Compartment syndrome in a patient treated with perineural liposomal bupivacaine (Exparel)

Acute compartment syndrome is a condition that may result in sensorimotor deficits and loss of function of the affected limb as a result of ischemic injury. It is considered a surgical emergency and prompt diagnosis and treatment results in more favorable outcomes. The use of regional anesthesia is controversial in patients at risk for compartment syndrome due to concern of its potential to mask symptoms of the condition. A 44-year-old African American male presented to surgery for open reduction and internal fixation of a comminuted distal radius fracture. As part of an off-label, investigator-initiated, and institutional review board–approved study, he received a perineural injection of liposomal bupivacaine (Exparel) around the median, ulnar, and radial nerves at the level of the proximal forearm. The following morning, his initial complaints of numbness and incisional pain progressively evolved into worsening numbness, diffuse discomfort, and pain with passive movement. A diagnosis of compartment syndrome was made and he underwent an emergency fasciotomy. The diagnosis of compartment syndrome requires a high index of suspicion and prompt treatment. This patient’s changing pattern of symptoms—rather than his pain complaints alone—resulted in the diagnosis of compartment syndrome treated with emergent fasciotomy in spite of finger numbness that was initially attributed to the liposomal bupivacaine. While the use of liposomal bupivacaine did not preclude the diagnosis of compartment syndrome in our patient, it should be used with caution in patients at risk for compartment syndrome until additional data, particularly regarding block characteristics, are available.     

Comparison of ulnar shortening osteotomy and the wafer resection procedure as treatment for ulnar impaction syndrome

A retrospective review was performed that compared the results of 2 different surgical treatments for ulnar impaction syndrome in 22 patients over a 6-year period. Ulnar shortening osteotomy and wafer distal ulna resection (wafer resection procedure) were each performed in 11 patients based on the preference of 3 individual hand surgeons. All patients presented with ulnar wrist pain and positive ulnar variance on either neutral rotation or pronated-grip x-rays and each failed conservative management. At a minimum follow-up time of 18 months, 9 patients had good to excellent results following ulnar shortening osteotomy compared with 8 following the wafer resection procedure. This difference was not statistically significant. All patients regained functional wrist motion and 21 of the 22 patients had satisfactory pain relief. There was 1 poor result in the wafer group that required revision to complete resection of the distal ulna. Five secondary procedures were required in the osteotomy group to remove painful hardware and union was delayed in 2 patients. Although ulnar shortening osteotomy provides effective treatment for ulnar impaction syndrome, the wafer resection procedure provides favorable pain relief and restoration of function but without the potential for nonunion or hardware removal. (J Hand Surg 2000; 25A:55-60.     

The value of the pronated-grip view radiograph in assessing dynamic ulnar positive variance: a case report

Positive ulnar variance affects surgical decision making when ulnar wrist pain is refractory to conservative treatment and is either secondary to a posttraumatic triangular fibrocartilage tear or associated with ulnar impaction syndrome. In such settings, ulnar recession may be necessary to diminish load transmission across the ulnocarpal joint. We present a case of a 24-year-old man with chronic right ulnar wrist pain that illustrates the efficacy of the pronated-grip radiograph in assessing dynamic ulnar positive variance.     

Treatment of compartment syndrome in children

A compartment syndrome is a symptom complex caused by elevated tissue pressure in a closed osseofascial compartment of a limb. Left unrecognized, it results in permanent damage to muscle and nerve in that compartment. The diagnosis of a compartment syndrome is contingent on the recognition of pain out of proportion with the injury as the most important early symptom. The pain is increased with passive stretching of the muscles in the involved compartment or on palpation of the involved muscles. Once the diagnosis is suspected, prompt treatment by appropriate fasciotomy should result in maintenance of normal limb function.     

Compartment syndrome of the forearm following an electromyographic assessment

We present a case of compartment syndrome after electromyographic study of the upper limbs. The cause was the unintentional punction and laceration of the ulnar artery while the electromyography was being performed.     

尺骨撞击综合征的特点及早期诊断

目的探讨尺骨撞击综合征的特点及早期诊断方法并提出新的诊断标准。方法对1998年12月～2004年12月治疗的123例腕尺侧疼痛患者进行仔细检查,采用顾玉东等提出的诊断标准,特别结合腕部MRI检查,确诊尺骨撞击综合征48例。总结尺骨憧击综合征的X线及MRI影像学特点,分析腕部临床症状与Chun和Palmer评分及影像学表现的关系。结果本组33例患者存在尺骨阳性变异(68．8%),X线检查发现患者出现腕骨坏死比例为27．1%,其中以月骨坏死为主(64．7%)；MRI检查均发现腕骨不同程度信号改变,腕部骨坏死均位于月骨尺侧部分的近端和三角骨腰部及底部；患者腕部临床症状与Chun和Palmer评分及影像学表现关系密切。结论提高对尺骨撞击综合征的认识水平,以临床症状为基础,充分利用影像学检查,特别是MRI检查,可以明显提高该病征的早期诊断率。     

The ‘silent’ compartment syndrome

Intractable pain out of proportion to the injury sustained is considered to be the earliest and most reliable indicator of a developing compartment syndrome. We report 4 cases where competent sensate patients developed compartment syndromes without any significant pain. The first patient developed a painless compartment syndrome in the well leg following surgery for femoral fracture on the other side. The second patient developed the silent compartment syndrome post-operatively following a tibial nailing for a tibial fracture. The third patient presented with the painless compartment syndrome following a tibial plateau fracture. Our prevailing culture of a high-index of clinical suspicion and surveillance prompted us to perform compartment pressure measurements. The surgical findings at immediate fasciotomy confirmed the diagnoses.Our experience indicates that pain is not a reliable clinical indicator for underlying compartment syndrome, so in a competent sensate patient the absence of pain does not exclude compartment syndrome.We believe that a high index of clinical suspicion must prevail in association with either continuous compartment pressure monitoring or frequent repeated documented clinical examination with a low threshold for pressure measurement.     

Anatomy and intracompartmental pressure measurement technique of the pronator quadratus compartment

The compartment of the pronator quadratus muscle in 25 cadaver specimens is described. Defined by the radius, ulna, and distal interosseous membrane dorsally and the pronator quadratus fascia on the palmar side, the osteofibrous walls of the compartment confine the pronator quadratus muscle within a noncompliant space. A safe and reliable location for compartment pressure measurement was defined at a site 4 cm proximal to the scaphoid tubercule, on the radial side of the flexor carpi radialis tendon and on the ulnar side of the radial artery. These clear anatomic definitions might be useful in diagnosis of compartment syndrome of the pronator quadratus; a clinical investigation may be justified on the basis of pressure measurements made using this technique.     

Belastungsinduziertes Kompartmentsyndrom der Peronealloge nach Bowling

A 30-year-old man presented several times with pain in the calf after twisting his foot and injuring it during bowling. It was some time before the diagnosis of acute exertion-induced compartment syndrome was made, and an immediate fasciotomy could no longer prevent necrosis of the peroneal muscles. Because of the patient's drop-foot, we performed a tibialis posterior tendon transfer, fixing it to the cuneiform bone. The sort of compartment syndrome observed after engagement in various sports is a recognised, albeit uncommon, variant of acute compartment syndrome. A high level of suspicion and observation is required to make the diagnosis when any leg pain has no definite diagnosis. Fasciotomy should be performed early.     

Lumbar paraspinal compartment syndrome

The purpose of this study was to systematically review the available evidence on lumbar paraspinal compartment syndrome with specific reference to patient demographics, aetiology, types, diagnosis, clinical features, and treatment. This was an Institutional Review Board-exempt study performed at a Level 1 trauma center. A PubMed search was conducted with the title query: lumbar paraspinal compartment syndrome. Eleven articles met our search criteria. Three of the patients with acute paraspinal compartmental syndrome treated with fasciotomy had a full recovery and were able to resume skiing after four months. The aetiology of the onset of lumbar paraspinal compartment syndrome is broadly divided into acute and chronic. Lumbar paraspinal compartment syndrome is one of the causes of back pain with diagnostic clinical features which should be considered in the differential diagnosis of a patient with low back pain. Prospective multicentre trials may provide the surgeon with more insight into the diagnosis and management of lumbar paraspinal compartment syndrome.     

Corrective osteotomy for symptomatic increased ulnar tilt of the distal end of the radius

Twelve wrists in 10 patients with a mean age of 23.6 years were treated for symptomatic increased ulnar inclination of the joint surface with corrective osteotomy of the radius. Diagnoses included mild ulnar dysplasia, posttraumatic deformity, Madelung's disease, and multiple hereditary exostosis. All patients had radial-sided wrist pain and an ulnarly displaced arc of radioulnar deviation. Preoperative radiographs showed excessive ulnar inclination of the distal radius, ulnar carpal translation, adaptive carpal malalignment, and frequent distal radioulnar joint incongruency. The patients had decreased pain and improved wrist function at a mean of 5.1 years (range, 2-10 years) after surgery. Average radial deviation changed from 3 degrees to 16 degrees and ulnar deviation from 48 degrees to 29 degrees; flexion/extension and pronosupination remained unchanged. Realignment of the wrist was shown radiographically by a change of ulnar inclination of the radius from 33 degrees to 21 degrees, an increase in scaphoid height from 16.4 to 20.4 mm, and reversal of ulnar carpal translation as shown by an increase in lunate-covering ratio of 64% to 77%. Reduction of the ulnar inclination to normal values by corrective radial osteotomy restores a more physiologic range of motion, decreases symptomatic wrist pain, reverts adaptive carpal changes to normal, increases lunate coverage, and may prevent abnormal cartilage overload in the ulnar compartment of the wrist.     

Does epidural analgesia delay the diagnosis of lower limb compartment syndrome in children?

One of the cardinal symptoms of compartment syndrome is pain. A literature review was undertaken in order to assess the association of epidural analgesia and compartment syndrome in children, whether epidural analgesia delays the diagnosis, and to identify patients who might be at risk. Evidence was sought to offer recommendations in the use of epidural analgesia in patients at risk of developing compartment syndrome of the lower limb. Increasing analgesic use, increasing/breakthrough pain and pain remote to the surgical site were identified as important early warning signs of impending compartment syndrome in the lower limb of a child with a working epidural. The presence of any should trigger immediate examination of the painful site, and active management of the situation (we have proposed one clinical pathway). Avoidance of dense sensory or motor block and unnecessary sensory blockade of areas remote to the surgical site allows full assessment of the child and may prevent any delay in diagnosis of compartment syndrome. Focusing on excluding the diagnosis of compartment syndrome rather than failure of analgesic modality is vital. In the pediatric cases reviewed there was no clear evidence that the presence of an epidural had delayed the diagnosis.     

The treatment of ulnar impaction syndrome: a systematic review of the literature

Ulnar impaction syndrome is a common cause of ulnar-sided wrist pain that is thought to be a result of abutment between the ulna and the ulnar carpus. A systematic review of the literature was conducted to determine the effectiveness of different treatment options in managing ulnar impaction syndrome. PubMed, the Cochrane database, and secondary references were reviewed to identify all English-language articles with reported results on the treatment of ulnar impaction syndrome. A total of 16 articles met the criteria for review. Three procedures were identified as the most commonly used in treating this syndrome: ulnar shortening osteotomy, the wafer procedure, and the arthroscopic wafer procedure. Mean time to union and percentage nonunion for the osteotomy group was 10.3 weeks and 1.7%, respectively. The overall complication rate for patients in the ulnar shortening osteotomy group, the wafer procedure group, and the arthroscopic wafer group was 30%, 8.8%, and 21%, respectively. The authors were unable to determine a single best treatment option based on the available studies, mainly due to the variability in the reporting of subjective outcome measures. Ulnar shortening osteotomy was associated with a higher complication rate than other procedures.     

Concomitant compression of median and ulnar nerves in a hemophiliac patient: a case report

A 15-year-old boy, with a diagnosis of hemophilia A, suffered bleeding into his left forearm 5 months before being admitted to our medical center. His neurological examination revealed a pronounced median neuropathy and a minor ulnar neuropathy on the left side. There was marked muscle atrophy on the thenar side and, to a lesser degree, on the hypothenar side and in the forearm. Electromyographic findings demonstrated an evident, nearly complete, sensorimotor axonal loss in the median nerve. Magnetic resonance imaging studies showed atrophy in muscles of the left forearm and median nerve. The patient was diagnosed as having median nerve axonotmesis and ulnar nerve neuropraxia due to compartment syndrome. In hemophiliac patients, frequent single nerve compressions (often involving the femoral nerve) can be seen. However, concomitant median and ulnar nerve injuries with differing severity are rare.     

Evolving compartment syndrome not masked by a continuous peripheral nerve block: evidence-based case management

Compartment syndrome is a potentially devastating complication of many orthopedic surgeries. Whether regional anesthesia can delay the diagnosis of compartment syndrome remains a subject of debate. Previous case reports have described compartment syndrome primarily in the setting of an epidural infusion, but also following single-injection peripheral nerve blocks. A case of evolving compartment syndrome in an ambulatory setting that was not masked by a continuous peripheral nerve block is presented, followed by a discussion of the literature pertaining specifically to peripheral nerve blockade and the diagnosis of compartment syndrome. Diagnosis depends on close postoperative monitoring of analgesic use and pain trends, and patients with ambulatory catheters require thorough education about compartment syndrome so they can be evaluated in a timely manner. The current literature on compartment syndrome diagnosis and regional anesthesia is limited to case reports and expert opinion, making evidence-based recommendations difficult.     

An exercise-induced compartment syndrome of the dorsal forearm--a case report

A 46-year-old male patient experienced extreme pain in the dorsal forearm after strenuous work. He had the classical physical findings of compartment syndrome and elevation of compartment pressure of 45 mm by direct measurement. A decompressive fasciotomy of the dorsal musculature provided total relief of pain, and subsequently full recovery of all function occurred.     

The elbow flexion test. A clinical test for the cubital tunnel syndrome

The elbow flexion test is a little known, inadequately standardized, and poorly understood clinical test for the cubital tunnel syndrome. To evaluate and define this test, 13 patients with clinical and electrophysiologic evidence of cubital tunnel syndrome were tested with elbow flexion in a standardized manner. This consisted of full elbow flexion with full extension of the wrists for three minutes. All patients noted the onset of or the increase in one or more of the symptoms of pain, numbness, or tingling with this test. Numbness and tingling followed the sensory distribution of the ulnar nerve, but pain was not limited to the ulnar nerve distribution. The symptom complex, rapid onset, and rapid resolution of symptoms support a locally induced segmental ulnar nerve ischemia as the cause of symptoms. This study demonstrates the elbow flexion test to be a useful, reliable, and provocative test for the cubital tunnel syndrome.     

Chronic compartment syndrome: diagnosis and management.

Young people active in sports, especially cyclists, runners and soccer players, may develop a chronic compartment syndrome, typically after a few years of athletic involvement. Complaints frequently appear when the intensity or frequency of training is increased. It is remarkable that runners develop mainly an anterior compartment syndrome, whereas soccer players and cyclists suffer mostly from a deep posterior compartment syndrome. The chief complaint is a cramp-like pain and weakness in the lower leg during effort. A compartmental tissue-pressure measurement must be performed to evaluate the severity of the compartment syndrome and to determine which compartments are involved. A clear clinical history and abnormal values of tissue-pressure measurements are indicative for a fascial release of the involved compartments and help assure a satisfactory result after surgery.     

Supracondylar humeral fractures in children

Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion. Medial comminution is a subtle finding that, if treated nonoperatively, is likely to lead to unacceptable varus malunion. Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the vascular problem. A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of compartment syndrome. Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.     

The ulnar impaction syndrome

The ulnar impaction syndrome can be defined as the impaction of the ulnar head against the triangular fibrocartilage complex and ulnar carpus resulting in progressive degeneration of those structures. The differential diagnosis in patients who present with ulnar wrist pain and limitation of motion can also include ulnar impingement syndrome and arthrosis or incongruity of the distal radioulnar joint. Structural abnormalities involving the distal radioulnar joint, distal radius, and ulnar carpus must be carefully elucidated prior to developing a treatment plan. When such abnormalities are identified and appropriately addressed, surgical treatment can be expected to be effective in the majority of cases. It is important to remember that in the absence of obvious structural abnormalities, the ulnar impaction syndrome may result from daily activities that result in excessive intermittent loading of the ulnar carpus. In this group of patients, treatment is directed at decreasing ulnar load by shortening the distal ulna in any of several ways. If relative instability of the ulnar ligamentous complex is a factor, then ulnar shortening by recession is the treatment of choice. Malunion of the distal radius resulting in ulnar impaction syndrome is best treated by addressing the deformity; that is, corrective radial osteotomy. Patients who present with a combination of ulnar impaction syndrome along with distal radioulnar joint, abnormalities must have both of these abnormalities addressed at the time of surgery. The matched ulnar resection and the hemiresection interposition arthroplasty are both effective procedures; however, the Suave-Kapandji procedure also can be used to address relative ligamentous laxity at the ulnar aspect of the wrist. The Darrach procedure is presently not recommended as a first-line treatment in these cases; however, when used as a salvage procedure, satisfactory results can be obtained in properly selected patients. Careful preoperative evaluation and planning are therefore the key to successful treatment of the ulnar impaction syndrome.