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Lin Z, Hou Z, Guo J, Lin Y, Zhang Y. Risk factors for poor outcomes in patients with acute lower leg compartment syndrome: a retrospective study of 103 cases. J Orthop Surg Res 2024; 19:252. [PMID: 38643123 PMCID: PMC11031945 DOI: 10.1186/s13018-024-04719-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/05/2024] [Indexed: 04/22/2024] Open
Abstract
PURPOSE The primary aim of this study was to investigate the risk factors associated with poor outcomes following acute compartment syndrome (ACS) of lower leg. The secondary objective was to determine if delayed fasciotomy is linked to poor outcomes. METHODS In this retrospective case control study approved by the institutional review board, we identified 103 patients with ACS of the lower leg. Poor outcome was defined as a composite variable that included limb amputation, neurological deficit and contracture. Among these, 44 patients exhibited poor outcome while 59 patients demonstrated a good outcome. Patient-related factors, laboratory values, and treatment-related factors were analyzed using electronic medical records. Univariate statistical and logistic regression analyses were conducted to determine significance. RESULTS Bivariate analyses showed that the mechanism of injury (P = 0.021), open injury (P = 0.001), arterial injury (P<0.001), hemoglobin levels (HB) (P < 0.001), white blood cell count (WBC) (P = 0.008), albumin levels (ALB) (P<0.001), creatine kinase levels (CK) at presentation (P = 0.015), CK at peak (P<0.001), creatine kinase levels (Ca) (P = 0.004), dehydrating agent (P = 0.036), and debridement (P = 0.005) were found to be associated with the risk of poor outcomes. Logistic regression analyses revealed that arterial injury [ P< 0.001, OR = 66.172, 95% CI (10.536, 415.611)] was an independent risk factor for poor outcomes. However, HB [P = 0.005, OR = 0.934, 95% CI (0.891, 0.979)] was a protective factor against poor outcomes. Receiver operating characteristic (ROC) curve analysis showed that the cut-off values of HB to prevent poor outcome following ACS was 102.45 g/L. CONCLUSIONS ACS of the lower leg is a serious complication often associated with a poor prognosis. Patients with arterial injury or lower HB have a significantly increased risk of having poor outcomes. Poor outcomes were not found to be associated with the timing of fasciotomy in this study.
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Affiliation(s)
- Zhe Lin
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province, Shijiazhuang, China
- Orthopaedic Research Institution of Hebei Province, Hebei, China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China.
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province, Shijiazhuang, China.
- The Third Affiliated Hospital, Hebei Medical University, Shijiazhuang, 050051, Hebei, China.
| | - Jialiang Guo
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province, Shijiazhuang, China
- Orthopaedic Research Institution of Hebei Province, Hebei, China
| | - Yongsheng Lin
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province, Shijiazhuang, China
- Orthopaedic Research Institution of Hebei Province, Hebei, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Orthopaedic Biomechanics of Hebei Province, Shijiazhuang, China
- Orthopaedic Research Institution of Hebei Province, Hebei, China
- Chinese Academy of Engineering, Beijing, China
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Giotis D, Panagiotopoulos V, Plakoutsis S, Vardakas D, Konstantinidis C. Delayed Presentation of Acute Compartment Syndrome After Isolated Closed Fibular Shaft Fracture: A Case Report. Cureus 2024; 16:e55850. [PMID: 38590458 PMCID: PMC11001258 DOI: 10.7759/cureus.55850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2024] [Indexed: 04/10/2024] Open
Abstract
Post-traumatic compartment syndrome in the lower extremity has been commonly associated with fractures of the tibia. Only in rare cases, this critical condition might be related to isolated fibular fractures. We present a rare case of delayed onset of acute compartment syndrome after a solitary fracture of the fibula. A 40-year-old man with a history of coagulation disorders due to hepatic cirrhosis was admitted to a neighboring hospital after a car accident with left-sided fractures to ribs 9 and 10 and a transverse fracture in the mid-shaft of the left fibula. He was discharged from the hospital five days later with a posterior long leg splint and anticoagulant therapy. However, three days after discharge, he was seen in the emergency department of our hospital with severe pain and extensive swelling in the left leg. Weak posterior tibial and dorsalis pedis pulse in the right foot were detected. Moreover, sensory disturbances were found in the tibia and foot. Passive hallux dorsiflexion and plantar flexion were causing acute intense pain. A triplex ultrasound was negative for deep vein thrombosis. Apart from the clinical findings, the diagnosis of compartment syndrome was confirmed after evaluating intracompartment pressure measurements. The patient was taken emergently to the operating room for four-compartment fasciotomies. A large intramuscular hematoma was evacuated. Skin closure was accomplished in two stages within two weeks. Six weeks postoperatively, there was no sign of compartment syndrome sequelae and the patient was free of symptoms without any neurovascular deficiency in the operated limb and walked without crutches. Ten weeks later, he returned to his pre-injury daily activities. Although the majority of compartment syndrome cases are reported after high-energy trauma, patients with both coagulation disturbances and anticoagulation treatment are at higher risk of developing compartment syndrome secondary to simple fracture patterns.
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Affiliation(s)
- Dimitrios Giotis
- Orthopaedic Department, General Hospital of Ioannina "G. Hatzikosta", Ioannina, GRC
| | | | - Sotiris Plakoutsis
- Orthopaedic Department, General Hospital of Ioannina "G. Hatzikosta", Ioannina, GRC
| | - Dimitrios Vardakas
- Orthopaedic Department, General Hospital of Ioannina "G. Hatzikosta", Ioannina, GRC
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McKenna DP, McCarthy C, Higgins T. Isolated Extensor Hallucis Longus Compartment Syndrome: A Case Report. Cureus 2024; 16:e51772. [PMID: 38192525 PMCID: PMC10772309 DOI: 10.7759/cureus.51772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 01/10/2024] Open
Abstract
We present the case of an isolated extensor hallucis longus compartment syndrome following a diaphyseal fibular fracture. Our subject underwent syndesmotic fixation and experienced ongoing pain post-procedure. This was associated with an isolated loss of power in extension of the hallux. A diagnosis of an isolated extensor hallucis longus compartment syndrome followed. Our case highlights the vulnerability of this muscle belly to ischemia and reiterates the value of complete clinical examination in the postoperative patient.
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Affiliation(s)
- Daniel P McKenna
- Surgery, Royal College of Surgeons in Ireland, Dublin, IRL
- Trauma and Orthopaedics, University Hospital Kerry, Tralee, IRL
| | - Cathal McCarthy
- Trauma and Orthopaedics, University Hospital Kerry, Tralee, IRL
| | - Tony Higgins
- Trauma and Orthopaedics, University Hospital Kerry, Tralee, IRL
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Yalın M, Gölgelioğlu F. A Comparative Analysis of Fasciotomy Results in Children and Adults Affected by Crush-Induced Acute Kidney Injury following the Kahramanmaraş Earthquakes. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1593. [PMID: 37763712 PMCID: PMC10533083 DOI: 10.3390/medicina59091593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: The current study aims to determine the impact of fasciotomy on mortality and morbidity in children and adults with crush-related AKI following the 2023 Kahramanmaraş earthquakes. Materials and Methods: The study included individuals who had suffered crush injuries after the 2023 Kahramanmaraş earthquakes and were identified as having an acute kidney injury (AKI). Patients with an AKI were divided into two groups based on age: those under 18 years and those over 18 years. A comparative analysis was conducted between the mortality and morbidity rates of patients who underwent fasciotomy and those who did not. Disseminated intravascular coagulopathy (DIC), sepsis, and adult respiratory distress syndrome (ARDS) have all been identified as contributors to morbidity. Results: The study was conducted with a total of 40 patients (21 males and 19 females) aged between 4 and 83 years. A total of 21 patients underwent fasciotomy, and the patients underwent varying numbers of fasciotomy, ranging from 0 to 11. The mortality rate was 12.5%, corresponding to five adult patients. No instances of mortality were reported in the paediatric cohort. The application of fasciotomy in instances of crush-induced AKI did not result in elevated levels of mortality in either the paediatric or adult demographic. Within the adult population, a substantial difference in the duration of dialysis was observed between individuals who underwent fasciotomy and those who did not. A statistically significant increase in the number of fasciotomy incisions was observed in patients diagnosed with sepsis compared with those without sepsis. The study found a significant positive correlation between the number of fasciotomy incisions and dialysis days. Conclusions: Neither adult nor paediatric patients with crush-induced AKI showed an increased risk of death after fasciotomy. The number of fasciotomy incisions significantly correlated with the development of sepsis. Despite experiencing delays in hospital admission for paediatric patients, the incidence of both crush syndrome and mortality rates among children remained relatively low.
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Affiliation(s)
- Mustafa Yalın
- Department of Orthopaedics and Traumatology, Elazığ Fethi Sekin City Hospital, Elazığ 23050, Turkey;
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Wilson KL. Invited Commentary: Challenging the Dogma of Delayed Fasciotomy. J Am Coll Surg 2023; 236:1045-1046. [PMID: 36791150 DOI: 10.1097/xcs.0000000000000655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Wang T, Yang S, Guo J, Long Y, Hou Z. Predictors of muscle necrosis in patients with acute compartment syndrome. INTERNATIONAL ORTHOPAEDICS 2023; 47:905-913. [PMID: 36715712 PMCID: PMC9885051 DOI: 10.1007/s00264-023-05699-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/09/2023] [Indexed: 01/31/2023]
Abstract
PURPOSE The predictors of muscle necrosis after acute compartment syndrome (ACS) remain debated. This study aimed to investigate the predictors for muscle necrosis in ACS patients. METHODS We collected data on ACS patients following fractures from January 2010 to November 2022. Patients were divided into the muscle necrosis group (MG) and the non-muscle necrosis group (NG). The demographics, comorbidities, and admission laboratory indicators were computed by univariate analysis, logistic regression analysis, and receiver-operating characteristic (ROC) curve analysis. RESULTS In our study, the rate of MN was 37.6% (83 of 221). Univariate analysis showed that numerous factors were associated with muscle necrosis following ACS. Logistic regression analysis indicated that crush injury (p = 0.007), neutrophil (NEU, p = 0.001), creatine kinase myocardial band (CKMB, p = 0.047), and prothrombin time (PT, p = 0.031) were risk factors. Additionally, ROC curve analysis identified 11.415 109/L, 116.825 U/L, and 12.51 s as the cut-off values for NEU, CKMB, and PT to predict muscle necrosis, respectively. Furthermore, the combination of NEU, CKMB, and PT had the highest diagnostic accuracy. CONCLUSIONS Our findings showed that crush injury and the level of NEU, CKMB, and PT were risk factors for muscle necrosis after ACS. Additionally, we also identified the cut-off values of NEU, CKMB, and PT and found the combination of crush injury, PT, and NEU with the highest diagnostic accuracy, helping us individualize the assessment risk of muscle necrosis to manage early targeted interventions.
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Affiliation(s)
- Tao Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
- Orthopaedic Research Institute of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
| | - Shuo Yang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
- Orthopaedic Research Institute of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
| | - Junfei Guo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
- Orthopaedic Research Institute of Hebei Province, Shijiazhuang, Hebei, People's Republic of China
| | - Yubin Long
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.
- Orthopaedic Research Institute of Hebei Province, Shijiazhuang, Hebei, People's Republic of China.
- The Third Department of Orthopedics, Baoding First Central Hospital, Baoding, Hebei, People's Republic of China.
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China.
- Orthopaedic Research Institute of Hebei Province, Shijiazhuang, Hebei, People's Republic of China.
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Third Hospital of Hebei Medical University, Shijiazhuang, China.
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Yıldırım A, Önal İÖ, Çelik ZE, Vatansev H, Hataysal EP. Early assessment of extremity compartment syndrome by biochemical markers in a rat model. Turk J Med Sci 2023; 53:1-9. [PMID: 36945953 PMCID: PMC10387976 DOI: 10.55730/1300-0144.5552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/10/2022] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND This experimental study aimed to define a biochemical marker that will enable early diagnosis of acute compartment syndrome (ACS) of extremities, a mortal condition that occurs due to trauma. METHODS A total of 15 Wistar rats were included in the study in which saline infusion technique, a clinically compatible ACS model, was applied. After the rats were anesthetized with ketamine-xylazine, the in-compartment pressure of the hind limb was slowly increased with saline delivered through the angiocatheter, and after reaching the target compartment pressure, the pressure level was kept with a rubber tourniquet. The in-compartment pressure level was continuously monitored with a pressure transducer. The rats were divided into three groups. No intervention was applied to the control group (CG) (n = 3). In study group 1 (SG1) (n = 6), ACS was created using the saline infusion technique, keeping the in-compartment pressure between 30 and 40 mmHg for 45 min. In study group 2 (SG2) (n = 6), ACS was created using the saline infusion technique, keeping the in-compartment pressure between 30 and 40 mmHg for 90 min. Fasciotomy was performed on all rats. Tissue samples were obtained for histopathological examination and blood samples for biochemical analysis. RESULTS Total oxidant status (TOS) (p = 0.004), ischemia-modified albumin (IMA) (p = 0.030), aspartate transferase (AST) (p = 0.003) and neopterin (p = 0.012) levels differed significantly between groups in the early period of muscle ischemia. In fact, TOS levels differed significantly between the groups even in the cellular phase where signs of ischemia were not observed (p = 0.048, p = 0.024). According to histopathological evaluation, there was no significant difference between the groups. DISCUSSION TOS can be detected in the early reversible stage of ischemia, when the histopathological findings of ACS do not occur.
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Affiliation(s)
- Ahmet Yıldırım
- Department of Orthopedics and Traumatology, Medova Private Hospital, Konya, Turkey
| | - İbrahim Özkan Önal
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Selçuk University, Konya, Turkey
| | - Zeliha Esin Çelik
- Department of Pathology, Faculty of Medicine, Selçuk University, Konya, Turkey
| | - Hüsamettin Vatansev
- Department of Biochemistry, Faculty of Medicine, Selçuk University, Konya, Turkey
| | - Esra Paydaş Hataysal
- Department of Biochemistry, Göztepe Prof. Dr. Süleyman Yalçın City Hospital, İstanbul, Turkey
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Gong DC, Patel V, Farrar N, Hake ME, Perdue AM, Ahn J. Compartment Syndrome After Tibial Intramedullary Nail Removal and Intramedullary Debridement: A Case Report. JBJS Case Connect 2023; 13:01709767-202303000-00064. [PMID: 36927886 DOI: 10.2106/jbjs.cc.22.00365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
CASE A 45-year-old man who sustained an open tibial shaft fracture treated with intramedullary (IM) nailing 9 years earlier presented with persistent pain and concern for occult infection. He underwent tibial nail removal and debridement with reamer-irrigator-aspirator. Postoperative course was complicated by acute compartment syndrome. CONCLUSION This is a unique case of postoperative compartment syndrome after IM debridement and tibial hardware removal. A high index of suspicion should be prioritized in patients who complain of severe or unexpected pain to mitigate delays in diagnosis and aid in early treatment.
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Affiliation(s)
- Davin C Gong
- Department of Orthopaedic Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan
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Laverdiere C, Montreuil J, Bouklouch Y, Lorange JP, Dion CA, Harvey EJ. Predictors of Foot Acute Compartment Syndrome: Big Data analysis. J Foot Ankle Surg 2022; 62:27-30. [PMID: 35473922 DOI: 10.1053/j.jfas.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/07/2022] [Indexed: 02/03/2023]
Abstract
Acute compartment syndrome (ACS) in the foot is a challenging diagnosis and can lead to significant disabilities to patients. The present study aims to investigate the incidence, risk factors, demographics and association in the analysis of acute compartment syndrome (ACS) of the foot. We performed a retrospective review of the Trauma Quality Programs data from the American College of Surgeons including 70,525 patients who sustained a fracture of the foot from 2015 to 2018 (4 calendar years). Fasciotomies were performed in 0.7% of all foot fractures. Open fractures, crush injuries and multiple foot fractures were the strongest predictors of fasciotomies, with odds ratios of 2.38, 2.38 and 2.33 respectively. Being a male was associated with an increased likelihood of fasciotomies of 64% (p < .0001 O.R. = [1.42-1.90]), while a dislocation in the foot increased likelihood of fasciotomies by 48% (p = .0008 O.R. = [1.18-1.86]). Trauma centre level III had higher rate of fasciotomy than Tertiary Trauma centers. Multiple other factors were addressed while controlling for cofounders. This big data analysis provided information not previously reported on the risk factors, demographics, and clinical association of ACS in the foot.
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Affiliation(s)
- Carl Laverdiere
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada.
| | - Julien Montreuil
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | | | | | - Charles-Antoine Dion
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Edward J Harvey
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
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Steadman W, Wu R, Hamilton ATM, Richardson MD, Wall CJ. Review article: A comprehensive review of unusual causes of acute limb compartment syndrome. Emerg Med Australas 2022; 34:871-876. [PMID: 36192364 PMCID: PMC9828535 DOI: 10.1111/1742-6723.14098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/27/2022] [Accepted: 09/14/2022] [Indexed: 01/12/2023]
Abstract
Acute limb compartment syndrome (ALCS) is a surgical emergency that can have serious consequences unless promptly diagnosed and treated, which is particularly challenging when there is an unusual cause. This is a comprehensive review of reported causes of ALCS. From 1068 included articles, we found 299 discrete causes of ALCS including toxins, infections, endocrine pathology, haematological emergencies, malignancy and iatrogenic ALCS. Familiarity with this wide range of ALCS causes may assist in early diagnosis of this limb-threatening condition.
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Affiliation(s)
- William Steadman
- Orthopaedic DepartmentToowoomba HospitalToowoombaQueenslandAustralia,Rural Clinical SchoolThe University of QueenslandToowoombaQueenslandAustralia
| | - Rui Wu
- Orthopaedic DepartmentToowoomba HospitalToowoombaQueenslandAustralia
| | - Alistair TM Hamilton
- Rural Clinical SchoolThe University of QueenslandToowoombaQueenslandAustralia,Emergency DepartmentToowoomba HospitalToowoombaQueenslandAustralia
| | - Martin D Richardson
- Epworth Clinical SchoolThe University of MelbourneMelbourneVictoriaAustralia
| | - Christopher J Wall
- Orthopaedic DepartmentToowoomba HospitalToowoombaQueenslandAustralia,Rural Clinical SchoolThe University of QueenslandToowoombaQueenslandAustralia
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Montreuil J, Corban J, Reindl R, Harvey EJ, Bernstein M. Novel digital continuous sensor for monitoring of compartment pressure: a case report. OTA Int 2022; 5:e208. [PMID: 36425093 PMCID: PMC9580258 DOI: 10.1097/oi9.0000000000000208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/20/2022] [Indexed: 06/16/2023]
Abstract
Case The American Academy of Orthopaedic Surgeons has recently identified continuous intracompartmental pressure monitoring as 1 of the few means to assist in ruling out acute compartment syndrome (ACS). There are very few methods that allow this measurement. This manuscript describes the use of a new digital monitoring system for ACS in 3 patients. This minimally invasive device, the MY01 (NXTSENS, Montreal, Canada) is capable of continuously and precisely measuring variations in intracompartmental pressure. Conclusion MY01 detected the occurrence of ACS at early-stage and expedited the timing of surgery for 2 patients. This tool also objectively excluded a suspected diagnosis of ACS in a medically comorbid patient, obviating the need for unnecessary fasciotomies and potential complications.
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Affiliation(s)
- Julien Montreuil
- Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Jason Corban
- Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Rudolf Reindl
- Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Edward J Harvey
- Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Mitchell Bernstein
- Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Kani KK, Porrino JA, Chew FS. Low-velocity, civilian firearm extremity injuries-review and update for radiologists. Skeletal Radiol 2022; 51:1153-1171. [PMID: 34718857 DOI: 10.1007/s00256-021-03935-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/03/2021] [Accepted: 09/05/2021] [Indexed: 02/02/2023]
Abstract
Firearm injuries are a preventable epidemic in the USA. Extremities are commonly affected in gunshot injuries. Such injuries may be complex with concomitant osseous, soft tissue, and neurovascular components. The maximum wounding potential of a projectile is determined by its kinetic energy and the proportion of the kinetic energy that is transmitted to the target. Accurate assessment of ballistic injuries is dependent on utilizing the principles of wound ballistics, accurate bullet count, and ballistic trajectory analysis. The goals of this article are to review wound ballistics and the imaging evaluation of extremity civilian firearm injuries in the adult population, with emphasis on ballistic trajectory analysis, specific ballistic fracture patterns, and diffuse, secondary soft tissue ballistic injuries.
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Affiliation(s)
- Kimia Khalatbari Kani
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Jack A Porrino
- Yale Radiology and Biomedical Imaging, 330 Cedar Street, New Haven, CT, 06520-8042, USA
| | - Felix S Chew
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
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Mueller JW, Mcleod CB, Rabenhorst BM. Isolated Acute Lateral Compartment Syndrome in an Adolescent Athlete: A Case Report. JBJS Case Connect 2022; 12:01709767-202206000-00054. [PMID: 35703162 DOI: 10.2106/jbjs.cc.22.00088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CASE A 17-year-old adolescent boy presented with anterolateral, right leg pain and numbness of his right foot 2 days after participating in football practice. He denied a traumatic event, and radiographs were negative for fracture. His imaging and physical examination raised suspicion for acute compartment syndrome (ACS). Single-incision fasciotomy with anterior and lateral compartment release was performed. The peroneus longus muscle was detached at the musculotendinous junction. The peroneus longus was then debrided and transferred to the peroneus brevis. CONCLUSION Atraumatic ACS, although rare, is a diagnostic challenge. Prompt recognition of this atypical presentation is important for proper treatment.
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Affiliation(s)
- Joshua W Mueller
- Division of Pediatric Surgery, Department of Orthopedic Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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Chen JS, Tejwani NC. Compartment Syndrome of the Foot. Orthop Clin North Am 2022; 53:83-93. [PMID: 34799026 DOI: 10.1016/j.ocl.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Foot compartment syndrome is an uncommon condition that should be recognized by all orthopedic surgeons. The clinical presentation is often less clear than other limb compartment syndromes and requires high clinical suspicion with a low threshold for direct measurement of compartment pressure. Controversy exists regarding the number of anatomic compartments and the most effective treatment. Both acute surgical intervention and delayed management can result in significant morbidity and long-term sequelae.
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Affiliation(s)
- Jeffrey S Chen
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, 14th Floor, New York, NY 10003, USA
| | - Nirmal C Tejwani
- Department of Orthopedic Surgery, New York University Langone Orthopedic Hospital, NYU Langone Health, 301 East 17th Street, 14th Floor, New York, NY 10003, USA.
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Kameda T, Yokota T, Ejiri S, Konno SI. Forearm compartment syndrome due to acquired hemophilia that required massive blood transfusions after fasciotomy: A case report. World J Clin Cases 2021; 9:9592-9597. [PMID: 34877295 PMCID: PMC8610864 DOI: 10.12998/wjcc.v9.i31.9592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/21/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acquired hemophilia is rare. In some cases, the bleeding in muscle causes compartment syndrome. However, it is not clear whether fasciotomy should be performed for the compartment syndrome caused by acquired hemophilia because of the risk of bleeding and the unknown functional results.
CASE SUMMARY A 75-year-old woman was admitted with severe pain of the right forearm with no preceding traumatic event. The right forearm was obviously swollen, and stretch pain was observed. Subcutaneous hematomas were suspected in various parts of the body. Compartment pressure was 110 mmHg on the volar side. Activated partial thromboplastin time (aPTT) was prolonged to 54.9 s. Fasciotomy was performed, and hematoma was observed in the volar compartment. Postoperative laboratory examinations revealed a low level of factor VIII (FVIII) activity (12.5%) and a high level of FVIII inhibitor (15.2 bethesda units/mL). Acquired hemophilia A was diagnosed. Though recombinant clotting factors were administered, transfusion of red blood cells reached 46 units (140 mL/unit). Hemostasis was achieved 9 d after fasciotomy. The total cost of the clotting factor concentrates administered reached 28834600 yen. With prednisolone, FVIII activity and aPTT recovered gradually. Final function of the hand was good in the index finger and excellent in the others.
CONCLUSION Fasciotomy resulted in good function of the hand in a case of non-traumatic compartment syndrome caused by acquired hemophilia, but life-threatening bleeding occurred, and the cost of clotting factor treatment was high. Preparation of sufficient blood transfusion, preoperative administration of recombinant activated clotting factor VII, and prompt fasciotomy could be ideal for such cases.
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Affiliation(s)
- Takuya Kameda
- Department of Orthopaedic Surgery, Fukushima Medical University, Fukushima 960-1295, Fukushima, Japan
| | - Takeru Yokota
- Department of Orthopaedic Surgery, Fukushima Medical University, Fukushima 960-1295, Fukushima, Japan
| | - Soichi Ejiri
- Department of Hand and Limb Reconstructive Surgery, Fukushima Medical University, Fukushima 960-1295, Fukushima, Japan
| | - Shin-ichi Konno
- Department of Orthopaedic Surgery, Fukushima Medical University, Fukushima 960-1295, Fukushima, Japan
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Hines EM, Dowling S, Hegerty F, Pelecanos A, Tetsworth K. Bacterial infection of fasciotomy wounds following decompression for acute compartment syndrome. Injury 2021; 52:2914-2919. [PMID: 34233855 DOI: 10.1016/j.injury.2021.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/10/2021] [Accepted: 06/23/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Acute Compartment Syndrome (ACS) is a serious complication generally requiring treatment with an emergency decompressive fasciotomy. The aim of this study was to identify the most prevalent organisms involved in fasciotomy wound infections, and to determine the best strategies to mitigate this risk. DESIGN Retrospective review. SETTING Single tertiary referral centre. PATIENTS/PARTICIPANTS Patients (n = 370) who underwent fasciotomy for emergency ACS were included in this study. Positive wound swabs and tissue samples within 30 days post fasciotomy were identified, and extended antibiotic sensitivities were recorded. Patient medical charts were reviewed to assess infection rate, causative organism(s), and clinical outcomes. INTERVENTION Fasciotomy Main Outcome Measurements: Most prevalent organism in fasciotomy wound infections, and the rate of any associated morbidity and mortality. RESULTS The overall infection rate was 16.7%. Infection rates were significantly higher in burns (27%) and trauma (22%) patients than vascular patients (13%) (p = 0.002). The most prevalent organism was Pseudomonas aeruginosa, isolated from 23% of all wound specimens and comprising over a third (35%) of infections overall. Ten patients required amputation for infection control. Six of these were secondary to Pseudomonas infection, whereby one patient mortality occurred. CONCLUSION In this series, one in six fasciotomies for ACS developed an infection within 30 days of their index procedure. Burns and trauma comprised the highest risk groups. Facultative anaerobes were the predominant organisms involved in fasciotomy wound infections. A combination of aminoglycosides and beta-lactams with quinolones should be considered when commencing empiric therapy for fasciotomy wound infections. Antibiotic coverage for routine peri‑operative prophylaxis following emergency decompression for acute compartment syndrome should be strongly considered, particularly in burns or trauma cases. LEVEL OF EVIDENCE Aetiologic Level III.
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Affiliation(s)
- Elizabeth Magdelin Hines
- Department of Internal Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Department of Orthopaedic Surgery, Mater, Brisbane, QLD, Australia.
| | - Samantha Dowling
- Department of Internal Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Department of Orthopaedic Surgery, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Fergus Hegerty
- Department of Internal Medicine, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.
| | | | - Kevin Tetsworth
- Department of Orthopaedic Surgery, The Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Orthopaedic Research Centre of Australia, Brisbane, QLD, Australia; Limb Reconstruction Centre, Macquarie University Hospital, Sydney, NSW, Australia
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Dwyer T, Burns D, Nauth A, Kawam K, Brull R. Regional anesthesia and acute compartment syndrome: principles for practice. Reg Anesth Pain Med 2021; 46:1091-1099. [PMID: 34187911 DOI: 10.1136/rapm-2021-102735] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/10/2021] [Indexed: 11/04/2022]
Abstract
Acute compartment syndrome (ACS) is a potentially reversible orthopedic surgical emergency leading to tissue ischemia and ultimately cell death. Diagnosis of ACS can be challenging, as neither clinical symptoms nor signs are sufficiently sensitive. The cardinal symptom associated with ACS is pain reported in excess of what would otherwise be expected for the underlying injury, and not reasonably managed by opioid-based analgesia. Regional anesthesia (RA) techniques are traditionally discouraged in clinical settings where the development of ACS is a concern as sensory and motor nerve blockade may mask symptoms and signs of ACS. This Education article addresses the most common trauma and elective orthopedic surgical procedures in adults with a view towards assessing their respective risk of ACS and offering suggestions regarding the suitability of RA for each type of surgery.
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Affiliation(s)
- Tim Dwyer
- Department of Surgery, University of Toronto Division of Orthopaedics, Toronto, Ontario, Canada .,Department of Surgery, Women's College Hospital, Toronto, Ontario, Canada.,Department of Surgery, Mt Sinai Hospital, Toronto, Ontario, Canada
| | - David Burns
- University of Toronto Division of Orthopaedics, Toronto, Ontario, Canada
| | - Aaron Nauth
- Department of Surgery, University of Toronto Division of Orthopaedics, Toronto, Ontario, Canada.,Department of Surgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Kaitlin Kawam
- University of Toronto Division of Orthopaedics, Toronto, Ontario, Canada
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Bernal JA, Torres-Reveron A, Gonzalez JA. Complications and Comorbidities in Hispanic Patients Who Develop Traumatic and Non-traumatic Acute Compartment Syndrome. Cureus 2021; 13:e12792. [PMID: 33628662 PMCID: PMC7891797 DOI: 10.7759/cureus.12792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Acute compartment syndrome (ACS) is a medical emergency that remains under-recognized and understudied. This study aimed to identify risk factors for the traumatic and non-traumatic presentation of ACS within a majority Hispanic population. A four-year retrospective analysis of medical records in a single institution revealed 26 with traumatic and 21 non-traumatic patients presenting with ACS. Traumatic ACS occurred in younger males following fractures, as previously described in the field. After controlling for age differences, non-traumatic ACS occurred in older patients with multiple comorbidities, increased use of statins, and anticoagulants as compared to the traumatic ACS group. A large proportion (80%) of the non-traumatic ACS group also presented with hypertension. Patients taking anticoagulants and statins should be carefully monitored for ACS development after non-traumatic qualifying events and advanced age. Further studies should identify how statins interact with the patients' racial/ethnic profile and the incidence of comorbidities to promote earlier identification and reduce morbidities.
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Affiliation(s)
- Jorge Alejandro Bernal
- Internal Medicine Residency Program, University of Texas Rio Grande Valley - DHR Health, Edinburg, USA
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19
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Slade HJT, De Ridder K. A rare cause of acute compartment syndrome in the thigh: a case report. J Surg Case Rep 2020; 2020:rjaa546. [PMID: 33391660 PMCID: PMC7769571 DOI: 10.1093/jscr/rjaa546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/01/2020] [Indexed: 11/09/2022] Open
Abstract
Acute compartment syndrome (ACS) is an orthopaedic emergency that requires urgent fasciotomy and decompression to avoid significant morbidity. It is most commonly caused by a fracture or crush injury. We present a case of a patient who developed ACS of the posterior compartment of the thigh secondary to a low energy fall and avulsion of sclerotic arterioles. There was no fracture and the patient was not anti-coagulated. They had fasciotomy and embolization of responsible vessels. This case demonstrates the need for high clinical suspicion needed for ACS and the morbidity associated with a delayed fasciotomy. A literature research demonstrated no case reports of a patient developing ACS with no fracture, no crush injury and no history of anti-coagulation.
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Affiliation(s)
- Henry J T Slade
- Department of Orthopaedic Surgery, Wellington Regional Hospital, Wellington, New Zealand
| | - Koen De Ridder
- Department of Orthopaedic Surgery, Wellington Regional Hospital, Wellington, New Zealand
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Park JP, Montreuil J, Nooh A, Martineau PA. Telemedicine-guided forearm emergency decompressive fasciotomy for compartment syndrome. J Telemed Telecare 2020; 29:28-32. [DOI: 10.1177/1357633x20964359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction We highlight the utility of telemedicine and telementoring for the management of orthopaedic emergencies using a case of forearm compartment syndrome following a penetrating trauma in a northern Inuit community in Nunavik, Quebec, Canada. Methods & Results As in many cases of compartment syndrome in rural settings, the patient was at a high risk of developing irreversible complications. A prompt diagnosis followed by an emergency decompressive fasciotomy was warranted. Using telemedicine and telementoring guidance, the diagnosis of compartment syndrome was made, and the patient’s volar compartment was successfully decompressed by a local emergency physician in a timely manner. Subsequently, the patient was able to be safely transferred to a level 1 trauma centre for further surgical management. This included a second-look operative exploration, irrigation and debridement, completion of volar fasciotomy and ulnar nerve decompression. No complications were seen. Discussion Our experience highlights two important clinical implications. First, telemedicine can be successfully implemented to facilitate clinical diagnosis of surgical emergencies in the rural setting. Second, telementoring can effectively allow surgeons to guide physicians remotely to perform emergency decompressive fasciotomy, which can help salvage the affected limb and significantly decrease the risk of debilitating complications.
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Affiliation(s)
- J Patrick Park
- Department of Orthopaedic Surgery, McGill University Health Center, Canada
| | - Julien Montreuil
- Department of Orthopaedic Surgery, McGill University Health Center, Canada
| | - Anas Nooh
- Department of Orthopaedic Surgery, McGill University Health Center, Canada
| | - Paul A Martineau
- Department of Orthopaedic Surgery, McGill University Health Center, Canada
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21
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Mortensen SJ, Zhang D, Mohamadi A, Collins J, Weaver MJ, Nazarian A, von Keudell AG. Predicting factors of muscle necrosis in acute compartment syndrome of the lower extremity. Injury 2020; 51:522-526. [PMID: 31767373 DOI: 10.1016/j.injury.2019.11.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/15/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Acute physiologic compartment syndrome (ACS) is a disorder of increased intra-compartmental pressure leading to decreased tissue perfusion and muscle necrosis. Tissue ischemia can result in irreversible muscle and nerve injury and requires urgent fasciotomy. The aim of this study was to determine the factors associated with the presence of necrotic muscle in patients undergoing leg fasciotomy. METHODS This is a retrospective cohort study of all patients undergoing fasciotomies for ACS of the leg at two level 1 trauma centers from 2000 to 2015. We found 1,028 patients who underwent leg fasciotomies. We excluded ACS at other sites than the leg, the index fasciotomy performed at an outside institution, prophylactic fasciotomy with no clinical signs of ACS, and patients with inadequate medical records. A total of 357 patients were included in the final analysis. We used bivariate analysis to assess which explanatory variables are associated with the main outcome measure, the presence of necrotic muscle at fasciotomy. We used multivariable regression analysis to determine association accounting for any confounding. RESULTS Of 357 cases of ACS of the leg, 14.6% of patients presented with an open fracture and 21.3% of patients were multiply injured. Overall, 14.3% of cases had muscle necrosis at the time of fasciotomy. Fifty-nine percent of patients with necrotic muscle required more than 3 debridements. Open fracture was the only statistically significant predictor of muscle necrosis (OR=2.8). Crush injury (OR=3.1) and soft tissue injuries (OR=2.8) were at an increased odds of necrotic muscle, but only marginally significant. CONCLUSION ACS is a potentially limb threatening condition often associated with poor outcomes, particularly when the diagnosis is delayed. Patients with open fracture have a three-fold increase in odds of necrotic muscle at the time of fasciotomy.
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Affiliation(s)
- Sharri J Mortensen
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Dafang Zhang
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Amin Mohamadi
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Jamie Collins
- Orthopedic and Arthritis Center for Outcome Research, Brigham and Women's Hospital, Boston, MA, United States
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, United States
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, United States; Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
| | - Arvind G von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA, United States
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22
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Schitz F, Schabus R. Seltene Gefahr eines Kompartmentsyndroms bei arthroskopischer Versorgung der Tibiaplateaufraktur. ARTHROSKOPIE 2020. [DOI: 10.1007/s00142-019-00334-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
ZusammenfassungFrakturen des Tibiaplateaus gehen häufig mit Begleitverletzungen (z. B. vorderes Kreuzband, Seitenbänder, Meniskus) sowie einer komplexen Beteiligung der Gelenkflächen einher. Die Therapie erfolgt in der Regel durch eine operative Versorgung mittels winkelstabiler Platten. In diesem Beitrag wird der Fall einer 61-jährigen Patientin nach Sturz in der häuslichen Umgebung beschrieben, bei dem sie sich eine Fraktur des vorderen Tibiakopfes und der medialen Femurkondyle mit einer multiligamentären Ruptur sowie eine Lappenruptur des lateralen Meniskus zuzog, sodass die Indikation für eine arthroskopische Operation bestand. Aufgrund der Gefahr eines Kompartmentsyndroms musste der Eingriff jedoch vorzeitig abgebrochen werden. Im Anschluss wurde die Patientin erfolgreich mit einer Knietotalendoprothese versorgt. Das Kompartmentsyndrom stellt eine sehr seltene, aber ernsthafte Komplikation der Arthroskopie dar. Eine gute invasive Therapieoption ist die Fasziotomie, wobei deren Indikation u. a. vom Druck des Kompartiments abhängt. Genaue Richtlinien bezüglich der Behandlung des Kompartmentsyndroms liegen noch nicht vor. Die Therapie sollte in erster Linie patientenorientiert erfolgen.
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Diagnosing acute compartment syndrome-where have we got to? INTERNATIONAL ORTHOPAEDICS 2019; 43:2429-2435. [PMID: 31468110 PMCID: PMC6848051 DOI: 10.1007/s00264-019-04386-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/29/2019] [Indexed: 12/17/2022]
Abstract
Purpose Acute compartment syndrome is a condition whereby tissue ischaemia occurs due to increased pressure in a closed myofascial compartment. It is a surgical emergency, with rapid recognition and treatment—the keys to good outcomes. Methods The available literature on diagnostic aids was reviewed by one of the senior authors 15 years ago. Now, we have further reviewed the literature, to aim to ascertain what progress has been made. Results In this review, we present the evidence around a variety of available diagnostic options when investigating a potential case of acute compartment syndrome, including those looking at pressure changes, localised oxygenation, perfusion, metabolic changes and available blood serum biomarkers. Conclusions A significant amount of work has been put into developing modalities of diagnosis for acute compartment syndrome in the last 15 years. There is a lot of promising outcomes being reported; however, there is yet to be any conclusive evidence to suggest that they should be used over intracompartmental pressure measurement, which remains the gold standard. However, clinicians should be cognizant that compartment pressure monitoring lacks diagnostic specificity, and could lead to unnecessary fasciotomy when used as the sole criterion for diagnosis. Therefore, pressure monitoring is ideally used in situations where clinical suspicion is raised.
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Ganesan K, Tan JSH, Kumar P. Guidewire perforation and compartment syndrome after lower extremity angioplasty. VASA 2019; 49:72-76. [PMID: 31414968 DOI: 10.1024/0301-1526/a000813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chronic total occlusion remains one of the most challenging lesions to treat despite continuing developments in medical devices and increasing operator experience. Guidewire perforation complications are being increasingly observed. Early recognition and timely institution of appropriate treatment are essential to prevent potentially devastating sequelae.
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Affiliation(s)
| | - Janice Ser Huey Tan
- Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Pradesh Kumar
- Vascular and Interventional Radiology, Singapore General Hospital, Singapore
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25
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Current Approach to the Evaluation and Management of Acute Compartment Syndrome in Pediatric Patients. Pediatr Emerg Care 2019; 35:432-437. [PMID: 31157749 DOI: 10.1097/pec.0000000000001855] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute compartment syndrome is an emergent condition caused by increased pressure within a closed compartment. The most common etiology is fractures, but there a number of atraumatic causes cited in the literature. Acute compartment syndrome occurs most frequently in the anterior compartment of the lower leg, followed by the volar forearm. Patients may present with severe pain, pain with passive stretch, swelling, paresthesias, numbness, weakness, decreased pulses, and delayed capillary refill. No finding in isolation can exclude the diagnosis. Direct measurement of the intracompartmental pressure is the most important diagnostic test. Treatment involves removal of compressive dressings and surgical consultation for emergent fasciotomy.
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26
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Long B, Koyfman A, Gottlieb M. Evaluation and Management of Acute Compartment Syndrome in the Emergency Department. J Emerg Med 2019; 56:386-397. [DOI: 10.1016/j.jemermed.2018.12.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/17/2018] [Accepted: 12/08/2018] [Indexed: 12/30/2022]
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Nudel I, Dorfmann L, deBotton G. The compartment syndrome: is the intra-compartment pressure a reliable indicator for early diagnosis? MATHEMATICAL MEDICINE AND BIOLOGY-A JOURNAL OF THE IMA 2018; 34:547-558. [PMID: 27756790 DOI: 10.1093/imammb/dqw016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 09/10/2016] [Indexed: 12/12/2022]
Abstract
Compartment syndrome (CS) occurs when the pressure in an enclosed compartment increases due to tissue swelling or internal bleeding. As the intra-compartmental pressure (ICP) builds up, the blood flow to the tissue or the organ is compromised, resulting in ischemia, necrosis and damage to the nerves and other tissues. At the present there are no established diagnostic procedures, and clinical observations such as pain, paralysis and even compartment pressure monitoring are an unreliable determinant of the presence of the syndrome. Late diagnosis may result in fasciotomy, neurological dysfunctions, amputation and even death. Focusing on the frequently occurring CS of the lower leg, this work is aimed toward introducing a coherent, mechanically motivated analysis of the disease within the framework of poroelasticity. The fascia enclosing the compartment is treated as an inextensible and impermeable layer, and the tissue inside the compartment is represented as a fully saturated poroelastic solid. The model quantitatively predicts the highly non-uniform ICP buildup as a function of both time and location. These findings, which are in good agreement with clinical observations reported in the literature, shed light on the difficulties associated with the identification of the syndrome and may assist in improved diagnostic procedures.
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Affiliation(s)
- Iftah Nudel
- Department of Biomedical Engineering, Ben-Gurion University, Beer-Sheva 8410501, Israel
| | - Luis Dorfmann
- Department of Civil and Environmental Engineering, Tufts University, Medford, MA 02155, USA
| | - Gal deBotton
- Department of Biomedical Engineering, Ben-Gurion University, Beer-Sheva 8410501, Israel
- Department of Mechanical Engineering, Ben-Gurion University, Beer-Sheva 8410501, Israel
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Schellenberg M, Chong V, Cone J, Keeley J, Inaba K. Extremity compartment syndrome. Curr Probl Surg 2018; 55:256-273. [PMID: 30470346 DOI: 10.1067/j.cpsurg.2018.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/09/2018] [Indexed: 01/04/2023]
Affiliation(s)
- Morgan Schellenberg
- Fellow in Trauma and Surgical Critical Care LAC + USC Medical Center, Los Angeles, CA
| | - Vincent Chong
- Fellow in Trauma and Surgical Critical Care LAC + USC Medical Center, Los Angeles, CA
| | - Jennifer Cone
- Assistant Professor of Surgery Division of Trauma and Acute Care Surgery, University of Chicago Medical Center, Chicago, IL
| | - Jessica Keeley
- Fellow in Trauma and Surgical Critical Care LAC + USC Medical Center, Los Angeles, CA
| | - Kenji Inaba
- Professor of Surgery, Emergency Medicine, and Anesthesia Medical Director, Surgical Intensive Care Unit Associate Trauma Medical Director University of Southern California, Los Angeles, CA.
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Near-Infrared Spectroscopy Monitoring for Early Detection of Limb Ischemia in Patients on Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J 2018; 63:613-617. [PMID: 28125467 DOI: 10.1097/mat.0000000000000532] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
This study aimed to investigate the effectiveness of near-infrared spectroscopy (NIRS) monitoring for the early detection of limb ischemia in patients who were placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) via femoral artery. We prospectively used NIRS monitoring for the early detection of limb ischemia in 28 adult patients, who were supported with peripheral VA-ECMO between August 2013 and August 2014 (NIRS group). A decision to perform distal perfusion catheterization was made in accordance with the regional oxygen saturation (rSO2) values provided by the NIRS system. For the comparison of outcome, the medical records of 36 adult patients who had been previously supported with peripheral VA-ECMO without NIRS monitoring (Control group), between July 2012 and July 2013, were retrospectively reviewed. There was no significant difference between the frequency of distal perfusion in both groups (p = 0.435). The mean time to distal perfusion is shorter in the NIRS group (19.6 ± 21.4 vs. 42.0 ± 69.0 hours). No patient underwent fasciotomy in the NIRS group, while 13.9% did in the control group (p = 0.040). We think that NIRS monitoring is a useful and reliable method for the early detection of limb ischemia in patients undergoing peripheral VA-ECMO. Its application may allow timely correction of perfusion deficits and the prevention of compartment syndrome and limb complications.
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30
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The Controversy of Regional Anesthesia, Continuous Peripheral Nerve Blocks, Analgesia, and Acute Compartment Syndrome. Tech Orthop 2017. [DOI: 10.1097/bto.0000000000000260] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Martinez AP, Moser TP, Saran N, Paquet M, Hemmerling T, Berry GK. Phonomyography as a non-invasive continuous monitoring technique for muscle ischemia in an experimental model of acute compartment syndrome. Injury 2017; 48:2411-2416. [PMID: 28867642 DOI: 10.1016/j.injury.2017.08.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/22/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND In acute compartment syndrome (ACS), clinicians have difficulty diagnosing muscle ischemia provoked by increased intra-compartmental pressure in a timely and non-invasive manner. Phonomyography records the acoustic signal produced by muscle contraction. We hypothesize that alterations in muscle contraction caused by muscle ischemia can be detected with phonomyography, serving as a potential non-invasive technique in the detection of ACS. METHODS The left hind limb of 15 Sprague-Dawley rats was submitted to a reversible ischemic model of limb injury for 30min and 1, 2, 4, 6h (3 rats in each group). The right limb served as control. Phonomyography microphones were placed over the posterior calf of both limbs and the sciatic nerve was stimulated percutaneously at 10-min intervals to evaluate muscle contraction. Histopathological analysis of muscles and nerves biopsies was performed and correlation was made between duration of injury, phonomyography output and degree of muscle and nerve necrosis. RESULTS There was a statistically significant decrease in the phonomyography signal output in the ischemic limb that correlated with the duration of ischemia and histological findings of muscle and nerve necrosis. The phonomyography signal decrease and histological findings were respectively: 55.5% (n=15;p=0.005) with rare muscle and nerve necrosis at 30min, 65.6% (n=12;p=0.005) with 5-10% muscle necrosis at 1h, 68.4% (n=9;p=0.015) with 100% muscle necrosis and little nerve damage at 2h, 72.4% (n=6;p=0.028) with 100% muscle necrosis and severe nerve damage at 4h, and 92.8% (n=3;p=0.109) with 100% muscle necrosis and severe nerve degeneration at 6h. CONCLUSION Changes in phonomyography signal are observed in early ischemic injury prior to the onset of nerve or muscle necrosis. Therefore, phonomyography could serve as a non-invasive technique to detect early ischemic muscle changes in acute compartment syndrome. CLINICAL RELEVANCE The detection of abnormal muscle contraction in a timely fashion and non-invasive manner is of interest in clinical settings where the presence of ischemia is not easy to diagnose.
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Affiliation(s)
| | - Thomas P Moser
- Department of Radiology, Université de Montréal, Montreal, Canada.
| | - Neil Saran
- Department of Orthopaedic Surgery, Shriners Hospital for Children, McGill University, Montreal, Quebec, Canada.
| | - Marilène Paquet
- Département de pathologie et de microbiologie, Faculté de Médecine Vétérinaire, Université de Montréal, Montreal, Canada.
| | | | - Greg K Berry
- Department of Orthopaedic Surgery, McGill University, Montreal, Canada.
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Cone J, Inaba K. Lower extremity compartment syndrome. Trauma Surg Acute Care Open 2017; 2:e000094. [PMID: 29766095 PMCID: PMC5877908 DOI: 10.1136/tsaco-2017-000094] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/25/2017] [Indexed: 12/11/2022] Open
Abstract
Lower extremity compartment syndrome is a devastating complication if not rapidly diagnosed and properly managed. The classic symptoms of compartment syndrome can be deceiving as they occur late. Any concern for compartment syndrome based on mechanism, or the presence of pain in the affected extremity, should prompt a compartment pressure check. Both absolute compartment pressures above 30 mm Hg and a pressure differential of less than 30 mm Hg are used to make the diagnosis. The treatment goal is first to save the patient’s life and second to salvage the affected limb. Fasciotomy is the only accepted treatment of compartment syndrome and should be performed quickly after the diagnosis is made. Outcomes after fasciotomy are best when there is no delay in treatment.
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Affiliation(s)
- Jennifer Cone
- Trauma and Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California, USA
| | - Kenji Inaba
- Trauma and Acute Care Surgery, LAC+USC Medical Center, Los Angeles, California, USA
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Padegimas EM, Schoch BS, Kwon J, DiMuzio PJ, Williams GR, Namdari S. Evaluation and Management of Axillary Artery Injury: The Orthopaedic and Vascular Surgeon’s Perspective. JBJS Rev 2017. [DOI: 10.2106/jbjs.rvw.16.00082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
Acute compartment syndrome is a well-known complication of tibial fractures, yet it remains difficult to diagnose and the only effective treatment is surgical fasciotomy. Delayed fasciotomy is the most important factor contributing to poor outcomes, and as a result, treatment is biased towards performing early fasciotomy. Current diagnosis of ACS is based on clinical findings and intramuscular pressure (IMP) measurement, and is targeted at identifying safe thresholds for when fasciotomy can be avoided. Since clinical findings are variable and difficult to quantify, measurement of IMP - ideally continuously - is the cornerstone of surgical decision - making. Numerous investigators are searching for less invasive and more direct measurements of tissue ischemia, including measurement of oxygenation, biomarkers, and even neurologic monitoring. This article provides a brief but thorough review of the current state of the art in compartment syndrome diagnosis and treatment.
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Affiliation(s)
- Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin County Medical Center, University of Minnesota, 701 Park Ave. South, Mailcode G2, Minneapolis, MN, USA.
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Abstract
Acute compartment syndrome (ACS) is a well-known pathophysiologic complication of trauma or tissue ischemia. ACS affects the appearance, function, and even the viability of the involved limb, and demands immediate diagnosis and treatment. However, ACS is difficult to diagnose and the only effective treatment is decompressive surgical fasciotomy. The clinical signs and symptoms may easily be attributed to other aspects of the injury, which further complicates the diagnosis. This article highlights the latest information regarding the diagnosis of ACS, how to perform fasciotomies, how to manage fasciotomy wounds, and also reviews complications and outcomes of ACS.
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Affiliation(s)
- Andrew H Schmidt
- Department of Orthopaedic Surgery, Hennepin County Medical Center, 701 Park Avenue South, Mail Code G2, Minneapolis, MN 55415, USA.
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Tuna S, Duymus TM, Mutlu S, Ketenci IE, Ulusoy A. Upper extremity acute compartment syndrome during tissue plasminogen activator therapy for pulmonary embolism in a morbidly obese patient. Int J Surg Case Rep 2015; 8C:175-8. [PMID: 25618841 PMCID: PMC4353933 DOI: 10.1016/j.ijscr.2015.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/11/2015] [Accepted: 01/13/2015] [Indexed: 12/21/2022] Open
Abstract
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are more frequently observed morbidly obese patients. As the use of thrombolytic therapy has become more common in the treatment of myocardial infarction (MI) and PE, acute compartment syndrome (ACS) has been reported as a rare complication of thrombolytic therapy. As soon as the diagnosis of compartment syndrome is made, an emergency fasciotomy should be performed. Close follow-up is required to avoid wound healing problems after the fasciotomy.
Introduction Deep vein thrombosis (DVT) and pulmonary embolism (PE) are more frequently observed in morbidly obese patients. Tissue plasminogen activator (tPA) is a thrombolytic agent which dissolves the thrombus more rapidly than conventional heparin therapy and reduces the mortality and morbidity rates associated with PE. Compartment syndrome is a well-known and documented complication of thrombolytic treatment. In awake, oriented and cooperative patients, the diagnosis of compartment syndrome is made based on clinical findings including swelling, tautness, irrational and continuous pain, altered sensation, and severe pain due to passive stretching. These clinical findings may not be able to be adequately assessed in unconscious patients. Presentation of case In this case report, we present compartment syndrome observed, for which fasciotomy was performed on the upper right extremity of a 46-year old morbidly obese, conscious female patient who was receiving tPA due to a massive pulmonary embolism. Discussion Compartment syndrome had occurred due to the damage caused by the repeated unsuccessful catheterisation attempts to the brachial artery and the accompanying tPA treatment. Thus, the bleeding that occurred in the volar compartment of the forearm and the anterior compartment of the arm led to acute compartment syndrome (ACS). After relaxation was brought about in the volar compartment of the forearm and the anterior compartment of the arm, the circulation in the limb was restored. Conclusion As soon as the diagnosis of compartment syndrome is made, an emergency fasciotomy should be performed. Close follow-up is required to avoid wound healing problems after the fasciotomy.
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Affiliation(s)
- Serkan Tuna
- Department of Orthopaedics, Haydarpasa Numune Training Research Hospital, Istanbul, Turkey
| | - Tahir Mutlu Duymus
- Department of Orthopaedics, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Serhat Mutlu
- Department of Orthopaedics, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey.
| | - Ismail Emre Ketenci
- Department of Orthopaedics, Haydarpasa Numune Training Research Hospital, Istanbul, Turkey
| | - Ayhan Ulusoy
- Department of Orthopaedics, Haydarpasa Numune Training Research Hospital, Istanbul, Turkey
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Hua SY, Li YT, Hung CC, Pan RY. Compartment Syndrome Following Directly Repair of Hernia of Anterior Tibialis. JOURNAL OF MEDICAL SCIENCES 2015. [DOI: 10.4103/1011-4564.173009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ali P, Santy-Tomlinson J, Watson R. Assessment and diagnosis of acute limb compartment syndrome: A literature review. Int J Orthop Trauma Nurs 2014. [DOI: 10.1016/j.ijotn.2014.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Jentzsch T, Brand-Staufer B, Schäfer FP, Wanner GA, Simmen HP. Illustrated operative management of spontaneous bleeding and compartment syndrome of the lower extremity in a patient with acquired hemophilia A: a case report. J Med Case Rep 2014; 8:132. [PMID: 24886030 PMCID: PMC4109126 DOI: 10.1186/1752-1947-8-132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 02/03/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Spontaneous bleeding resulting in compartment syndrome at the lower adult leg due to acquired hemophilia A is rare. There are no reports on operative management of this entity. CASE PRESENTATION We present a case of atraumatic compartment syndrome of the lower leg due to acquired factor VIII deficiency, in an 83-year-old Caucasian man of European descent. He was treated surgically with a long and complicated postoperative course after presenting to a community hospital with a 2-day history of increasing pain and swelling in his left lower leg without a previous history of trauma. CONCLUSIONS Awareness, prompt diagnosis and effective treatment of compartment syndrome caused by a rare bleeding disorder, which is usually acquired by the elderly, is essential and may spare a patient from surgery or even limb loss, if early administration of recombinant factor VIIa is effective. The course of disease in a patient with operative management of spontaneous bleeding, compartment syndrome and acquired hemophilia A may be prolonged. However, an interdisciplinary approach with meticulous surgical treatment and bleeding management with recombinant factor VIIa as well as inhibitor eradication by immunosuppressive treatment can be successful and expensive.
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Affiliation(s)
- Thorsten Jentzsch
- Division of Trauma Surgery, Department of Surgery, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland.
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Bauer EC, Koch N, Janni W, Bender HG, Fleisch MC. Compartment syndrome after gynecologic operations: evidence from case reports and reviews. Eur J Obstet Gynecol Reprod Biol 2014; 173:7-12. [DOI: 10.1016/j.ejogrb.2013.10.034] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 10/10/2013] [Accepted: 10/31/2013] [Indexed: 11/26/2022]
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Extremity compartment syndrome and fasciotomy: a literature review. Eur J Trauma Emerg Surg 2013; 39:561-7. [DOI: 10.1007/s00068-013-0329-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 09/07/2013] [Indexed: 10/26/2022]
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Hori D, Noguchi K, Nomura Y, Lefor A, Tanaka H. Small incision fasciotomy in a patient with compartment syndrome and peripheral arterial occlusive disease. Ann Thorac Cardiovasc Surg 2012; 19:234-8. [PMID: 23232306 DOI: 10.5761/atcs.cr.12.01904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
An 82-year-old-man with a previous history of atrial fibrillation was admitted with acute limb ischemia. Emergent embolectomy was performed, but after the operation, the patient suffered from recurrent ischemic pain. Peripheral angiography revealed thrombosis of the distal popliteal artery due to pre-existing peripheral arterial occlusive disease. Bypass surgery of the popliteal artery and posterior tibial artery was then performed. Although peripheral blood flow was restored after the operation, he suffered from compartment syndrome the next day. The patient was treated with an emergent bed-side fasciotomy using a small incision, achieving full recovery of blood flow to the distal artery. The wound closed secondarily without surgical closure. In a patient with peripheral arterial occlusive disease, fasciotomy should be performed at a lower compartment pressure due to a lack of peripheral perfusion pressure. Emergent small incision fasciotomy was effective in this patient with an acute compartment syndrome and an ischemic limb.
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Affiliation(s)
- Daijiro Hori
- Department of Cardiovascular Surgery, Showa University, Fujigaoka Hospital, Kanagawa, Japan.
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Mabvuure NT, Malahias M, Hindocha S, Khan W, Juma A. Acute compartment syndrome of the limbs: current concepts and management. Open Orthop J 2012; 6:535-43. [PMID: 23248724 PMCID: PMC3522209 DOI: 10.2174/1874325001206010535] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 09/07/2012] [Accepted: 09/19/2012] [Indexed: 11/22/2022] Open
Abstract
Acute compartment syndrome (ACS) of the limb refers to a constellation of symptoms, which occur following a rise in the pressure inside a limb muscle compartment. A failure or delay in recognising ACS almost invariably results in adverse outcomes for patients. Unrecognised ACS can leave patients with nonviable limbs requiring amputation and can also be life–threatening. Several clinical features indicate ACS. Where diagnosis is unclear there are several techniques for measuring intracompartmental pressure described in this review. As early diagnosis and fasciotomy are known to be the best determinants of good outcomes, it is important that surgeons are aware of the features that make this diagnosis likely. This clinical review discusses current knowledge on the relevant clinical anatomy, aetiology, pathophysiology, risk factors, clinical features, diagnostic procedures and management of an acute presentation of compartment syndrome.
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Ferlic PW, Singer G, Kraus T, Eberl R. The acute compartment syndrome following fractures of the lower leg in children. Injury 2012; 43:1743-6. [PMID: 22795846 DOI: 10.1016/j.injury.2012.06.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 06/20/2012] [Accepted: 06/26/2012] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The acute compartment syndrome (ACS) of the lower leg is a rare but serious complication following either fractures or soft tissue injuries. An acute intervention consisting of fasciotomy is indicated as ACS may cause muscle and nerve damage. The aim of the present study was to evaluate the cause, the incidence, the time to fasciotomy and the outcome of ACS of the lower leg following fractures in a paediatric population. PATIENTS AND METHODS A retrospective analysis of all patients with ACS following a fracture of the lower leg treated from 1998 to 2010 was performed. The time from admission to occurrence of the ACS, the kind of fracture and surgical treatment was evaluated. Accident mechanisms were recorded. RESULTS A total of 1028 fractures of the lower leg were treated. 31 patients (3%) with a median age of 14.6 years (range 7.3-17.1 years) developed an ACS. In the group of patients younger than 12 years the incidence was even lower (1.3%). 81% of injuries leading to ACS were caused by high-energy trauma, with motorcycle accidents being the most common (45%). External fixation was used in 45%, including all open fractures. The diagnosis of an ACS was primarily based on clinical symptoms. In 23 cases an intracompartmental pressure of median 55mmHg (range 40-100mmHg) were measured. ACS was diagnosed after 19h mean (range: 1.5-65h). There was a tendency that the ACS occurred earlier after high-energy trauma than after low energy trauma (mean 16.9 vs. mean 28h). No complications linked to the compartment syndrome were observed. DISCUSSION ACS can occur up to 65h after an accident and therefore clinical monitoring is fundamental in order to be able to surgically intervene as soon as possible when needed. With early decompression complications can be prevented.
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Affiliation(s)
- Peter W Ferlic
- Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria.
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Abstract
Acute compartment syndrome is a limb-threatening condition in which early diagnosis and surgical consultation for fasciotomy are required to preserve functional outcome. The diagnosis is typically considered in patients with traumatic mechanisms of injury such as a direct blow and crush to the compartment, particularly when there is a fracture in the same compartment. We report the case of a patient with acute compartment syndrome of the dorsal forearm that occurred as a result of an atypical noncontact traumatic mechanism. Establishing the diagnosis of compartment syndrome was complicated in this patient, as some of the signs and symptoms of acute compartment syndrome could have been attributed to the presence of a coexisting rupture of the extensor digitorum muscle. This report serves to remind emergency physicians that, although rare, acute compartment syndrome can result from exertional and noncontact traumatic mechanisms.
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Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment syndrome of the lower leg and foot. Clin Orthop Relat Res 2010; 468:940-50. [PMID: 19472025 PMCID: PMC2835588 DOI: 10.1007/s11999-009-0891-x] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Accepted: 04/30/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED 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. LEVEL OF EVIDENCE Level III. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael Frink
- Department of Traumatology, Hannover Medical School, Hannover, Germany
| | - Frank Hildebrand
- Department of Traumatology, Hannover Medical School, Hannover, Germany
| | - Christian Krettek
- Department of Traumatology, Hannover Medical School, Hannover, Germany
| | - Jurgen Brand
- Praxisklinik Uelzen, Celler Str. 26A, 29525 Uelzen, Germany
| | - Stefan Hankemeier
- Department of Traumatology, Hannover Medical School, Hannover, Germany
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Abstract
Although fasciae have long interested clinicians in a multitude of different clinical and paramedical disciplines, there have been few attempts to unite the ensuing diverse literature into a single review. The current article gives an anatomical perspective that extends from the gross to the molecular level. For expediency, it deals only with fascia in the limbs and back. Particular focus is directed towards deep fascia and thus consideration is given to structures such as the fascia lata, thoracolumbar fascia, plantar and palmar fascia, along with regional specializations of deep fascia such as retinacula and fibrous pulleys. However, equal emphasis is placed on general aspects of fascial structure and function, including its innervation and cellular composition. Among the many functions of fascia considered in detail are its ectoskeletal role (as a soft tissue skeleton for muscle attachments), its importance for creating osteofascial compartments for muscles, encouraging venous return in the lower limb, dissipating stress concentration at entheses and acting as a protective sheet for underlying structures. Emphasis is placed on recognizing the continuity of fascia between regions and appreciating its key role in coordinating muscular activity and acting as a body-wide proprioceptive organ. Such considerations far outweigh the significance of viewing fascia in a regional context alone.
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Affiliation(s)
- Mike Benjamin
- School of Biosciences, Cardiff University, Cardiff, UK.
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Abstract
Lower-extremity burns in a pediatric patient require special consideration. The management of burn reconstruction in pediatric patients is often complex, requiring multiple reconstructive operations, and the primary intention of the surgeon is to prevent burn scar deformities. Timely management of the burn wound and postburn scars has decreased the incidence of burn scar deformities and contractures of the lower extremity in recent years. We present an overview of the principles of reconstruction techniques using skin grafting and biologic skin substitutes to restore the important barrier lost secondary to burns. In addition, we address methods of repairing scar contracture, a common occurrence in burn patients, at specific locations on the lower extremity. Finally, special scenarios such as burns associated with fractures, burn injury in insensate children, and Marjolin ulcer are discussed.
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Infrared imaging of trauma patients for detection of acute compartment syndrome of the leg. Crit Care Med 2008; 36:1756-61. [PMID: 18496371 DOI: 10.1097/ccm.0b013e318174d800] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Early compartment syndrome is difficult to diagnose, and a delay in the diagnosis can result in amputation or death. Our objective was to explore the potential of infrared imaging, a portable and noninvasive technology, for detecting compartment syndrome in the legs of patients with multiple trauma. We hypothesized that development of compartment syndrome is associated with a reduction in surface temperature in the involved leg and that the temperature reduction can be detected by infrared imaging. DESIGN Observational clinical study. SETTING Level I trauma center between July 2006 and July 2007. PATIENTS Trauma patients presenting to the emergency department. INTERVENTIONS Average temperature of the anterior surface of the proximal and distal region of each leg was measured in the emergency department with a radiometrically calibrated, 320 x 240, uncooled microbolometer infrared camera. MEASUREMENTS AND MAIN RESULTS The difference in surface temperature between the thigh and foot regions (thigh-foot index) of the legs in trauma patients was determined by investigators blinded to injury pattern using thermographic image analysis software. The diagnosis of compartment syndrome was made intraoperatively. Thermographic images from 164 patients were analyzed. Eleven patients developed compartment syndrome, and four of those patients had bilateral compartment syndrome. Legs that developed compartment syndrome had a greater difference in proximal vs. distal surface temperature (8.80 +/- 2.05 degrees C) vs. legs without compartment syndrome (1.22 +/- 0.88 degrees C) (analysis of variance p < .01). Patients who developed unilateral compartment syndrome had a greater proximal vs. distal temperature difference in the leg with (8.57 +/- 2.37 degrees C) vs. the contralateral leg without (1.80 +/- 1.60 degrees C) development of compartment syndrome (analysis of variance p < .01). CONCLUSIONS Infrared imaging detected a difference in surface temperature between the proximal and distal leg of patients who developed compartment syndrome. This technology holds promise as a supportive tool for the early detection of acute compartment syndrome in trauma patients.
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Thati S, Carlson C, Maskill JD, Anderson JG, Bohay DR. Tibial compartment syndrome and the cavovarus foot. Foot Ankle Clin 2008; 13:275-305, vii. [PMID: 18457774 DOI: 10.1016/j.fcl.2008.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Compartment syndrome of the leg is an orthopedic emergency that requires a high index of suspicion for diagnosis and a low threshold for surgical management to prevent devastating complications. Where the clinical findings are subtle, continuous monitoring of compartment pressures, with clinical correlation, is the key to diagnosis. Surgical management should include decompression of all four compartments and early rehabilitation to prevent ischemic contracture. If contracture develops, it may cause varying degrees of equinocavovarus deformity of the foot and ankle. Appropriate evaluation and careful surgical planning that considers all components of this complex deformity are essential for obtaining good clinical results.
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Affiliation(s)
- Srinivas Thati
- Orthopaedic Associates of Grand Rapids, P.C., Foot and Ankle Division, Grand Rapids, MI 49525, USA
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