Compartment Syndrome Evaluation

CHAPTER 188 Compartment Syndrome Evaluation



Michelle E. Szczepanik, Francis G. O’Connor


Compartment syndrome occurs when the pressure inside the fascial compartment of an extremity is higher than the pressure of the blood in the vessels going into the compartment. This variance can be caused by bleeding into or edema in the area, which in turn can lead to compromise of the circulation to the soft tissues, especially the muscles and nerves, and cause tissue ischemia and eventual necrosis. If the compartment syndrome is present for 8 hours or more, irreversible tissue damage will likely occur and can lead to subsequent fibrosis and contracture of the muscles and compartment tendons. The flexor tendons are involved most often and are usually the earliest to be involved because they are in the deepest compartments of the calf and forearm. To merely monitor distal pulses for development of compartment syndrome is not adequate. An absent arterial pulse may indicate only damage to a single artery, congenital absence of an artery, or hypovolemia; conversely, normal pulses may be present despite dangerously elevated compartment pressures. Lack of pulse accompanied by pain and pallor are end-stage compartment syndrome signs and symptoms; if these are relied on to make the diagnosis, it will be too late for optimal treatment in most cases. Surgical release using an incision through the fascial compartments (fasciotomy) is required to relieve the excessive pressure.


Compartment syndrome can occur at any age but is much more common in adults than in children. Be aware that the swelling may not peak for 24 to 72 hours after an injury; therefore, the clinician needs to consider this diagnosis, perform a careful examination, and consider measuring compartment pressures up to 3 days after severe injuries.


Compartment pressures can be measured once (as a spot check), periodically, or continuously with a needle being left in place. This chapter discusses measurement of compartment pressures using a needle; wick or slit catheters can be used in a similar manner but are not covered here. Wick and slit catheters are generally used for more prolonged, in-hospital monitoring or research.



Conditions Associated with Compartment Syndrome



• Soft tissue injury only (without a fracture in forearm, calf, hand, or foot)

• Soft tissue injury with a fracture of forearm, calf, hand, or foot

• Supracondylar fracture of the elbow (Volkmann’s ischemia)

• Crush injury to thigh

• Gluteal trauma

• Prolonged tourniquet application (>2 hours)

• Anticoagulated patient or patient with coagulopathy

• Electrical injury

• Burns

• Bites (e.g., dog, shark, snake) in susceptible areas

• Exercise-induced compartment syndrome

It is important to understand that compartment syndrome can occur as a result of many different types of insults. Although it is more common in the calf or the forearm, compartment syndrome can also occur in the hand, foot, thigh, or buttocks. The rule followed is the greater the amount of soft tissue trauma, the greater the chance of compartment syndrome. For this reason, any high-velocity injury should be treated with caution because the energy dissipated through the soft tissue can cause extreme swelling. Injuries commonly associated with compartment syndrome include automobile accidents and pedestrian trauma, especially bumper injuries to the buttocks, calf, or forearm.


Compartment syndrome is a common result of trauma or a fracture. “Volkmann’s ischemia” is compartment syndrome in the forearm occurring after supracondylar fractures that cause a large amount of swelling around the elbow. Calcaneal fractures can also cause compartment syndrome, although this is rare. Compartment syndrome can occur in the thigh because of a severe crush injury. Gluteal compartment syndrome, which is frequently associated with an automobile accident or fall from a height, is due to the direct trauma and associated swelling of the muscle compartment. A patient with trauma, especially one with a coagulopathy or on anticoagulation, can develop bleeding into a muscle compartment, leading to increased pressure.


A chronic form of compartment syndrome can occur with exertion, usually increasing as a training program progresses. Also known as exercise-induced compartment syndrome, chronic exertional compartment syndrome presents as a gradual development of pain with activity followed by a gradual resolution of symptoms with cessation of the activity. It is more common in runners, usually involves the calf, and must be distinguished from other causes of chronic leg pain such as medial tibial stress syndrome, stress fracture, nerve or arterial entrapment, or muscle strain. A good history and postexercise examination are fundamental in differentiating between these different causes of chronic leg pain.


Finally, some less common but certainly notable causes of compartment syndrome include prolonged use of a tourniquet, large animal bites, snakebites, infection, electrical injuries, and burns. Prolonged application of a tourniquet (>2 hours) has been associated with development of compartment syndrome when the tourniquet is released and reperfusion causes swelling and increased pressure. Bites in an extremity from large animals such as sharks or dogs can cause crush injuries; snakebites are also associated with significant edema. Scratches, cuts, or bites from smaller animals or insects can result in infection that may cause a compartment syndrome or mask or restrict one. Patients who have electrical injuries, with or without a visible skin burn, can develop compartment syndrome. The mechanism is similar to that of a device available on the market to cook a hot dog, which is how the injury got its nickname “hot dogger.” After a hot dog is punctured at both ends with a metal spike, an electrical current is delivered through the hot dog. This causes intense heat, thus cooking the hot dog. The same mechanism occurs with burn injuries with an entrance and exit point for the electrical energy. The “cooked” tissue inside swells, nearly to the point of bursting, but is restrained by the surrounding tissue. The extent of injury may not be visible on the patient’s initial visit but can develop over the next 1 to 3 days. A clinician should always consider compartment syndrome when evaluating burns of any source.



Conditions That Can Create, Mask, or Worsen Compartment Syndrome



• Applying heat to injury

• Spinal cord injury or regional anesthetic block

• Intoxication, altered mental status, or changes in sensorium (e.g., head trauma, coma)

• Infection, burns, scarring, tight bandages, or being in a cast

An injury, with or without fracture, that is later subjected to warm water or any other intervention resulting in vasodilation will have increased swelling and an increased chance of compartment syndrome. Patients with a severe bruise from a fall who then soak it in a hot tub of water can develop compartment syndrome. It can also happen when expansion of the soft tissue envelope (skin) is constricted by a cast, scarring, or infection. If any patient has pain out of proportion to objective findings, especially after trauma to an extremity or placement of a cast, the cast and Webril should be removed entirely and the patient examined carefully for compartment syndrome. If removal of the cast and Webril does not bring immediate and complete relief of the intense pain, evaluation for compartment syndrome is indicated (with subsequent surgical treatment if present). Even without a cast, any feeling of tense, tight swelling in the forearm, hand, calf, or foot should lead to suspicion of compartment syndrome.


Another presentation for compartment syndrome is the intoxicated individual who falls and sustains an injury. Because of the intoxication (or any other reason for an altered sensorium), the pain is ignored. In addition, patients who have a spinal cord injury resulting from a motor vehicle accident will not have pain in the forearm or calf in spite of the swelling that may also occur as a result of the accident. Postoperative patients with a regional block may not have pain for the same reason. For the aforementioned reasons, immediate evaluation may be necessary and a fasciotomy considered in any such patient with a tense and swollen forearm, calf, hand, or foot.



Indications


A diagnosis of compartment syndrome made after loss of pulses and loss of capillary refill comes too late for optimal treatment. The most important and earliest symptom associated with compartment syndrome is pain. If pain after an injury is associated with swelling in an extremity and the pain is not relieved by medication (e.g., up to one or two Percocet tablets every 4 hours), compartment syndrome should be suspected, especially if the pain is progressive.


The earliest physical findings are (1) loss of fine touch and (2) pain with extension of the great toe or the thumb. Compartment syndrome most commonly occurs first in the volar/dorsal compartment of the forearm, where the long flexor tendon of the thumb travels, and in the calf, where the long flexor tendon for the great toe is located. By passively extending the thumb or great toe, the muscle tendon unit in this deep compartment is stretched. If the muscle is ischemic because of early compartment syndrome, pain will be present and increased by extension of the thumb or toe. Two-point discrimination is also impaired early.


For chronic exertional compartment syndrome, certain symptoms help distinguish it from other causes of chronic leg pain. Aching or cramping leg pain, gradual rather than immediate development of pain with activity, neurologic symptoms such as numbness or tingling, gradual resolution with cessation of activity, and shorter distances or intensities being required to produce the discomfort are all typical symptoms. Because routine physical examination is usually negative, a postexercise examination should be included to demonstrate tightness of the compartment involved, discomfort and tenderness with palpation, and involvement of the muscle mass rather than the muscle–tendon junction. The calf is most commonly involved, and about 80% of the time compartment syndrome occurs bilaterally.


Measurement of compartment pressures should be considered in any patient with a compatible history, a swollen and tense muscle group, and


• Pain (the earliest and most sensitive symptom)

• Pain out of proportion to objective findings, especially if progressive

• Increasing pain not relieved by usual narcotic pain medication

• Loss of fine touch or two-point discrimination

• Pain with passive motion of the affected muscles (e.g., extension of great toe or thumb of affected limb)

• Increased discomfort when muscle trapped in fascial compartment is moved (actively or passively), especially the flexor muscles

• Excessive constriction of the affected compartment

• Suspected chronic exertional compartment syndrome


Contraindications to Measurement



• When compartment syndrome is clinically obvious and measurement would delay definitive treatment

• Cellulitis directly over the area to be measured (relative contraindication)

• Anticoagulation (relative contraindication)


Preprocedure Patient Preparation


Indications, alternatives, risks, potential benefits, and expected results should be discussed with the patient or representative and signed informed consent should be obtained. The patient should expect some discomfort as needles are inserted. The procedure may need to be repeated at various locations and intermittently over time. Alternatively, a continuous monitor may be left in place (usually in a comatose patient). Let conscious patients know they will be warned before insertion of a needle. It will also be important for them to remain very still during certain portions of the procedure. If moderate (conscious) sedation is to be used, intravenous access should be obtained and the patient should be monitored with pulse oximetry.



Equipment



• Gloves and other necessary equipment for the clinician to follow universal blood and body fluid precautions

• Povidone–iodine (Betadine) or chlorhexidine (Hibiclens) antiseptic solution

• Sterile drapes and towels

• 4 × 4 gauze squares

• Band-Aids to cover needle insertion sites

• Local anesthetic (1% lidocaine), syringe, and needles (optional)


Stryker System



• Prefilled syringe with saline

• Side-port needle

• Diaphragm chamber

• Hand-held pressure monitor

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Compartment Syndrome Evaluation

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