Magnetresonanztomographische Beurteilung des Unterschenkels bei Zustand nach Kompartmentsyndrom

For the purpose of follow-up of the disease as well as the availability of magnetic resonance imaging (MRI) as a method for diagnosing soft tissue changes 20 patients with imminent and manifest compartment syndrome were examined for their fluid content of the lower limb. Considering the normal side as well as 10 healthy volunteers a significant reduction of fluid content was diagnosed in the manifest compartment syndrome after fasciotomy in the late phase of disease (r=0.49, p>0.005, n=29). This was interpreted as a sign of fibrosis. The patients with imminent compartment syndrome and fasciotomy (r=0.83, p>0.001, n=19) demonstrated no significant changes compared to the normal volunteers (r=0.91, p>0.001, n=40) as well as the normal compartments of the diseased lower extremities (r=0.85, p>0.001, n=32). MRI is a useful method in the examination of soft tissue changes and underlines the importance of an early fasciotomy in case of imminent compartment syndrome.     

Compartment syndrome in popliteal artery injury

Between 1973 and 1988 50 patients with injuries of the popliteal artery were treated at the Medical School of Hannover University. While 26 patients with dislocations of the knee joint had mild soft tissue injuries, most of the 24 patients with periarticular fractures of the tibia and/or femur showed excessive soft tissue damage. In both groups 11 patients who were admitted with prolonged ischemia had to undergo amputations. Primary amputations were performed according to the recommendations of. The mean duration of ischemia was 5.5 h (range 2.2-9 h) in patients with knee dislocations (n = 21); fasciotomy was performed in 14 patients (67%). In patients with popliteal artery injuries combined with fractures (n = 18) the average duration of ischemia was 6.5 h (3-13.5 h); in 16 cases in this group (89%) fasciotomy had to be performed. Fasciotomy was always necessary in patients with combined injuries of the popliteal vein and artery. Moreover, all patients with ischemia of more than 6 h duration required fasciotomy. It can be concluded that fasciotomy will probably be necessary in patients with injuries of the popliteal artery and (a) severe soft tissue damage of the thigh and/or lower leg with compartment pressure of more than 30 mmHg; (b) ischemia of more than 6 h duration; (c) combined injuries of the popliteal vein and artery; (d) reconstruction of severely injured extremities. In general, fasciotomy should always be considered after reconstruction of the popliteal artery.     

Management of chronic exertional anterior compartment syndrome of the lower extremity

Eighteen patients (28 compartments) with chronic exertional compartment syndrome and 14 normal asymptomatic volunteers (18 compartments) were studied. Evaluation included clinical assessment followed by quantitative determination of intracompartmental pressures as monitored by wick or slit catheters before and after exercise. Intramuscular pressures measuring greater than or equal to 10 mmHg at rest and/or greater than or equal to 25 mmHg five minutes after exercise were defined as abnormally elevated. The patients with chronic compartment syndrome described reproducible exertional anterolateral leg pain, and 39% of these patients had a fascial hernia. Such a defect was present in less than five percent of the normal volunteers. Nonsurgical treatment was selected by five patients and all five reported persistent inability to participate in athletics because of their exertional pain. Of the remaining 13 patients, 12 were treated by decompressive fasciotomy and 11 of the 12 (92%) had pain relief and increased exercise tolerance. A single patient had had fascial closure instead of fasciotomy, and this procedure produced an acute compartment syndrome. Effective treatment of the chronic compartment syndrome consists of reduction of exertional activities or surgical decompression by fasciotomy.     

Das traumatisch bedingte Kompartmentsyndrom des Unterschenkels

Zusammenfassung Um den Stellenwert der Sonographie als Methode der Diagnostik von Sp?tsch?den der Muskulatur nach operativ behandeltem Kompartmentsyndrom zu prüfen, wurden 27 Patienten (sechs Frauen, 21 M?nner) der Abteilung für Unfallchirurgie des Universit?tsklinikums Essen am ventralen Unterschenkel nach durchschnittlich 98 Monaten (43 bis 154 Monate) nach dem Trauma standardisiert untersucht und ein Vergleich mit der gesunden Gegenseite durchgeführt. Bei 15 Patienten war die Dermatofasziotomie wegen eines drohenden und bei zw?lf Patienten wegen eines manifesten Kompartmentsyndroms erfolgt. Im Vergleich zur gesunden Gegenseite konnte eine qualitative Gradeinteilung (0 bis 3) der Ver?nderungen erstellt werden, die das Ausma? der Echogenit?tsvermehrung sowie des Verlustes der muskeltypischen Textur wiedergibt. Grauwerthistogramme konnten die qualitative Einteilung best?tigen. Die Gruppe mit manifestem Kompartmentsyndrom zeigte ausschlie?lich deutliche und massive Ver?nderungen (Grad 2 und 3). Bei drohendem Kompartmentsyndrome fand sich zweimal Grad 2 und 13mal Grad 0 oder 1. Die sonographischen Ver?nderungen sind erkl?rbar durch die bekannten pathomorphologischen Zust?nde nach Kompartmentsyndrom der Muskulatur (Denervierung, Vernarbung). Die Sonographie eignet sich zur Beurteilung der Weichteile nach Kompartmentsyndrom. Die Ergebnisse unterstützen die Forderung nach einer frühzeitigen Fasziotomie bei drohendem Kompartmentsyndrom zur Pr?vention vor Muskel- und Nervensch?digungen.

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Traumatic compartment syndrome of the lower limb: Significance of ultrasonography in evaluating long-term damage of muscle after dermatofasciotomy

To determine the significance of sonography in evaluating long-term damage of muscle surgically treated for compartment syndrome 27 patients of the Department for Trauma Surgery, University Clinic Essen, Germany, were examined on their anterior lower limb after an average of 98 (43 to 154) months after trauma. They had had a fasciotomy for imminent (n=15) or manifest (n=12) compartment syndrome. Comparing the healthy side a qualitative grading (0 to 3) of the changes could be introduced reflecting the extent of the increase in echogenicity and the loss of the typical muscle texture. Gray scale histograms confirmed the qualitative grading. Patients with manifest compartment syndrome showed severe changes (grade 2 and 3). In imminent compartment syndrome 2 patients with grade 2 and 13 patients with grade 0 or 1 were found. The sonographical changes can be explained by the known pathomorphological changes after compartment syndrome (denervation, scarification). Sonography is useful in the evaluation of soft tissue after compartment syndrome. The results underline the demands of early fasciotomy in imminent compartment syndrome for prevention of damage of muscle and nerve.

     

Long-term physical outcome of patients who suffered crush syndrome after the 1995 Hanshin-Awaji earthquake: prognostic indicators in retrospect.

BACKGROUND: The 372 cases of crush syndrome that followed the 1995 Hanshin-Awaji earthquake have provided a unique opportunity to investigate the long-term physical outcomes and to establish indications for specific treatments in such patients. The objectives of this study were to identify independent predictors of physical outcome in patients suffering from crush syndrome and to clarify the influence of fasciotomy on outcomes. METHODS: Sensory and motor functions were examined 2 years after the earthquake in 42 patients with a total of 58 compressed lower extremities. The influences of time to rescue, fasciotomy, and radical debridement on lower leg muscle strength were evaluated by stepwise regression analysis. Correlation between the time to fasciotomy and lower leg muscle strength was also analyzed. RESULTS: Severe disabilities related to the lower leg compartment were present in 47% (8/17) of patients who underwent fasciotomy and in 16% (4/25) of patients who did not. The anterior compartment was damaged more severely than the posterior compartment. Severe sensory and motor disturbances occurred at a higher rate in relation to anterior and posterior compartments that were treated by fasciotomy than in relation to those that were not. Stepwise regression analysis showed fasciotomy/debridement score to be an independent predictor of long-term lower leg muscle strength (R = 0.67, p < 0.0001) and showed time to rescue to be an independent predictor when debrided compartments were not included in the analysis (R = 0.36, p = 0.009). In all debrided anterior compartments, muscle contractility was completely abolished. There was a significant negative correlation between time to fasciotomy and lower leg muscle strength. CONCLUSION: Secondary compartment syndrome affects physical outcome in crush syndrome patients. We obtained no evidence that fasciotomy improves outcome. Delayed rescue, delayed fasciotomy, and radical debridement may worsen the physical prognosis. Indications for fasciotomy in crush syndrome during the acute phase need further deliberation.     

Compartment Syndrome of the Lower Leg and Foot

Compartment syndrome of the lower leg or foot, a severe complication with a low incidence, is mostly caused by high-energy deceleration trauma. The diagnosis is based on clinical examination and intracompartmental pressure measurement. The most sensitive clinical symptom of compartment syndrome is severe pain. Clinical findings must be documented carefully. A fasciotomy should be performed when the difference between compartment pressure and diastolic blood pressure is less than 30 mm Hg or when clinical symptoms are obvious. Once the diagnosis is made, immediate fasciotomy of all compartments is required. Fasciotomy of the lower leg can be performed either by one lateral incision or by medial and lateral incisions. The compartment syndrome of the foot requires thorough examination of all compartments with special focus on the calcaneal compartment. Depending on the injury, clinical examination, and compartment pressure, fasciotomy is recommended via a dorsal and/or medial plantar approach. Surgical management does not eliminate the risk of developing nerve and muscle dysfunction. When left untreated, poor outcomes with contractures, toe deformities, paralysis, and sensory neuropathy can be expected. In severe cases, amputation may be necessary.     

Vacuum-assisted closure for fasciotomy wounds following compartment syndrome of the leg

This study evaluated the efficacy of vacuum-assisted closure (VAC) for treatment of fasciotomy wounds for traumatic compartment syndrome. The authors reviewed the records of a consecutive series of 34 patients who had compartment syndrome of the leg requiring the standard two-incision release of all four compartments and received the application of VAC therapy until the time of definitive wound closure or coverage. A matched series of 34 consecutive antecedent patients with the same entry criteria, except for the use of the VAC, were also studied and served as a control group. The main parameter of interest was the time to "definitive closure" (delayed primary closure with sutures or skin graft coverage) of the wounds. Of the 68 wounds in 34 patients managed with VAC, the average time to definitive closure for both the lateral and the medial wounds was 6.7 days. For the 70 wounds in the 34 control patients, the average time to definitive closure was 16.1 days. This difference in time to wound closure between the VAC group and the non-VAC group was statistically significant (p < .05). Subatmospheric treatment for compartment syndrome of the leg after fasciotomy theoretically helps to speed the resolution of the swelling and tissue edema that are often components of this clinical entity. Experimental work has shown vacuum-assisted wound management to be effective in hastening the resolution of wound edema, enhancing local blood flow, promoting granulation tissue, and thwarting bacterial colonization. These factors may account for its utility in the management of fasciotomy wounds in the setting of compartment syndrome of the leg.     

Compartment syndrome. Principles of therapy

Compartment syndrome can be classed as imminent, with moderate disturbances of muscular perfusion, no neurological symptoms and increasing tissue pressure, and manifest, with compromised circulation and loss of tissue function in the space and pathologic tissue pressure. When compartment syndrome is suspected, the most important immediate measure is wide splitting of any constricting dressings that have been applied. For decompression, the only adequate therapy, in imminent compartment syndrome, subcutaneous fasciotomy is required. The skin incision can be closed. Manifest compartment syndrome necessitates therapeutic fasciotomy, which means long incisions of skin and fascia, splitting of retinacula, excision of necrotic tissues, evacuation of hematoma and, if possible, rigid fixation of fractures. Skin closure is not permitted because of postoperative swelling, which can produce a rebound compartment syndrome. After 4-8 days edema decreases and the wound is closed by delayed sutures or a mesh graft. In the same session a second look operation for re-debridement of the tissues is done. Special problems arise in complex lesions of the foot, because of the thin layer of soft tissue coverage and the diminished blood supply to the bones of the foot. In the foot, decompression requires not only that the compartments of the short pedal muscles be opened, but also that the skin be adequately released.     

Syndromes des loges

The hallmark of any compartment syndrome, whether acute or chronic, is the elevation of soft tissue pressure within a closed space even if the primary event was different. Acute cases are most often trauma-related and can lead to irreversible neuromuscular dysfunction. They require immediate dermofasciotomy to decompress the soft tissue and avoid ischemia. The diagnosis should rely on physical examination and be confirmed by tissue pressure measurement. If not treated in time, they can result in major sequelae and even amputation. Chronic compartment syndromes are mostly exercise-induced and then mainly related to sport practice. Pressure measurements during provocative test are required to ascertain that exercise-related pain is due to a compartment syndrome. Percutaneous fasciotomy is necessary to alleviate symptoms.     

Compartment Syndrome of the Arm After Cable-Wakeboard Accident

Abstract   A compartment syndrome is an increased tissue pressure within a closed osteofascial compartment. This compromises blood flow to the muscles and nerves within that compartment, which –if not treated adequately in an early stage-results in permanent tissue and nerve damage. It most frequently occurs in the lower leg, but can also occur elsewhere when muscles are enclosed in tight fascial compartments, such as the forearm and hand. In this report a patient is described who developed an acute compartment syndrome of the arm after a cable-wakeboard accident in which his arm was strangulated. Cable-wakeboarding is an extreme sport that has become very popular over the last years. Early recognition and treatment of an acute compartment syndrome is of extreme importance since in short term necrotic muscles can lead to severe irreversible complications. Accidents with cable-wakeboarding often occur during the start. This is caused by the strong forces that are on the cable during the start. Strangulation injuries of the arm can cause a compartment syndrome of the arm. Possibly a wet-suit or dry-suit offers some protection. However, the duration of strangulation determines much of the damage. Although diagnosis of a compartment syndrome can be difficult, a high index of suspicion combined with fast and adequate treatment with a fasciotomy improve outcome and prognosis.     

Compartment syndrome in open tibial fractures

A retrospective review of the cases of 180 patients who had 198 acute open fractures of the tibial shaft and were admitted to a multiple-trauma referral center over a three-year period revealed an incidence of accompanying compartment syndrome of 9.1 per cent (eighteen fractures in sixteen patients). Each of the eighteen compartment syndromes was documented by measurements of intracompartmental pressure that were obtained by the saline-injection technique, and all were treated by four-compartment fasciotomy. The incidence of compartment syndrome was found to be directly proportional to the degree of injury to soft tissue and bone; this complication occurred most often in association with a comminuted, grade-III open injury to a pedestrian. The physician must maintain a high index of suspicion to detect a compartment syndrome in the patient who has multiple trauma, as its clinical signs and symptoms may be masked by a closed injury of the head or the need for ventilatory support or prolonged anesthesia for other surgical procedures.     

One-portal technique of endoscopic fasciotomy: Chronic compartment syndrome of the lower leg

Many athletes complain of exercise-induced pain in the lower leg that can be caused by inflammatory diseases, peripheral nervous system disease, fatigue fracture, shin splint, and chronic compartment syndrome (CCS). CCS is the most typical exercise-induced condition and it often requires surgical decompression of the several compartments. There are already many techniques reported in the literature. Recently, an endoscopic technique for CCS was reported with which excellent results were achieved. We have modified it and developed a new technique for treating CCS of the lower leg. We report a case of CCS of the lower leg treated with 1-portal endoscopic fasciotomy. The technique helps to decrease damage to soft tissue and patients will immediately return to normal activities of daily living.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 8 (October), 2001: E33     

Minimally invasive subcutaneous fasciotomy for chronic exertional compartment syndrome of the lower extremity

Chronic exertional compartment syndrome of the lower extremity can be debilitating in the active population. Open fasciotomy typically provides a cure or significant improvement in up to 90% of patients, provided that the compartments are adequately released. Cosmetic deformity from the surgery may be a major concern, especially in the young female athlete. A technique for minimally invasive subcutaneous fasciotomy is described that allows adequate compartment release and a favorable cosmetic result.     

Early fasciotomy for acute clinically evident posttraumatic compartment syndrome

Our understanding of the effectiveness of early decompressive fasciotomy for acute posttraumatic compartment syndrome is incomplete. Thirty-two patients who developed acute clinically evident compartment syndrome (23 in the leg, 9 in the forearm) were treated with decompressive fasciotomy an average of 16 hours after injury. Thirty patients (94 percent) underwent fasciotomy in conjunction with other urgent operative procedures mandated by concomitant injuries. Three patients required early amputation for a failed arterial repair. Only 2 of 29 patients with limb salvage (7 percent) had postoperative myoneural deficits after decompressive fasciotomy. Both of these patients had preoperative myoneural deficits. Decompressive fasciotomy before the development of ischemic myoneural deficits prevents the ischemic sequelae of acute clinically evident compartment syndrome.     

Management of compartment syndromes of the foot.

Twelve patients with isolated extremity injuries had 14 compartment syndromes of the feet. An interstitial pressure of more than 30 mm of mercury in either the central or interosseous compartment was considered pathologic and was treated by fasciotomy, performed dorsally in nine feet and medially in five. Open reduction of fractures amenable to internal fixation (eight tarsometatarsal, three calcaneus, and one metatarsal) was performed after completion of the fasciotomies. The fasciotomy wounds were covered by primary split-thickness skin excision (three), delayed split-thickness skin grafting (eight), and delayed primary wound closure (three). Patients were evaluated at a mean of 22 months (range, 17-36 months) after injury, and the examination was directed specifically toward symptoms and signs of myoneural ischemia. Absolute compartment pressure measurements are more accurate than clinical findings in the diagnosis of a compartment syndrome of the foot. Fasciotomy may be performed medially or dorsally, depending on the configuration of the pattern of fracture or dislocation. To ensure satisfactory results, all compartments should be decompressed, and the pressures remeasured after the completion of fasciotomy.     

Changes in tibial venous blood flow in the evolving compartment syndrome

A sustained increase in muscle compartment pressures can cause tissue necrosis. When compartment pressures exceed recumbent tibial vein pressures, blood flow in tibial veins may be impaired. These changes can be detected by Doppler venous flow evaluation. In 26 patients at risk for compartment syndrome, serial examinations, Doppler venous flow, and measurements of compartment pressures were performed. All patients with abnormal Doppler venous flow results had or developed neuromuscular deficits. Patients with normal Doppler venous flow either initially or after fasciotomy did not develop the compartment syndrome. This syndrome can be evaluated and followed up sequentially by measuring Doppler venous flow in tibial veins.     

Acute lumbar paraspinal compartment syndrome: a systematic review

While still a rare entity, acute lumbar paraspinal compartment syndrome has an increasing incidence. Similar to other compartment syndromes, acute lumbar paraspinal compartment syndrome is defined by raised pressure within a closed fibro‐osseous space, limiting tissue perfusion within that space. The resultant tissue ischaemia presents as acute pain, and if left untreated, it may result in permanent tissue damage. A literature search of ‘paraspinal compartment syndrome’ revealed 21 articles. The details from a case encountered by the authors are also included. A common data set was extracted, focusing on demographics, aetiology, clinical features, management and outcomes. There are 23 reported cases of acute compartment syndrome. These are typically caused by weight‐lifting exercises, but may also result from other exercises, direct trauma or non‐spinal surgery. Pain, tenderness and paraspinal paraesthesia are key clinical findings. Serum creatine kinase, magnetic resonance imaging and intracompartment pressure measurement confirm the diagnosis. Half of the reported cases have been managed with surgical fasciotomy, and these patients have all had good outcomes relative to those managed with conservative measures with or without hyperbaric oxygen therapy. These good outcomes were despite significant delays to operative intervention. The diagnostic uncertainty and subsequent delay to fasciotomy result from the rarity of this disease entity, and a high level of suspicion is recommended in the appropriate setting. This is particularly true in light of the current popularity of extreme weight lifting in non‐professional athletes. Operative intervention is strongly recommended in all cases based on the available evidence.     

Compartment pressures, limb length changes and the ideal spherical shape: a case report and in vitro study

BACKGROUND: Changes in compartment pressures have been noted during traction, reduction, and intramedullary fixation of fractures. Changes in limb length and compartment volumes are suspected contributing factors. Pressure and volume changes are known to be related in animal models. If an acute increase in limb length can adversely affect compartment pressures, reversal or delay of such an increase in length may be of value in the treatment and prevention of compartment syndromes. METHODS: A clinical example is presented in which a documented anterior compartment syndrome was successfully treated by deliberate loss of fracture reduction, without fasciotomy. Fracture reduction was later restored when swelling subsided. Anterior compartment pressures were recorded in response to limb length changes in osteotomized cadaver limbs stabilized with external fixation. RESULTS: The pressure in the anterior compartment varies directly with acute changes in the length of the leg, in an experimental model. Mathematical analysis indicates that available volume within a compartment varies inversely with acute changes in its length. CONCLUSIONS: Fracture reduction that restores the length of an acutely injured extremity may increase pressure in the compartments by decreasing available volume. Deliberate loss of reduction can decrease pressure in the compartments, offering a potential alternative to fasciotomy in the care of compartment syndrome in cautiously selected, monitored patients. Early stabilization without reduction, followed by delayed reduction, may be preferable during treatment of fractures prone to compartment syndrome. Decreased available compartment volume may contribute to compartment syndrome after distraction with intramedullary rods or skeletal traction.     

The use of near-infrared spectrometry for the diagnosis of lower-extremity compartment syndrome

While intracompartmental pressure monitoring is a widely used diagnostic tool to measure intracompartmental pressures in the setting of compartment syndrome, its invasive nature has prompted the development of noninvasive techniques, such as near-infrared spectrometry. We prospectively assessed the association between tissue oxygen saturation measured by near-infrared spectrometry and compartment pressure measured by intracompartmental pressure monitoring in a cohort of patients with compartment syndrome of the lower extremity. We hypothesized that tissue oxygen saturation measured by near-infrared spectrometry would negatively correlate with intracompartmental pressures. Tissue oxygen saturation was determined for all 4 compartments of the lower extremity in 7 patients using near-infrared spectrometry. All patients subsequently underwent lower-extremity fasciotomies. Mechanism of injury, compartment pressures, blood pressure, near-infrared spectrometry measurement of tissue oxygen saturation, and characteristics of the muscle at the time of fasciotomy were recorded. The strength of the correlations between tissue oxygen saturation and absolute and relative compartment pressures was estimated based on mixed linear (growth) models with repeated observations nested within patients. Our analyses demonstrated no significant relationship between tissue oxygen saturation measured by near-infrared spectrometry and the absolute or relative compartment pressures. This suggests that compartment tissue oxygen saturation measurements by near-infrared spectrometry do not correlate with the diagnosis of compartment syndrome, and that near-infrared spectrometry would not serve as a reliable diagnostic tool.