Acute compartment syndrome

Compartment syndrome can occur in any myofascial muscle compartment. If left untreated it can lead to ischaemic contractures and severe disabilities. A high index of suspicion is required in at risk cases. Compartment pressure monitoring is a useful adjunct in the diagnosis of raised compartment pressure especially when clinical assessment is difficult. The key to a successful outcome is early diagnosis and decompression of affected compartments.     

Modified mini-open technique with skin transillumination for decompression fasciotomy in the treatment of chronic exertional compartment syndrome

Fasciotomy for chronic exertional compartment syndrome can be achieved by a variety of methods, many of which involve the blind passage of scissors or a fasciotome to release the affected compartments. We describe a modified open technique of fasciotomy which provides direct visualization of the fascia and the superficial peroneal nerve, using a single small incision. This technique requires a 4-cm longitudinal incision centered at the midpoint of the fibula. Subcutaneous tissues are dissected and a fascial incision is made. Langenbach retractors are used to lift the skin from either end of the wound. A light is used to transilluminate the skin proximal and then distal to the wound, and a fasciotome is used to extend the fasciotomies for both anterior and lateral compartments. Fasciotomy using this method was carried out on 20 cadaveric legs from 10 specimens. After decompression, a fulllength skin incision was made and the subcutaneous tissues were dissected to assess adequacy of release, anatomic course of the superficial peroneal nerve and complications. Fasciotomy was completed in twenty legs for both the anterior and lateral compartments. A complete fascial release was attained for both compartments in all legs. There were no retained fascial bands or nerve injuries. Fasciotomy using this method may be a safe and reliable method for compartment decompression, and may reduce iatrogenic risk to neurovascular and muscular structures in clinical practice.     

Useful technique using negative pressure wound therapy on postoperative lower leg open wounds with compartment syndrome

BackgroundCompartment syndrome (CS) of the lower leg in need of a fasciotomy for quick decompression and closure of the wound remains an issue. We report positive outcomes from combining two methods, the shoelace technique and negative pressure wound therapy (NPWT) together, to address this problem.Patients and methodsFive patients were diagnosed with the lower leg CS and underwent surgery. The wounds were treated by combining the shoelace technique and V.A.C.^® Therapy, and the wounds’ shoelaces were gradually tightened.ResultsEight emergency fasciotomies were performed in five patients with CS. The mean time to wound closure by suturing was 16.2 days and additional skin grafting was performed in only one case.ConclusionThe use of this combination of treatments may prevent the need to use a skin graft, which has problems providing pleasing aesthetic results.     

Opioid-related compartment syndrome and associated morbidity

IntroductionOpioid-related compartment syndrome (ORCS) is an understudied complication related to opioid overdose. We hypothesized that ORCS would be associated with worse clinical outcomes, including higher amputation rates, need for multiple surgical procedures, and rhabdomyolysis on admission, compared with nonopioid-related compartment syndrome (NORCS).MethodsWe used Current Procedural Terminology codes for fasciotomy as a proxy marker for cases of compartment syndrome treated at 1 health system from January 1, 2016, to December 21, 2018. We excluded patients younger than 18 years, those treated for exertional compartment syndrome, and those who underwent elective fasciotomies. Seventy-four patients met our inclusion criteria. Data reviewed included patient characteristics, cause of compartment syndrome, time until evaluation for compartment syndrome, peak creatinine kinase levels, number of surgical procedures required, duration of hospital stay, and postoperative inpatient morbidity and death. Patients were categorized as having ORCS (n = 8) or NORCS (n = 66). Alpha = .05.ResultsAll cases of ORCS occurred in men. Opioid use was the third most common cause of compartment syndrome. Two patients underwent amputation, both in the ORCS group (p < 0.01). The median number of debridements was significantly higher for the ORCS group (median, 4; interquartile range [IQR]: 3–6) than for the NORCS group (median, 3; IQR 2–4) (p = 0.03). Duration of hospital stay was longer for the ORCS group (median, 27 days; IQR 16–38) compared with the NORCS group (median, 9 days; IQR: 5–13) (p < 0.001). Mean (± standard deviation) peak creatinine kinase level was significantly higher in the ORCS group (224,000 ± 225,052 U/L) compared with the NORCS group (7550 ± 32,500) (p < 0.001). The proportion of patients who underwent hemodialysis was higher in the ORCS group (88%) than in the NORCS group (35%) (p < 0.001). All ORCS patients presented >8 h after immobilization in a dependent position.ConclusionPatients in the ORCS group had delayed presentations and significantly more morbidity compared with patients in the NORCS group.     

Endoscopic fasciotomy for chronic exertional compartment syndrome of the forearm: Systematic review of outcomes and complications

BACKGROUNDEndoscopic fasciotomy of the forearm for chronic exertional compartment syndrome (CECS) has gained popularity recently.AIMTo systematically review the literature of endoscopic fasciotomy for CECS of the forearm, aiming to assess the outcomes and complications of the different endoscopic fasciotomy techniques described in the literature.METHODSOn January 18, 2021, PubMed and EMBASE were searched by 3 reviewers independently, and all relevant studies published up to that date were considered based on predetermined inclusion/exclusion criteria. The subject headings “endoscopic fasciotomy” and “compartment syndrome” and their related key terms were used. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles.RESULTSA total of seven studies including 183 patients (355 forearms) were included. The mean age of the patients was 31.2 years (range: 15-42 years). The postoperative follow-up duration ranged from 6 wk to 4.9 years. All patients were able to return to sport activities between postoperative weeks 1 to 8. Recurrence of the compartment syndrome occurred in three patients, giving a rate of 1.6% per patient and 0.8% per forearm. The overall complication rate was 8.7% per patient, and 4.5% per forearm. The most common reported complication was hematoma (7 forearms; 2.0%).CONCLUSIONEndoscopic fasciotomy for CECS of the forearm has favorable short- and mid-term outcomes with very low recurrence and complication rates. This, however, needs to be confirmed in larger, long-term follow-up, prospective, comparative studies between open, mini-open and endoscopic fasciotomy techniques.     

Continuous compartment pressure monitoring vs. clinical monitoring in tibial diaphyseal fractures

A cohort of 109 consecutive patients with a tibial fracture who underwent continuous compartment pressure monitoring of the anterior compartment of the leg were reviewed and compared to a historical control group of the immediate previous 109 patients who were clinically monitored. Of these patients 33 underwent fasciotomies for acute compartment syndrome in association with tibial diaphyseal fractures. Seventeen patients had continuous compartment pressure monitoring and 16 clinical assessments alone. The fasciotomy rate of patients who underwent continuous compartment pressure monitoring was 15.6%. Patients who were not monitored had a fasciotomy rate of 14.7%. The mean time delay from injury to fasciotomy was 22h in the monitored group and 23h in the non-monitored group. Continuous compartment pressure monitoring did not increase the rate of unnecessary fasciotomies. We could not demonstrate a significant difference in terms of clinical outcome and time delay from injury to fasciotomy.     

Spontaneous bilateral compartment syndrome of the legs: A case report and review of the literature

INTRODUCTIONBilateral acute compartment syndrome of the legs is a rare presentation requiring emergent surgical intervention.PRESENTATION OF CASEWe report the case of 41-year-old woman who presented with acute bilateral compartment syndrome of the legs, complicated by rhabdomyolysis and acute renal failure.DISCUSSIONThere are very few previously reported cases of bilateral compartment syndrome of the legs. In the present case, despite any clear causative factor, we suggest that the aetiology is related to inadvertent posture during sleep.CONCLUSIONThe diagnosis of acute bilateral compartment syndrome of the legs requires a high index of suspicion, particularly in the absence of obvious aetiology. A successful outcome can be achieved with early diagnosis, prompt surgical intervention and a multidisciplinary approach.     

Isolated medial foot compartment syndrome after ankle sprain

Foot compartment syndrome is a serious potential complication of foot crush injury, fractures, surgery, and vascular injury. An acute compartment syndrome isolated to the medial compartment of the foot after suffering an ankle sprain is a rare complication.We report the case of a 31-year-old man who developed a medial foot compartment syndrome after suffering a deltoid ligament rupture at ankle while playing football. The patient underwent a medial compartment fasciotomy with resolution of symptoms.Compartment syndromes of the foot are rare and have been reported to occur after severe trauma. But, there are some reports in the literature of acute exertional compartment syndrome. In our case, the compartment syndrome appeared after an ankle sprain without vascular injuries associated.     

Acute compartment syndrome of the limb

In this review the aetiology, clinical signs, diagnosis and therapy of the acute compartment syndrome of the limb is discussed. It is a limb- and untreated life threatening emergency. For good results, early detection is necessary. It is important to educate those taking care of patients of risk, especially in the early symptoms and signs. In uncooperative, unconscious and sedated patients pressure monitoring is recommended. The critical level of the absolute intracompartmental pressure is unclear. It is recommended to use a delta p pressure of 30 mm Hg. Below this pressure in the presence of clinical signs a fasciotomy of all compartments is the treatment of choice.     

Exercise Induced Chronic Compartment Syndrome of the First Dorsal Interosseous Compartment of the Hand: A Case Report

Exercise-induced chronic compartment syndrome in the first dorsal compartment is an uncommon entity and relatively rare condition which is not very well understood. It is a usually activity-related condition and is associated with decreased function of muscle with intracompartmental swelling. We present a case with proven exercise-induced raised compartment pressure that responded well to surgical fasciotomy.     

Acute compartment syndrome of the upper extremity in children: diagnosis, management, and outcomes

Purpose

Acute compartment syndrome (ACS) of the upper extremity is a rare but serious condition. The purpose of this study was to determine the etiology, diagnosis, treatment, and outcome of ACS of the upper extremity in a pediatric population.

Methods

We performed a retrospective chart review of all patients who underwent a decompressive fasciotomy for ACS of the upper extremity. Data collected included demographics, injury details, presenting symptoms, compartment measurements, time to diagnosis, time to treatment, and outcomes at the latest follow-up.

Results

Twenty-three children underwent fasciotomies for ACS of the forearm (15) and hand (8), at an average age of 9.3 years (range 0–17.8 years). The most common etiologies were fracture (13) and intravenous (IV) infiltration (3). The most common presenting symptoms were pain (83 %) and swelling (65 %). Compartment pressures were measured in 17/23 patients, and all but two patients had at least one compartment with a pressure >30 mmHg. The final two patients were diagnosed and treated for ACS based on clinical signs and symptoms. The average time from injury to fasciotomy was 32.8 h (3.7–158.0 h). Long-term outcome was excellent for 17 patients (74 %) and fair for 5 (22 %), based on the presence of loss of motor function, stiffness, or decreased sensation. One patient with brachial plexus injury and poor baseline function was excluded from functional outcome scoring. There was no association between the time from diagnosis to fasciotomy and functional outcome at the final follow-up (p = 1.000).

Conclusions

Although ACS of the upper extremity in children is often associated with a long delay between injury and fasciotomy, most children still achieve excellent outcomes. The majority of patients presented with pain and at least one additional symptom, but treatment was often delayed, implying that ACS of the upper extremity in children is a difficult diagnosis to establish and may be associated with a prolonged clinical time course.     

Comparison of vacuum-assisted closure device and conservative treatment for fasciotomy wound healing in ischaemia-reperfusion syndrome: preliminary results

Ischaemia-reperfusion syndrome (IRS) is a condition that may require early fasciotomy. In the past, fasciotomies ultimately required prolonged hospitalisation. Vacuum-assisted closure (VAC) therapy system is an innovative method which promotes wound healing by reducing wound oedema, increasing microcirculation, and stimulation of granulation tissue. The aim of this retrospective study was to compare the VAC treatment with the conservative treatment of the fasciotomy wound until definitive surgical closure. The researchers retrospectively identified 15 patients, 3 females and 12 males, with a mean age of 69 years, who underwent a fasciotomy between January 2003 and December 2009 at the University Hospital of Geneva. All of the fasciotomies performed on the patients were on account of IRS. Seven patients were subjected to wound treatment using the VAC-system device and eight patients underwent treatment through the usual conservative method. The data were analysed by comparing the operative wound size, length of time for wound closure and duration of hospital stay in both groups. The number of days after fasciotomy until surgical wound closure in the VAC-system group (n = 7) ranged from 8 to 13 days with a mean of 11 days. The wound size at the day of closure was decreased in length by a mean of 58% (range 29-67%) and in diameter by a mean of 56% (range 33-75%). The duration of hospital stay for this group ranged from 12 to 18 days with a mean of 14 days. No signs of infections were observed and no re-operation was required after first closure. In the conservative group (n = 8), the time to wound closure ranged between 12 and 20 days with a mean of 15 days. The wound size was decreased in length by a mean of 40% (range 32-53%) and in diameter by a mean 46% (range 30-70%). The mean duration of hospital stay was 18·5 days. Three of the patients in the conservative treatment group manifested wound infection during the course of the treatment. VAC device could be a new standard for treatment of fasciotomy wound. VAC therapy is a recent innovation and becoming more and more a necessary complementary therapy to hasten wound healing. In our preliminary study, the VAC-system device showed significantly reduction of the wound size, decreased tissue oedema, duration of hospital days and improvement of granulation tissue.     

Acute compartment syndrome

Compartment syndrome is an orthopaedic emergency. It is defined as an increase in pressure within an osseofascial compartment, which results in hypoxia and necrosis of the structures within the compartment. It is commonly associated with high energy injuries, particularly tibial fractures. Diagnosis is largely based on clinical assessment, with pain as the most important and reliable feature. Other features such as nerve compromise or pulselessness are late signs. Urgent treatment should be based on guidelines written by the British Orthopaedic Association. Fasciotomy of the affected limb is required within an hour of the diagnosis being made to reduce morbidity associated with the condition. In the leg there are four compartments, which can be decompressed through two skin incisions. The wounds cannot be closed primarily, and multiple theatre attendances may be required. If a fracture is present as well as compartment syndrome, this will need to be stabilized at the same time. A variety of options for managing the wounds are available, with no single ideal method.     

四肢坏死性筋膜炎的诊断与治疗

目的：探讨四肢坏死性筋膜炎的早期诊断与治疗方法。方法：2000年1月—2008年1月间收治11例四肢坏死性筋膜炎患者,男8例,女3例;平均年龄32.9岁。所有患者予以急诊清创、抗感染、对症支持治疗,后期行康复锻炼。结果：11例患者均获治愈且肢体功能恢复良好,住院时间27～61d,平均43d。结论：对四肢坏死性筋膜炎进行早期诊断、彻底清创、合理用药、积极支持治疗与及时康复锻炼,能取得较好的治疗效果。     

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.     

Autoerythrocyte sensitization (Gardner-Diamond) syndrome mimicking compartment syndrome

We report a case with an unusual manifestation of autoerythrocyte sensitization syndrome (Gardner-Diamond syndrome). The patient had the clinical signs of compartment syndrome of the forearm requiring fasciotomy. Dermatological signs identical to Gardner-Diamond syndrome should alert the physician to avoid unnecessary fasciotomy, as these patients respond well to psychiatric treatment as in the present case.     

Ultrastructural modifications of muscle in three types of compartment syndrome

The histological and ultrastructural aspects of three cases representing different types of compartment syndromes are analyzed. In the acute syndrome edema is the prominent feature. The two chronic cases are characterized by an accumulation of intermyofibrillar lipid globules. All three have in common mitochondrial enlargement, disorganization of the cristae and paracrystalline inclusions. These pathological findings are discussed in the light of lesions seen in striated muscle ischaemia or in certain metabolic myopathies.

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Résumé Analyse des images histologiques et ultrastructurelles de trois cas présentant différentes formes de syndrome des loges de la jambe. Dans le cas aigu, l'oedème est au premier plan. Les deux cas d'évolution chronique se caractérisent par une accumulation de gouttelettes lipidiques intermyofibrillaires. Les trois cas ont en commun d'importantes modifications mitochondriales comportant une augmentation de la taille des organelles, une désorganisation des cristae et des inclusions paracristallines. Ces images histologiques sont discutées dans le cadre des lésions rencontrées lors d'ischémie musculaire ou lors de certaines myopathies métaboliques.