Ultrastructural modifications of muscle in three types of compartment syndrome

Acute compartment syndrome: How long before muscle necrosis occurs?

Objectives:

Acute compartment syndrome (ACS) is a limb-threatening condition often first diagnosed by emergency physicians. Little is known about the rapidity with which permanent damage may occur. Our objective was to estimate the time to muscle necrosis in patients with ACS.

Methods:

This historical cohort analysis of all patients who had a fasciotomy for ACS was conducted in 4 large teaching hospitals. Diagnosis was confirmed clinically or by needle measurement of compartment pressure. Muscle necrosis was determined using pathology reports and surgeons’ operative protocols. We used descriptive statistics and estimated tissue survival probability using the Vertex exchange method for interval-censored data.

Results:

Between 1989 and 1997 there were 76 cases of ACS. Most cases occurred in young men (median age 32) as a result of a traumatic incident (82%). Forty-nine percent (37/76) of all patients suffered some level of muscle necrosis, and 30% (11/37) of those with necrosis lost more than 25% of the muscle belly. Necrosis occurred in 2 of 4 cases in which the patient had been operated on within 3 hours of the injury, and our exploratory survival analysis estimates that 37% (95% confidence interval, 13%-51%) of all cases of ACS may develop muscle necrosis within 3 hours of the injury.

Conclusions:

This is the largest cohort of ACS and the first clinical estimation of time to muscle necrosis ever published. Ischemia from ACS can cause muscle necrosis before the 3-hour period post-trauma that is traditionally considered safe. Further research to identify risk factors associated with the development of early necrosis is necessary.

Acute compartment syndrome in children: a case series in 24 patients and review of the literature

Trauma-associated acute compartment syndrome (ACS) of the extremities is a well-known complication in adults. There are only a handful of articles that describe the symptoms, the diagnostic procedure and treatment of ACS in children. The aim of this study was to analyse the diagnostic procedures in children compared to adolescents with ACS to obtain evidence for the diagnosis, treatment and outcome of children with ACS. Twenty-four children and adolescents with ACS have been treated at the Department of Trauma Surgery of the Medical University of Vienna, Austria. Two age-related groups were investigated to compare the diagnostic and therapeutic algorithm: group A comprising children aged 2-14 years (n = 12) and group B comprising adolescents aged 15-18 years (n = 12). Patient characteristics, diagnosis and therapy-associated data, complications and clinical outcome were analysed. In both groups we found fractures in most of our patients (n = 19) followed by contusion of the soft tissues (n = 3). In group A most of our patients were injured as pedestrians in car accidents (n = 5) followed by low-energy blunt trauma (n = 3). The most common region of injury and traumatic ACS was the lower leg (n = 7) followed by the feet (n = 3). For fracture stabilisation most of the patients (n = 6) received an external fixator. The mean time from admission to the fasciotomy was 27.9 hours. In four patients a compartment pressure measurement was performed with pressure levels from 30 to 75 mmHg. A histological examination of soft tissue was performed in five patients. From fasciotomy to definitive wound closure 2.4 operations were necessary. The mean hospital stay was 18.9 days. In group B most of our patients had a motorcycle accident (n = 5). The most common region for traumatic ACS in this group was also the lower leg (n = 9). In most of the patients (n = 6) intramedullary nails could be implanted. The mean time from admission to the fasciotomy was 27.1 hours. In six patients a compartment pressure measurement was performed with pressures from 25 to 90 mmHg. In five patients a histological examination was performed. From fasciotomy to definitive wound closure 2.3 operations were necessary. The mean hospital stay was 18.4 days. Secondary fasciotomy closure was performed in all cases. A split-skin graft was only necessary in three patients (13%). We avoided primary closure in the same setting when the fasciotomy was performed. Thus, we found no difference between the two groups in the diagnostic procedures, the indication for fasciotomy, the number of operations needed from fasciotomy to definitive wound closure, time of hospitalisation and clinical outcome. The rate of permanent complications was 4.2% (one patient from group A), which means that nearly all patients experienced full recovery after fasciotomy. ACS represents a surgical emergency and the indication should be determined early even in doubtful cases to avoid complications.

Chronic compartment syndrome, an important cause of work-related upper limb disorder

OBJECTIVES

Work-related upper limb disorders (WRULD) are common and disabling complaints in industry, but a tissue diagnosis can be difficult where the pain is diffuse and variable, and this prevents effective treatment. Diffuse arm pain is frequently found in those doing rapid or strenuous repetitive work, such as factory assembly workers or keyboard operators. Similar symptoms occur in the legs in athletes, where chronic compartment syndrome (CCS) is a recognized entity, so we investigated the possibility that this might also be caused by prolonged repetitive work.

METHODS

Patients were selected if they were unable to continue with work because of chronic forearm pain. They were divided into three groups: 42 patients with symptoms consistent with CCS as defined in the text, 15 volunteers and patients with other arm complaints, and 10 asymptomatic arms of patients with unilateral CCS. We measured the pressure inside the extensor muscle compartment of the forearm at rest and after a 2 min repetitive gripping exercise using an electronic pressure-sensitive probe.

RESULTS

The results show that CCS is a common and disabling forearm complaint associated with prolonged repetitive work. Fifteen patients have now had decompressive surgery on the extensor muscle compartment with good relief of symptoms.

CONCLUSION

CCS is responsible for chronic peripheral neurological dysfunction in addition to muscle pain, and awareness of this diagnosis allows early identification and treatment of a currently unrecognized disorder with potential resolution of a long-lasting arm disability.

Acute compartment syndromes

BACKGROUND

Acute compartment syndrome is both a limb- and life-threatening emergency that requires prompt treatment. To avoid a delay in diagnosis requires vigilance and, if necessary, intracompartmental pressure measurement. This review encompasses both limb and abdominal compartment syndrome, including aetiology, diagnosis, treatment and outcome.

METHODS

A Pubmed and Cochrane database search was performed. Other articles were cross-referenced.

RESULTS AND CONCLUSION

Diagnosis of limb compartment syndrome is based on clinical vigilance and repeated examination. Many techniques exist for tissue pressure measurement but they are indicated only in doubtful cases, the unconscious or obtunded patient, and children. However, monitoring of pressure has no harmful effect and may allow early fasciotomy, although the intracompartmental pressure threshold for such an undertaking is still unclear. Abdominal compartment syndrome requires measurement of intra-abdominal pressure because clinical diagnosis is difficult. Treatment is by abdominal decompression and secondary closure. Both types of compartment syndrome require prompt treatment to avoid significant sequelae.