory disturbance. The prognosis is directly related to the speed at which the diagnosis is made and treatment begun. It has been shown that muscle can tolerate only four hours of ischaemia without injury (Heppenstall et al 1988; Heckman et al 1993). We describe a patient with a fracture of the tibial shaft in whom the diagnosis of compartment syndrome was delayed because of the use of a local nerve block given in the operating theatre after intramedullary nailing. Case report. A 28-year-old man presented after a football injury with a closed fracture of the tibial shaft (42-A2.2 according to the AO classification (Muller et al 1990)). Before operation there were no signs of neurovascular compromise or of a compartment syndrome. The fracture was initially stabilised in a plaster back slab and closed, unreamed locked intramedullary nailing then performed. At the end of the operation, the patient was given a triple nerve block (femoral, obturator, lateral cutaneous nerve of thigh) using bupivacaine 0.5% for pain control. After operation, he was entirely free from pain, although he did complain of areas of altered sensation in his foot and leg, but these varied in site and were initially thought to be a result of the nerve block rather than a symptom of a developing compartment syndrome. Pressure measurements were made 48 hours after operation because symptoms persisted and there was inability actively to extend the big toe. They showed a pressure of 108 mmHg in the anterior compartment. We performed fasciotomy urgently but all the muscles in the anterior compartment were dead. No other compartment was involved. The whole of the anterior tibial compartment was debrided 48 hours later as there was no sign of recovery. The patient now walks with an orthosis. Discussion. The treatment of postoperative pain in patients whose tibial fractures have been stabilised is usually by elevation of the injured leg and the use of oral or intramuscular analgesics, especially non-steroidal anti-inflammatory agents. Local anaesthetic nerve blocks are now also commonly given to patients with fractures of the lower limb; they are effective and especially useful after fracture of the femoral shaft. A nerve block using bupivacaine persists for about eight hours (Macrae and Davies 1993), but recovery from the block may be patchy and erratic over a period of several hours. The diagnosis of compartment syndrome is essentially

Delayed diagnosis of acute compartment syndrome (ACS) can be catastrophic. Reporting abnormal presentations to facilitate timely diagnosis and treatment is vital. We present a case of ACS in the deep posterior compartment of the leg with an unusual presentation and cause. The patient presented to the emergency department complaining of numbness on the plantar aspect of his left foot, and described a history of cocaine use, increased exercise and creatine supplementation. The patient was diagnosed with acute deep posterior compartment syndrome of the left leg and underwent a lower extremity fasciotomy. There are case reports demonstrating that strenuous activity, drug use and creatine supplementation cause increased compartment pressures and ACS. Rare in the literature is a case where these activities occur concurrently with the abnormal presentation of symptoms seen in this case. We hope this case brings awareness of atraumatic risk factors and uncommon presentations to the medical community.

The Journal of Bone and Joint Surgery. British volumeVol. 68-B, No. 3 ArticlesFree AccessWhy resect the neck?MA FreemanMA FreemanSearch for more papers by this authorPublished Online:1 May 1986https://doi.org/10.1302/0301-620X.68B3.3733794AboutSectionsPDF/EPUB ToolsAdd to FavouritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited ByWhat is the fate of the neck after a collum femoris preserving prosthesis? a nineteen years single center experience26 November 2016 | International Orthopaedics, Vol. 41, No. 7Short-Stem Total Hip Replacement21 December 2016The Rationale for Short Uncemented Stems in Total Hip ArthroplastyOrthopedic Clinics of North America, Vol. 45, No. 1Neck-Preserving Femoral Stems7 September 2012 | HSS Journal ®, Vol. 8, No. 3The Use of a Novel “Conservative Hip Replacement” to Reconstruct an Osteoarthritic Hip With an Occluded Femoral CanalThe Journal of Arthroplasty, Vol. 26, No. 8Bone Integration of New “Stemless” Hip Implants (Proxima Vs. Nanos). A DXA Study: Preliminary Results1 January 2011 | International Journal of Immunopathology and Pharmacology, Vol. 24, No. 1_suppl2Medium Term Follow up of the Biodynamic Neck Sparing Prosthesis28 January 2011 | HIP International, Vol. 21, No. 1Mid-term results of a custom-made short proximal loading femoral componentF. S. Santori, N. Santori1 September 2010 | The Journal of Bone and Joint Surgery. British volume, Vol. 92-B, No. 9The Freeman femoral component with hydroxyapatite coating and retention of the neckAN UPDATE WITH A MINIMUM FOLLOW-UP OF 17 YEARSK. Mannan, M. A. R. Freeman, G. Scott1 April 2010 | The Journal of Bone and Joint Surgery. British volume, Vol. 92-B, No. 4Hip arthroplasty with proximal transmission of force: first clinical results with a new partially cemented femoral stem7 December 2006 | Archives of Orthopaedic and Trauma Surgery, Vol. 127, No. 3The effect of a neck-retaining femoral implant on leg-length inequality following total hip arthroplastyA RADIOLOGICAL STUDYV. Khanduja, V. Tek, G. Scott1 June 2006 | The Journal of Bone and Joint Surgery. British volume, Vol. 88-B, No. 6The Stability of the Femoral Component of a Minimal Invasive Total Hip Replacement System8 May 2006 | Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine, Vol. 220, No. 3Ten-year survival of the MS-30 matt-surfaced cemented stemB. J. Berli, D. Schäfer, E. W. Morscher1 July 2005 | The Journal of Bone and Joint Surgery. British volume, Vol. 87-B, No. 7Strain Adaptive Bone Remodelling in Total Joint ReplacementClinical Orthopaedics & Related Research, Vol. 430Radiological Assessment and Predictive Meaning of Bone Remodeling in Cementless ImplantsNeck-Preserving Implants in the Treatment of Femoral Head Avascular NecrosisPhotoelastic and Thermoelastic Measurement of Stress on the Proximal Femur Before and After Implantation of a Hip Prosthesis With Retention of the Femoral NeckOrthopedics, Vol. 25, No. 55- to 8-Year results of the freeman press-fit hip arthroplasty without HA coatingThe Journal of Arthroplasty, Vol. 14, No. 5Comparative results of a distal modular sleeve, circumferential coating, and stiffness relief using the Anatomic Porous Replacement IIThe Journal of Arthroplasty, Vol. 11, No. 4Is stem length important in uncemented endoprostheses?Medical Engineering & Physics, Vol. 17, No. 4Der zementfreie FemurschaftThe Cementless Femoral StemUncemented total hip replacements and thigh painArchives of Orthopaedic and Trauma Surgery, Vol. 113, No. 6Traumatic medial displacement of a Rotalok uncemented acetabular componentThe Journal of Arthroplasty, Vol. 9, No. 2Torsional Fixation of the Femoral Component in Cementless Total Hip Arthroplasty: Newly Designed Funnel Shape Femoral ComponentFailure of Cementless Fixation of the Femoral Component in Total Hip ArthroplastyOrthopedic Clinics of North America, Vol. 23, No. 2The effect of retention of the femoral neck and of cement upon the stability of a proximal femoral prosthesisThe Journal of Arthroplasty, Vol. 5Effect of interface conditions on the behaviour of a Freeman hip endoprosthesisJournal of Biomedical Engineering, Vol. 11, No. 6Rotational Movement of Femoral Components of Total Hip Replacements in Response to an Anteriorly Applied Load1 December 2016 | Engineering in Medicine, Vol. 17, No. 3Femoral neck retention in hip arthroplasty A cadaver study of mechanical effects8 July 2009 | Acta Orthopaedica Scandinavica, Vol. 59, No. 1Outcome with the MS-30 StemThe French Paradox Vol. 68-B, No. 3 Metrics Downloaded 77 times History Published online 1 May 1986 Published in print 1 May 1986 InformationCopyright © 1986, The British Editorial Society of Bone and Joint Surgery: All rights reservedPDF download

The acute compartment syndrome is caused by bleeding or edema in a closed muscle compartment surrounded by fascia and bone. It is characterized by increased intracompartmental pressure and decreased tissue perfusion. Well-known causative incidents are acute trauma and reperfusion after treatment for acute arterial obstruction. Most commonly the lower leg is involved. Inadequate therapy of the syndrome usually leads to muscle ischemia, rhabdomyolysis, and renal insufficiency. Perioperative morbidity and mortality are high. Although compartment syndromes can be caused by various factors, up until now no comparative studies have been published on clinical outcome of compartment syndromes of different origin. In this retrospective study we analyzed 40 successive cases of fasciotomy for acute lower leg compartment syndrome to study whether different causes of the syndrome lead to different clinical outcomes. We also studied other predictive factors for clinical outcome. The causes for the compartment syndromes were trauma, vascular deobstruction, cardiac surgery, and gastrointestinal surgery in lithotomy position. Clinical outcome showed a mortality of 15% and serious overall morbidity. Multivariate analysis showed the only significant predictive determinant of outcome to be the age of the patient. Fasciotomy for acute compartment syndrome is associated with serious morbidity and mortality. No correlation between causative factors and clinical outcome could be found.

Use of acrylic prosthesis in the treatment of fracture of the head of the radius.

Dupuytren's disease.

Manual compartment palpation is used as a component of the clinical diagnosis of acute compartment syndrome (ACS), particularly in obtunded patients. However, its utility and accuracy in the upper limb are unknown. The purposes of this study were to assess the accuracy of manual compartment palpation of ACS in the forearm in a cadaveric model and to assess the role of clinician experience in this setting. Reproducible, sustained elevation of intracompartmental pressure was established in 8 fresh upper-limb cadaveric specimens. The 3 forearm compartments (volar, dorsal, and mobile wad) were randomized to pressures of 20 and 40 mm Hg (negative controls) and 60 and 80 mm Hg (ACS). This was achieved by using fluid infusion and a pressure monitoring system. Orthopaedic clinicians with varying experience (residents, registrars, and consultants) used palpation to assess forearm compartments with known intracompartmental pressures. The examiners were blinded to the compartment pressures and the other examiners' responses. After the examination, the following 3 questions were answered: (1) Was compartment syndrome present? (2) In which compartment(s) was the pressure elevated? (3) What would be the next management step (fasciotomy or observation)? Manual palpation of compartment pressure had an overall sensitivity of 70%, a specificity of 56%, a positive predictive value of 24%, a negative predictive value of 90%, and a likelihood ratio (LR) of 20.3 (p < 0.001). The sensitivity was similar in detecting ACS in the volar and dorsal compartments (70% and 69%, respectively). The sensitivity and specificity of combined volar and dorsal compartment palpation were 81% and 64% (LR, 16.6; p < 0.001) when performed by residents, 72% and 46% (LR, 4.2; p = 0.040) when performed by registrars, and 58% and 63% (LR, 3.6; p = 0.057) when performed by consultants. All of the compartments that were deemed positive for ACS were recommended for fasciotomy. In our study, manual palpation of compartment pressure had a low accuracy in the diagnosis of ACS of the forearm and was not improved by clinician experience. We recommend against the use of manual palpation of compartment pressure in the diagnosis of forearm ACS in an obtunded patient.

Acute compartment syndrome develops when intracompartmental pressure increases either due to intrinsic or extrinsic causes. Increase in compartment pressure eventually can lead to impaired tissue perfusion followed by tissue death if no urgent intervention is performed. Patients with acute compartment syndrome usually present with pain out of proportion to apparent injury. It can cause rhabdomyolysis, myoglobinuria, and eventually acute renal failure. The definite treatment is fasciotomy in a timely manner. We here report a very interesting case of acute compartment syndrome in a young patient cause by pressure over his axilla by an iPad.

BackgroundFasciotomy for compartment syndrome is an emergent procedure that is usually done in the operating theater under general anesthesia. Delay in performing the procedure can lead to worse outcome. Various reasons can cause delay in performing the surgery. Bedside fasciotomy under local anesthesia can be done in these cases to avoid delay in compartment release.Materials and methodsThis was a retrospective study of 34 cases of acute compartment syndrome for which fasciotomy was done at the bedside under local anesthesia. The minimum follow-up period was 6 months.ResultsAll patients had immediate and marked improvement in pain. Thirty-three patients regained their normal muscle strength. Thirty-two patients regained normal range of motion of adjacent joints. One patient developed flexion contracture of the great toe. There was no deep infection, chronic osteomyelitis, or amputation. Superficial wound infection was noted in three patients; one patient had persistent foot drop.ConclusionBedside fasciotomy under local anesthesia is a feasible, safe, and effective choice for treating compartment syndrome in patients with delayed presentation or those with anticipated delay to undergo surgery in the operating theater under general or regional anesthesia. The results of this study are encouraging, as all wounds healed satisfactory and there were no cases of deep infections. The formal release of compartments in the operating room under general anesthesia continues to be the standard of care. This is the first description in the literature for bedside fasciotomy under local anesthesia with a relatively large number of patients.

BackgroundAcutely painful lower limb is a common presentation to the emergency department, and acute compartment syndrome is an important differential diagnosis to consider given the correct predisposing history and clinical presentation. However, idiopathic spontaneous compartment syndrome is an uncommon occurrence.Case presentationA 54-year-old Caucasian man with no previous comorbidities presented with acute right-sided lower limb pain with classical symptoms showing gradual evolution. He had no other history of medical relevance and no preceding injury. Examination showed a marginally enlarged right lower limb with stretched skin and tenderness. Routine blood tests were normal including D-dimer levels. However, in the absence of any underlying risk factors, acute compartment syndrome was suspected on clinical merit and confirmed with magnetic resonance imaging. He underwent successful surgical intervention with fasciotomy and achieved good recovery.DiscussionAcute compartment syndrome, though commonly attributed to trauma, can occur due to varied causes. Spontaneous acute compartment syndrome is attributed to diabetes mellitus. Idiopathic acute spontaneous compartment syndrome occurs in the absence of either intrinsic or extrinsic risk factors and is rarely documented in the literature. This case highlights the importance of appreciating classical clinical signs and having the clinical acumen to consider an obvious diagnosis even in its rarer form of presentation.

Acute compartment syndrome remains a challenging problem for orthopedic surgeons because its diagnosis is not always straightforward and it has a high risk of associated limb morbidity if left undiagnosed or untreated. Failure to diagnose and treat acute compartment syndrome is one of the most common causes of successful medical liability claims. The authors review the current literature concerning the diagnosis of acute compartment syndrome and discuss new non-invasive technologies that may allow for earlier and more accurate diagnosis of impending acute compartment syndrome.

Acute compartment syndrome secondary to disruption of the perforating branch of the peroneal artery following an acute inversion injury to the ankle

Acute compartment syndrome (ACS) is a surgical emergency that requires urgent fasciotomy to prevent irreversible sequelae. Symptoms usually include intense pain, tenderness in the affected area, tingling or burning sensation, and in severe cases, numbness or weakness and limb amputation due to ischemia from compression of the blood vessels, respectively. This case report describes a 19-year-old female who presented with complaints of severe pain and swelling in her right forearm. On examination, no bite marks, blisters, or skin necrosis were noted except for several surgical scars from her previous surgeries for the same condition, i.e., compartment syndrome. Upon thorough examination, including relevant investigation and clinical judgment, she was diagnosed with acute compartment syndrome, for which she underwent fasciotomy. There was no basic underlying pathology found in her case, making it an unidentified case of acute compartment syndrome.

A healthy 24-year-old woman developed rhabdomyolysis and acute bilateral thigh compartment syndrome after 10 minutes of spin class. She was successfully managed with early recognition, aggressive fluid resuscitation, and prompt bilateral surgical decompressive fasciotomy. Rhabdomyolysis with acute compartment syndrome is a rare but devastating combination of conditions. A high suspicion for rhabdomyolysis and progression to acute compartment syndrome is warranted for any patient presenting with increasing pain even with a limited history of trauma or exertion. Early recognition and medical and surgical treatment are paramount to preventing permanent damage.

CrossFit is a physical fitness program characterized by high-intensity workouts that can be associated with serious injury. Acute compartment syndrome in the upper limbs is a rare occurrence. It may occur after intense physical exercise, and its usual treatment is surgical. Hyperbaric oxygen therapy is a treatment described as adjunctive in cases of compartmental syndrome. We describe the case of a CrossFit practitioner who, after intense training, developed progressive symptoms of rhabdomyolysis and acute bilateral arm compartment syndrome, who was successfully treated with hyperbaric oxygen therapy and required no fasciotomy as surgical treatment. Acute compartment syndrome in the arms after intense physical exercise is a rare occurrence that should be suspected by practitioners of physical activity experiencing intense, disproportionate and progressive pain. In the case presented, hyperbaric oxygen therapy was successfully used in the treatment of the disorder, with satisfactory progress, and without the need for a surgical fasciotomy as therapy.