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Novak M, Penhaker M, Raska P, Pleva L, Schmidt M. Extremity compartment syndrome: A review with a focus on non-invasive methods of diagnosis. Front Bioeng Biotechnol 2022; 10:801586. [PMID: 35923576 PMCID: PMC9340208 DOI: 10.3389/fbioe.2022.801586] [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: 10/25/2021] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
The article deals with an overview of acute extremity compartment syndrome with a focus on the option of non-invasive detection of the syndrome. Acute extremity compartment syndrome (ECS) is an urgent complication that occurs most often in fractures or high-energy injuries. There is still no reliable method for detecting ECS. The only objective measurement method used in clinical practice is an invasive measurement of intramuscular pressure (IMP). The purpose of this paper is to summarize the current state of research into non-invasive measurement methods that could allow simple and reliable continuous monitoring of patients at risk of developing ECS. Clinical trials are currently underway to verify the suitability of the most studied method, near-infrared spectroscopy (NIRS), which is a method for measuring the local oxygenation of muscle compartments. Less explored methods include the use of ultrasound, ultrasound elastography, bioimpedance measurements, and quantitative tissue hardness measurements. Finding a suitable method for continuous non-invasive monitoring of the syndrome would greatly improve the quality of care for patients at risk. ECS must be diagnosed quickly and accurately to prevent irreversible tissue damage that can occur within hours of syndrome onset and may even warrant amputation if neglected.
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Affiliation(s)
- Martin Novak
- Trauma Surgery Clinic, University Hospital Ostrava, Ostrava, Czechia
| | - Marek Penhaker
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB—Technical University of Ostrava, Ostrava, Czechia
| | - Pavel Raska
- Department of Occupational and Process Safety, Faculty of Safety Engineering, VSB—Technical University of Ostrava, Ostrava, Czechia
| | - Leopold Pleva
- Trauma Surgery Clinic, University Hospital Ostrava, Ostrava, Czechia
| | - Martin Schmidt
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB—Technical University of Ostrava, Ostrava, Czechia
- *Correspondence: Martin Schmidt,
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Mortensen SJ, Vora MM, Mohamadi A, Wright CL, Hanna P, Lechtig A, Egan J, Williamson PM, Wixted JJ, Rutkove SB, Nazarian A. Diagnostic Modalities for Acute Compartment Syndrome of the Extremities: A Systematic Review. JAMA Surg 2020; 154:655-665. [PMID: 31042278 DOI: 10.1001/jamasurg.2019.1050] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Acute compartment syndrome (ACS) can cause catastrophic tissue damage leading to permanent muscle and nerve loss. Acute compartment syndrome is a clinical diagnosis, with intracompartmental pressure (ICP) used in equivocal cases. There are no reliable diagnostic methods. The clinical evaluation is impossible to standardize, and the threshold for ICP has been known to be unreliable; thus, guidelines for diagnosis can result in overtreatment or delayed diagnosis. Objective To present and review the advantages and disadvantages of each diagnostic modality and identify gaps that need to be addressed in the future and to review the most used and appropriate animal and human ACS models. Evidence Review We included clinical studies and animal models investigating diagnostic modalities for ACS of the extremities. A MEDLINE and Web of Science search was performed. The protocol for the study was registered on PROSPERO (CRD42017079266). We assessed the quality of the clinical studies with Newcastle-Ottawa scale and reported level of evidence for each article. Findings Fifty-one articles were included in this study, reporting on 38 noninvasive and 35 invasive modalities. Near-infrared spectroscopy and direct ICP measurement using a Stryker device were the most common, respectively. Cadaveric studies used saline infusions to create an ACS model. Most studies with human participants included injured patients with acquired ACS or at risk of developing ACS. In healthy human participants, tourniquets formed the most commonly used ACS model. Application of tourniquets and infusion of saline or albumin were the most used ACS models among animal studies. Conclusions and Relevance This article reports on the most common as well as many new and modified diagnostic modalities, which can serve as inspiration for future investigations to develop more effective and efficient diagnostic techniques for ACS. Future studies on diagnostic modalities should include the development of tools for continuous assessment of ICP to better identify the earliest alterations suggestive of impending ACS. With the advent of such technologies, it may be possible to develop far less aggressive and more effective approaches for early detection of ACS.
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Affiliation(s)
- Sharri J Mortensen
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Molly M Vora
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Amin Mohamadi
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Casey L Wright
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Philip Hanna
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Aron Lechtig
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Jonathan Egan
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Patrick M Williamson
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - John J Wixted
- Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Seward B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.,Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
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Walters TJ, Kottke MA, Hargens AR, Ryan KL. Noninvasive diagnostics for extremity compartment syndrome following traumatic injury: A state-of-the-art review. J Trauma Acute Care Surg 2019; 87:S59-S66. [PMID: 31246908 DOI: 10.1097/ta.0000000000002284] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute compartment syndrome (ACS) is a serious medical condition that can occur following traumatic injury to an extremity. If left undiagnosed, ACS can eventuate in amputation of the limb or even death. Because of this, fasciotomy to release the pressure within the muscle and restore tissue perfusion is often performed upon suspicion of ACS, as the sequelae to fasciotomy are less severe than those associated with not performing the fasciotomy. Currently, the "gold standard" of diagnosis is based on clinical assessment of such symptoms as pain out of proportion to the injury, obvious high pressure and swelling, pain on passive stretch of the muscles in the affected compartment, and deficits in sensory and/ormotor functions. Diagnosis is often confirmed using invasive measurements of intramuscular pressure (IMP); however, controversy exists as to how direct IMP measurement should be accomplished and threshold pressures for accurate diagnosis. Because of this and the attendant issues with invasive measurements, investigators have been searching over the last 25 years for a noninvasive means to quantitatively measure IMP or perfusion to the limb. The purpose of this review is to summarize the current state of the art of noninvasive devices that could potentially be used to diagnose ACS accurately and objectively. To do this, we divide the discussion into those medical devices that primarily measure mechanical surrogates of IMP (e.g., tissue hardness or myofascial displacement) and those that primarily measure indices of tissue perfusion (e.g., tissue oxygen saturation via near-infraredspectroscopy). While near-infrared spectroscopy-basedtechnologies have shown the most promise, whether such technologies will be of diagnostic benefit await the completion of ongoing clinical trials. LEVEL OF EVIDENCE: Systematic Review, level II.
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Affiliation(s)
- Thomas J Walters
- From the US Army Institute of Surgical Research (T.J.W., M.A.K., K.L.R.), Fort Sam Houston, San Antonio, Texas; and Department of Orthopaedic Surgery, Altman Clinical and Translational Research Institute (A.R.H.), University of California San Diego, San Diego, California
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Young KW, Kuo BPP, O'Connor SM, Radic S, Lieber RL. In Vivo Sarcomere Length Measurement in Whole Muscles during Passive Stretch and Twitch Contractions. Biophys J 2017; 112:805-812. [PMID: 28256239 DOI: 10.1016/j.bpj.2016.12.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/05/2016] [Accepted: 12/27/2016] [Indexed: 11/29/2022] Open
Abstract
Muscle force is dictated by micrometer-scale contractile machines called sarcomeres. Whole-muscle force drops from peak force production to zero with just a few micrometers of sarcomere length change. No current technology is able to capture adequate dynamic sarcomere data in vivo, and thus we lack fundamental data needed to understand human movement and movement disorders. Methods such as diffraction, endoscopy, and optical coherence tomography have been applied to muscle but are prohibitively invasive, sensitive to motion artifact, and/or imprecise. Here, we report dynamic sarcomere length measurement in vivo using a combination of our recently validated resonant reflection spectroscopy method combined with optical frequency domain interferometry. Using a 250-μm-wide fiber optic probe, we captured nanometer sarcomere length changes from thousands of sarcomeres on the sub-millisecond timescale during whole-muscle stretch and twitch contraction. We believe that this demonstrates the first large-scale sensing of sarcomere dynamics in vivo, which is a necessary first step to understand movement disorders and to create patient-specific surgical interventions and rehabilitation.
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Affiliation(s)
- Kevin W Young
- Department of Bioengineering, University of California, San Diego, La Jolla, California; VA San Diego Healthcare System, San Diego, California
| | - Bill P-P Kuo
- Department of Electrical and Computer Engineering, University of California, San Diego, La Jolla, California
| | - Shawn M O'Connor
- Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, California
| | - Stojan Radic
- Department of Electrical and Computer Engineering, University of California, San Diego, La Jolla, California
| | - Richard L Lieber
- Department of Bioengineering, University of California, San Diego, La Jolla, California; VA San Diego Healthcare System, San Diego, California; Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, California; Rehabilitation Institute of Chicago and Northwestern University, Chicago, Illinois.
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Abstract
Pediatric acute compartment syndrome (PACS) is a clinical entity that must be carefully differentiated from the adult version (ie, acute compartment syndrome). Healthcare providers must understand the variable etiologies of PACS, of which trauma is the most common but can also include vascular insult, infection, surgical positioning, neonatal phenomena, overexertion, and snake and insect bites. In addition to the unique etiologies of PACS, providers must also recognize the different signs and symptoms of PACS. The three As (ie, anxiety, agitation, analgesic requirement) of PACS have supplanted the classic adult signs as being more accurate and allowing earlier detection. In children with questionable clinical signs but concern for PACS, compartment pressure measurement may be necessary to confirm the diagnosis. Overall, outcomes after fasciotomy in children tend to be excellent; however, diagnostic delays secondary to unfamiliar clinical scenarios can lead to myonecrosis and subsequent poor outcomes.
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Sugamata A, Yoshizawa N, Okada T. Relaxation incisions of venomous snake "Japanese mamushi" bites to the hand. Int Med Case Rep J 2011; 4:87-91. [PMID: 23754913 PMCID: PMC3658245 DOI: 10.2147/imcrj.s27711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Gloydius blomhoffii, commonly known as Japanese mamushi, is a venomous viper species found widely in Japan. The most frequently bitten regions are the fingers and toes, and severe swelling causes compression of peripheral arteries and/or compartment syndrome of the extremities. We experienced four cases of mamushi bites to the hand, and undertook relaxation incision in the hands of three of these patients. As a result, the patients who underwent relaxation incision did not show any skin necrosis or permanent sensory disturbance in the affected fingers. Relaxation incision can be useful to not only decompress subcutaneous and compartment pressure of the hand, but also to wash out the venom from the bitten region by improving venous and lymphatic drainage.
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Affiliation(s)
- Akira Sugamata
- Department of Plastic and Reconstructive Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
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Steinberg B, Riel R, Armitage M, Berrey H. Quantitative muscle hardness as a noninvasive means for detecting patients at risk of compartment syndromes. Physiol Meas 2011; 32:433-44. [PMID: 21383493 DOI: 10.1088/0967-3334/32/4/005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this project was to study the efficacy of quantitative muscle hardness (QH) curve analysis for noninvasive measurement of muscle compartment interstitial pressure (IMP), and to eliminate the need for a comparison normal QH measurement to determine a pathologic reading. Elevation of IMP may lead to limb compartment syndrome, which may result in irreversible dysfunction, chronic pain and contracture. Two studies were performed by two separate independent examiners on male volunteers, where IMP measurements and QH curves were obtained. QH curves were divided into three parts comparing the third part to the second part using the coefficient of determination (R(2)). In 205 limb compartments, there were 1432 comparison readings of the IMP versus R(2). Using receiver operator characteristic curve analysis for all data from both studies, an R(2) cutoff of 0.974 best corresponded to a pathologic IMP of 50 mmHg. For both sets of data and for each compartment tested, the mean IMP values were statistically different (t-test: P < 0.0001) for the group with R(2) values less than 0.974 compared to the group of R(2) values greater than or equal to 0.974. In addition, a pressure prediction model was formulated with a strong overall correlation coefficient of 0.78. The data of this study support that QH analysis is potentially useful for the monitoring of IMP elevation in compartment syndrome.
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Affiliation(s)
- Bruce Steinberg
- Jacksonville Orthopaedic Institute, 1325 San Marco Blvd, Ste. 200, Jacksonville, FL 32207, USA
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Abstract
OBJECTIVES To review the efficacy of the current diagnostic methods of acute compartment syndrome (ACS) after leg fractures. DATA SOURCES A Medline (PubMed) search of the English literature extending from 1950 to May 2007 was performed using "compartment syndromes" as the main key word. Also a manual search of orthopaedic texts was performed. STUDY SELECTION AND EXTRACTION The results were limited to articles involving human subjects. Of 2605 primary titles, 489 abstracts limited to compartment syndromes in the leg and 577 articles related to the diagnosis of compartment syndromes were identified and their abstracts reviewed. Further articles were identified by reviewing the references. Sixty-six articles were found to be relevant to diagnostic techniques for compartment syndrome in the leg and formed the basis of this review. CONCLUSIONS Early diagnosis of an ACS is important. Despite its drawbacks, clinical assessment is still the diagnostic cornerstone of ACS. Intracompartmental pressure measurement can confirm the diagnosis in suspected patients and may have a role in the diagnosis of this condition in unconscious patients or those unable to cooperate. Whitesides suggests that the perfusion of the compartment depends on the difference between the diastolic blood pressure and the intracompartmental pressure. They recommend fasciotomy when this pressure difference, known as the Delta p, is less than 30 mm Hg. Access to a precise, reliable, and noninvasive method for early diagnosis of ACS would be a landmark achievement in orthopaedic and emergency medicine.
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