Compartment Syndromes

Fig. 38.1
Typical ventral incision across the volar forearm for the tretment of acute CS

Patients under 35 years old with a forearm fracture and polytrauma are at high risk of developing CS; therefore they require careful monitoring. In inhibited patients and in those with ambiguous clinical examination results, objective diagnostic measurements are necessary (Ronel et al. 2004).

38.2 Compartment Syndrome of the Lower Limbs

Acute compartment syndrome of the lower limb is a complication of fractures, soft tissue trauma, and reperfusion after acute arterial occlusion (McQueen et al. 2000). It can be caused by bleeding or swelling in a muscle compartment surrounded by fascia and bone tissue (Olson and Glasgow 2005). The long-term consequences of CS have already been described by Richard von Volkmann in the late nineteenth century as a result of a too tight plaster cast, but only after a few years was a connection made with high intracompartmental pressure. The incidence of foot CS is about 6% in patients with foot injuries caused by motorcycle accidents, while the incidence of leg CS seems lower (1.2% after closed diaphyseal fractures of the tibia). The lower limb compartment syndrome and its treatment were described in 1958, whereas until a few years ago, compartment syndrome of the foot was largely unknown and was described only in some case reports. Myerson first described this clinical entity in 1988 and presented surgical decompression as a therapeutic intervention (Myerson and Manoli 1993). The leg is composed of four compartments: anterior, lateral, surface, and deep posterior. On the contrary, there is no consensus in regard to the number of anatomical compartments of the foot. At the end of 1920, three compartments were described and later confirmed by Kamel and Sakla in 1961. After which Myerson identified four compartments (Myerson and Manoli 1993) while more recently in a cadaveric study, nine compartments were identified. However, there are only three compartments (medial, lateral, superficial) for the entire length of the foot. In a cadaveric study performed in 2008, the authors could not identify any distinct forefoot myofascial compartments, and so they concluded that a fasciotomy of the hindfoot compartments through a modified medial incision would be sufficient to decompress the whole foot (Ling and Kumar 2008). However, studies on cadavers cannot simulate physiological conditions so the conclusions of these studies should be interpreted with caution. The typical clinical presentation of leg and foot CS is no different from other regions of the body. In a systematic review of the literature, the pain has been identified as the earliest and most sensitive clinical sign of CS (Ojike et al. 2009). In a retrospective study, however, the foot pain was present in all patients with foot CS (Myerson 1990). It must be remembered that the indiscriminate use of analgesics in patients with severe pain may potentially mask the key symptom. Sensory deficits are also common in patients with CS (Ulmer 2002). Decreased discrimination between two points seems more reliable than the decreased feeling of a pinprick alone (Myerson and Manoli 1993).

When acute compartment syndrome is suspected, a careful examination is needed. Medical recommendations based on evidence (EBM) cannot, unfortunately, be made; serial laboratory tests should be performed at least hourly as it is widely recognized that muscle necrosis usually occurs within the first 3 h (Vaillancourt et al. 2004). However, contrary to what was thought in the past, muscle strength is not a good parameter to be considered, since it is difficult to determine whether the loss of strength is due to the pain or muscle necrosis. Even the examination of peripheral pulses is not reliable for the diagnosis of lower limb CS, because there may be false negatives if the intracompartmental pressure reaches the systolic blood pressure. On the other hand, invasive measurement of intracompartmental pressure is a rapid and safe procedure to reach a definite diagnosis. However, it should be emphasized that in a cohort study with more than 200 patients with diaphyseal fractures of the tibia, the continuous monitoring of intracompartmental pressure showed no differences in outcomes or possible delays in performing fasciotomy compared to the simple clinical examination of the patient (Al-Dadah et al. 2008). Another study showed that the rate of late complications was similar in patients whether they had undergone or not continuous monitoring of the intracompartmental pressure (Harris et al. 2006). Since nine compartments in the foot have been identified, it is not feasible to monitor the pressure for patients at high risk of developing CS in this anatomical area. It is also important to remember that intracompartmental pressure must be correlated with the diastolic pressure. The fasciotomy threshold is still under debate. While some authors suggest that for intracompartmental pressure the threshold for fasciotomy should be an absolute value of 30 mmHg (Willy et al. 2001), others indicate 20 mmHg less than the diastolic pressure as a threshold (Olson and Glasgow 2005). However today, the indication for fasciotomy should be based on clinical findings (neurological deficits) or on a difference between intracompartmental pressure and diastolic pressure lower than 30 mmHg (Olson and Glasgow 2005). Although most of these recommendations derive from studies of other anatomic regions, there is no reason to assume a different pathophysiological background for foot CS. Finally, it is important to remember that clinical results should be compared over time. In short, a history of trauma and the presence of serious injuries should make the physician consider the possibility of CS. Furthermore, the presence of open wounds does not implicitly decompress the compartment, for example, in the foot all nine compartments would rarely be involved. Although the management of CS consists of immediate surgical treatment, bandages and casts should be completely open in patients with severe postoperative pain. In the case of impending CS, the limb should not be raised because it reduces the blood supply that is already compromised. McQueen demonstrated that in patients with tibial fractures, the time between the onset of compartment syndrome and fasciotomy influences the outcome, rather than the time between trauma and osteosynthesis (McQueen et al. 1990). Generally, the existing literature is lacking in regard to the optimal management of tibial fractures in the presence of CS. On the other hand, multiple approaches have been used to decompress the compartments of the foot (Fulkerson et al. 2003). Although the etiology, pathophysiology, and treatment of CS are well described, little has been published about the long-term results. CS of the leg and foot has a low incidence rate (1.2% after closed tibial fractures, 6% after open tibial fractures); studies on a greater number of patients are, however, not available. A long follow-up with different surgeons and different surgical techniques does not allow a direct comparison of published results. One study has examined the quality of life after CS using the “EQ-5D score” (Giannoudis et al. 2002). Even if surgical decompression is an emergency procedure that is indicated in order to prevent further damage and long-term functional loss, several serious long-term sequelae after fasciotomy have been reported: aesthetic problems, altered sensorium, and dry and flaky skin.

In a study of 30 cases, patients with leg compartment syndrome had lower EQ-5D scores than the control group at 12 months after treatment, although their health status was not statistically different (Giannoudis et al. 2002). In addition, the authors reported that patients with faster wound closure times were healthier than those with longer wound closure times (Giannoudis et al. 2002). In another study about the results of follow-up in 26 patients with traumatic leg CS, 15.4% complained of pain at rest, and 26.9% reported pain under stress at 1–7 years after the trauma (Frink et al. 2007). In this population, more than 50% of the patients had reduced joint ROM and reported a reduction in sensitivity. Infections due to fasciotomy were described in up to 38% of the patients. Patients who had undergone a surgical flap with skin grafting for wound closure presented a lower incidence of infections. In another study, the presence of associated lesions seemed not to affect the long-term outcome after traumatic CS of the leg in regard to the joint Rom, sensory dysfunction, and loss of muscle strength. There is no information available about returning to work. Most of the studies about outcomes of foot compartment syndrome are only case reports.

In a series of 14 patients, Myerson (Myerson 1991) described the return to the previous working activity after trauma in four patients; six patients had only occasional symptoms that had developed during some daily activities, whereas three patients developed contractures with clawed fingers. No patients however needed amputation (Myerson 1991). However paresthesia and numbness of scars distal to the compartments involved were common long-term sequelae in eight patients. Complications of lower limb CS are serious and require immediate treatment. If CS is not promptly recognized, the damage caused to the affected region may be irreversible. Our experience shows that the literature available is quite limited in this specific field of orthopedics and traumatology. We found only one study using validated outcome measures to analyze the results of treatment of leg CS (Giannoudis et al. 2002). Therefore we believe that further studies are needed to describe long-term results. Although the pathophysiology of CS is well described, it is not yet clear when there is irreversible damage. A 1991 study suggested an ischemic time of 5–6 h, while other more recent studies in animal models reported muscle necrosis after less than 3 h (Verleisdonk et al. 2004). Moreover the information available in literature is inconsistent, and we believe further studies are necessary in this regard. Although clinical signs are well described (Verleisdonk et al. 2004), we believe that the most important factor in the CS diagnosis is the key figure of the doctor, who must put the patient at the center of his attention and base treatment on a “holistic-like approach.”

Moreover the physician should be aware that the pain, defined as a clinical sign of CS, could be masked in patients with a reduced state of consciousness or if previously treated with analgesics. Although literature lacks recommendations about the intervals at which serial examinations should be performed in patients at risk, we believe they should be performed at least every hour, as irreversible damage has been reported to occur within the first 3 h (Verleisdonk et al. 2004). In patients with uncertain signs, the intracompartmental pressure should be measured. Literature describes various approaches for leg fasciotomy through lateral or anterolateral and posterior combined incisions. However we were unable to find a study that compared both methods; therefore, literature lacks recommendations based on EBM criteria. Recommendations for surgical treatment of foot CS are most controversial; in fact, although many approaches have been described, literature lacks comparative studies. In conclusion, lower limb CS is a rare but serious complication of which the surgeon must be aware. Although immediate fasciotomy is the indisputed treatment for patients with CS, literature lacks guidelines for high-risk patients.

38.3 Chronic Exertional Compartment Syndrome

A separate paragraph should be dedicated to the treatment of chronic exertional compartment syndrome (CECS). Considering that the first report on this syndrome was written only 30 years ago, there is still uncertainty about the development of the syndrome in the majority of affected patients.

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Sep 6, 2017 | Posted by in ORTHOPEDIC | Comments Off on Compartment Syndromes

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