Compartment syndrome: diagnosis, management, and unique concerns in the twenty-first century

Compartment Syndrome in Association with Tibial Plateau Fracture: Standardized Protocols Ensure Optimal Outcomes

The purpose of this study was to report on the treatment, results, and longer-term outcomes of patients who sustained a tibial plateau fracture with an associated leg compartment syndrome (CS). A total of 766 patients who sustained 766 tibial plateau fractures met inclusion criteria. Fourteen patients (1.8%) were diagnosed with CS in association with a tibial plateau fracture during their initial hospitalization, 13 at the time of presentation and 1 delayed. The treatment protocol consisted of initial external fixation and fasciotomy, followed by irrigation and debridement, and eventual closure. Fasciotomy cases included 2/14 (14.3%) single incision approaches and 12/14 (85.7%) dual incision approaches. Operative treatment of the tibial plateau fracture was performed at the time of final closure or once soft tissues were permitted. One case of CS that developed following definitive fixation was treated with fasciotomy and delayed primary closure after initial stabilization. Ten (71.4%) were available at 1-year follow-up. We compared these 10 cases to the patients with operative tibial plateau fractures without CS to assess for surgical, radiographic, clinical, and functional outcomes. We used a propensity match based on age, body mass index, sex, Charleson comorbidity index, and fracture type to reduce the presence of confounding biases. Standard statistical methods were employed. Those in the CS cohort were younger males (p < 0.05). At latest follow-up, function did not differ between those in the CS group compared with the non-CS cohort (p > 0.05). Clinically, knee flexion (130.7 vs. 126; p = 0.548), residual depression (0.5 vs. 0.2; p = 0.365), knee alignment (87.7 vs. 88.3; p = 0.470), and visual analog scale pain scores (3.0 vs. 2.4; p = 0.763) did not differ between the cohorts. Although infection was higher in the CS cohort, the overall complication rates did not differ between the CS patients and non-CS cohort (p > 0.05). Early identification and standardized treatment protocols for the management of CS that develops in association with a tibial plateau fracture lead to outcome scores that were not significantly different from patients who did not develop CS.

Clinical Readiness: Can Providers Learn to Perform Lower Leg Fasciotomy Through a Tablet-based Augmented Reality Surgical Training Environment?

INTRODUCTION

The uses of on-demand, interactive tablet-based surgical training environments are of interest as potential resources for both the acquisition and maintenance of rarely performed, critical procedures for expeditionary surgical care. This study examined the effectiveness of a tablet-based augmented reality (AR) procedural training environment for lower leg fasciotomy with a cohort of novice surgical trainees in (1) procedural knowledge, (2) tablet-based procedural skills, (3) tablet-based procedural time, and (4) procedural performance on a cadaver. We hypothesized that engaging with the AR procedural training would increase procedural knowledge and tablet-based skills and procedural time. We hypothesized that the tablet-based AR training environment would be insufficient to acquire the ability to perform lower leg fasciotomy on a cadaver.

MATERIALS AND METHODS

This study was approved as exempt by the Institutional Review Board at USU. Surgical interns, sub-interns, and independent duty corpsman (n = 30) with no prior lower leg fasciotomy experience voluntarily participated. Tablet-based training activities included pre-training assessment, engagement with instruction, interactive procedural practice, and post-training assessment. Tablet-based knowledge assessment included 17 multiple choice questions covering concepts, reasoning, and judgment associated with the procedure. Tablet-based procedural completion and time were assessed within the training environment. Within 1 week of completing the tablet activities, participants were assessed by fellowship-trained trauma surgeons while performing cadaver-based lower leg fasciotomy. Statistical analysis included paired t-tests and effect size (Cohen's d). Statistical significance was set at P < .05.

RESULTS

Tablet-based AR procedural training significantly improved procedural knowledge (P < .001), tablet-based procedural skills (P < .001), and reduced tablet-based procedural time (P < .002). Effect sizes were very large for tablet-based procedural knowledge (d = 1.75) and skills (d = 3.2) and small (d = 0.42) for procedural time. There were no significant effects of procedural knowledge, tablet-based procedural skills, or time on cadaver-based performance. No participant was able to accurately and independently complete lower leg fasciotomy procedure on a cadaver.

CONCLUSIONS

Tablet-based AR procedural training improved procedural knowledge and tablet-based skills; however, those gains did not transfer to the ability to perform the procedure on a cadaver. The tablet's limited AR interface did not support the acquisition of requisite surgical technique, tissue handling, and decision-making in novice surgical trainees. Experienced surgeons may have different outcomes because their mature understanding of surgical constructs would allow extrapolation of abilities to other procedural contexts. Further investigation of the tablet-based training environments for surgical care is necessary before distributing such resources to support clinical readiness.

Comparison of Negative-Pressure Wound Therapy and Gradual Wound Approximation Treatments for Infected Fasciotomy Wounds

Negative-pressure wound therapy (NPWT) and gradual wound approximation (GWA) are effective and reliable methods of treating fasciotomy wounds. However, the effectiveness of these 2 methods in treating infected wounds remains unclear. The aim of our study was to compare these 2 delayed primary closure methods of treating infected fasciotomy wounds on the limbs. Patients who underwent fasciotomy surgery on the extremities after sustaining crushing injuries in the 2023 Kahramanmaraş-centered earthquakes and who were referred owing to infected open wounds during follow-up were included in the study. Patients who completed the wound closure process at our clinic were divided into 2 groups: the NPWT and GWA groups. Using retrospectively collected data, the groups were compared in terms of demographic characteristics, time until wound closure, number of surgeries, skin graft requirements, and complications. Laboratory parameters were also examined. Thirteen patients, (with 21 wounds) who underwent NPWT and 14 (with 22 wounds) who underwent GWA, were examined. The average age of the NPWT group was 32.85 ± 18.37 years, whereas that of the GWA group was 25.21 ± 16.31 years. The number of surgeries in the NPWT and GWA groups were 5.38 ± 2.11 and 4.23 ± 1.27, respectively, and the difference was statistically significant (P = .040). The average wound closure times of the NPWT and GWA groups (P = .0210) (11.00 ± 4.86 days and 8.27 ± 2.41 days, respectively) also differed significantly. Skin grafting was performed in 5 patients in the NPWT group and 2 in the GWA group. There were no significant differences between the 2 groups in terms of skin graft requirements or complication rates. NPWT and GWA are effective and reliable methods of closing infected fasciotomy wounds. Closure of these wounds can be achieved in a shorter time and with fewer surgeries using GWA than using NPWT.

Suspected gluteal compartment syndrome: Etiology predicts clinical course, outcomes and resource utilization

Background

Gluteal Compartment Syndrome (GCS) is a rare subtype of acute compartment syndrome (ACS), complex to diagnose and potentially fatal if left untreated. The incidence of ACS is estimated to be 7.3 per 100,000 in males and 0.7 per 100,000 in females [1-3]. Given its rare occurrence, the incidence of GCS is not well reported. In the case of GCS, the most common etiologies are surgical positioning, prolonged immobilization secondary to substance use or loss of consciousness, and traumatic injury. Clinical findings are pulselessness, pallor, parasthesia, paralysis, and most notably pain out of proportion. Swift diagnosis and treatment are imperative to reduce morbidity and mortality, however the ideal management of GCS is difficult to ascertain given the rare occurrence and variable presentation.

Methods

Orthopaedic trauma database at a level 1 trauma center was reviewed to identify patients for whom the orthopaedic service was consulted due to suspicion of gluteal compartment syndrome. This yielded 11 patients between 2011 and 2019. Patients with a measured ΔP greater than 30 upon initial consultation and with a concerning exam requiring monitoring were included. Patient demographics, comorbidities, GCS etiology, laboratory values, physical exam findings, pain scores (0-10) and patient outcomes were collected via chart review. Patient demographic and injury characteristics were summarized using descriptive statistics.

Results

Prolonged immobilization patients had worse outcomes including longer hospital stays (40.5 days) compared to trauma patients (4.5 days). All adverse medical outcomes recorded including acute renal failure, prolonged neuropathic pain, cardiopulmonary dysfunction were exclusively experienced by prolonged immobilization patients.

Conclusions

Our descriptive study demonstrates the bimodal distribution of GCS patients based on etiology. Prolonged immobilization patients have a longer hospital course and more complications. Our study confirms prior reports and provides information that can be used to counsel patients and families appropriately about treatment and recovery following GCS.

Level of evidence

IV.

Study type

Epidemiological.

Knowledge and associated factors with respect to prevention of post-traumatic compartment syndrome among surgical unit nurses; a multi-center cross-sectional study

BACKGROUND

Delayed recognition of compartment syndrome can result in devastating consequences such as the need for amputation or even death. Nurses are at the frontline of patient care and they must have a high index of suspicion for compartment syndrome. Even though nurses' knowledge about the prevention of compartment syndrome is important, there are no studies in Ethiopia. Therefore this study aims to assess the knowledge and associated factors of nurses towards the prevention of post-traumatic compartment syndrome.

METHOD

An institutional-based cross-sectional study was conducted among 410 nurses from 26 April to 25 May 2023 at five Comprehensive Specialized Hospital. A stratified sampling technique was employed to recruit the required participants for the study. The data were collected using a structured self-administered questionnaire. The descriptive statistics were presented in text and tables. Analytical analysis schemes including bivariable and multivariable logistic regression were computed considering P-value < 0.05 to identify statistically significant factors.

RESULT

Nearly three- fifths (61.6%; 95% CI: 56.7 to 66.3) of nurses had adequate knowledge and significantly associated with being male (AOR: 1.615, 95% CI: 1.050-2.485), nurse use of guidelines (AOR: 2.079, 95% CI: 1.307-3.307), nurses they have been trained (AOR = 1.650; 95 CI: 1.063-2.562), and nurses' who had more than 15 years' (AOR: 4.207, 95 CI: 1.762-10.045) experience had good knowledge with respect to prevention of compartment syndrome than the counterparts.

CONCLUSION

Even though nurses' knowledge regarding the prevention of post-traumatic compartment syndrome was found to be good, Diligent nursing assessment and monitoring of clinical signs should be critically performed. So, it is better to strengthen training, equip wards with standardized guidelines, and create a safe working environment should be routine activities.

Regional Anesthesia Is Safe and Effective for Low-Energy Tibial Plateau Fractures

The purpose of this study was to determine if the use of peripheral nerve blocks in the operative management of tibial plateau fractures is associated with improved outcomes when compared with the use of spinal and general anesthesia. Over a period of 16 years, 132 patients who underwent operative repair for a low-energy tibial plateau fracture and had at least 12 months of follow-up met the inclusion criteria and formed the basis of this study. Patients were grouped into cohorts based on the anesthetic method used during surgery: peripheral nerve block in combination with conscious sedation or general anesthesia (BA), general anesthesia alone (GA), or spinal anesthesia alone (SA). Outcomes were assessed at 3 months, 6 months, and 12 months. Length of stay was greatest in the GA cohort (P<.05), and more patients in the BA cohort were discharged to home (P<.05). Patients in the GA cohort had the highest pain scores at 3 months and 6 months (P<.05). Patients in both the SA and BA cohorts had better Short Musculoskeletal Function Assessment scores at 6 and 12 months when compared with the GA cohort (P<.05). Although knee range of motion did not differ among the three cohorts at 3 months, it did differ at 6 months and 12 months postoperatively, with those who had a preoperative nerve blockade (SA and BA) having the greatest knee range of motion (P<.05). Regional anesthesia was safe and was associated with lower pain scores in the early postoperative period and greater knee range of motion and functional outcome scores in the late postoperative period. [Orthopedics. 2023;46(6):358-364.].

Electrical impedance myography for the early detection of muscle ischemia secondary to compartment syndrome: a study in a rat model

Acute Compartment Syndrome (ACS) is one of the most devastating orthopedic conditions, affecting any of the body's many compartments, which, if sufficiently severe, may result in disability and amputation. Currently, intra-compartmental pressure measurements serve as the gold standard for diagnosing ACS. Diagnosing limbs at risk for ACS before irreversible damage to muscle and nerve is critical. Standard approaches for diagnosing impending compartment syndrome include clinical evaluation of the limb, such as assessment for "tightness" of the overlying skin, reduced pulses distally, and degree of pain, none of which are specific or sensitive. We have proposed a novel method to detect ACS via electrical impedance myography (EIM), where a weak, high-frequency alternating current is passed between one pair of electrodes through a region of tissue, and the resulting surface voltages are measured via a second pair. We evaluated the ability of EIM to detect early muscle ischemia in an established murine model of compression-induced muscle injury, where we collected resistance, reactance, and their dimensionless product, defined as Relative Injury Index (RII) during the study. Our model generated reproducible hypoxia, confirmed by Hypoxyprobe™ staining of endothelial regions within the muscle. Under conditions of ischemia, we demonstrated a reproducible, stable, and significant escalation in resistance, reactance, and RII values, compared to uninjured control limbs. These data make a reasonable argument for additional investigations into using EIM for the early recognition of muscle hypoperfusion and ischemia. However, these findings must be considered preliminary steps, requiring further pre-clinical and clinical validation.

Compartment Syndrome following Intramedullary Nail Fixation in Closed Tibial Shaft Fractures

Introduction

Compartment syndrome complicating intramedullary nailing of closed tibia fractures has been described as early as the 1980s, but currently remains less described in literature compared to compartment syndrome directly following trauma. This study aims to review this potentially disabling complication and highlight the importance of timely diagnosis and management of compartment syndrome following fracture fixation, not just after fracture itself, via a review of three cases.

Material and methods

A retrospective study of a series of three cases was conducted. The type of fracture, wait time to fixation, surgery duration, reaming, size of nail implant used, tourniquet time, and surgical technique were recorded. Time to diagnosis of compartment syndrome, compartment pressure if available, extent of muscle necrosis, reconstructive procedures performed, and post-operative complications were analysed.

Results

The three cases following high-energy trauma from road traffic accidents presented from January to May 2010. Compartment syndrome was diagnosed clinically for all cases, between one to six days post-operatively and supported by elevated compartment pressure measurements in two of the three cases.

Conclusion

This study advocates thorough clinical monitoring and maintaining strong clinical suspicion of compartment syndrome in patients even after intramedullary nail fixation of tibial shaft fractures to achieve timely limb-salvaging intervention. While intercompartmental pressure can be used to aid in diagnosis, we do not advise using it in isolation to diagnose compartment syndrome. Tendon transfer improves functional mobility and provides a good result in patients with severe muscle damage, while skin grafting sufficient in patients with minimal muscle damage.

Pro-Con Debate: Peripheral Nerve Blockade Should Be Provided Routinely in Extremity Trauma, Including in Patients At Risk for Acute Compartment Syndrome

In this Pro-Con commentary article, we discuss the controversial debate of whether to provide peripheral nerve blockade (PNB) to patients at risk of acute extremity compartment syndrome (ACS). Traditionally, most practitioners adopt the conservative approach and withhold regional anesthetics for fear of masking an ACS (Con). Recent case reports and new scientific theory, however, demonstrate that modified PNB can be safe and advantageous in these patients (Pro). This article elucidates the arguments based on a better understanding of relevant pathophysiology, neural pathways, personnel and institutional limitations, and PNB adaptations in these patients.

Gluteal Compartment Syndrome After Femoral Nail Extraction: A Case Report

Gluteal compartment syndrome is a rare disorder and no definitive treatment has yet been established. Fasciotomy is often the treatment of choice for gluteal compartment syndrome, but there have been only a few cases that have improved with conservative therapy. A 26-year-old male with a body mass index of 40.5 who underwent femoral nail extraction surgery had severe pain in the right buttock and numbness in the right lower extremity. Initially, we suspected transient pain due to prolonged exposure to the same posture, but muscle weakness in the lower extremities and worsening of renal function appeared over time. Orthopedic evaluation revealed physical examination findings and MRI imaging findings consistent with gluteal compartment syndrome. Conservative treatment with temporary dialysis was chosen instead of fasciotomy because of the time required for diagnosis. Dialysis was started on postoperative day 3, renal function and muscle weakness recovered over time, and the patient was discharged home on postoperative day 37. At six months post-op, the patient was walking without pain and he had no changes in his peripheral neurologic examination compared to his preoperative baseline. Orthopedic surgeons should always be aware of the possibility of gluteal compartment syndrome when especially obese patients with prolonged operation times appeal to acute buttock pain. Diagnosis should be made as early as possible to get a good prognosis.

Measurement of the gluteal compartment pressures: A cadaveric study describing safety and reproducibility of two methods

INTRODUCTION

Gluteal compartment syndrome is an uncommon entity and physicians may use intracompartmental pressure measurements for confirmation of the clinical diagnosis, or in cases where the physical exam is indeterminate. However, there is a paucity of literature describing a safe and reproducible technique to measure gluteal intracompartmental pressures during the diagnosis of gluteal compartment syndrome. The purpose of this cadaveric study is to evaluate the sole previous technique described in the literature to measure gluteal intracompartmental pressures and provide a modified technique which can be safely and reliably utilized clinically.

METHODS

A cadaveric study with three phases was performed in 16 gluteal regions in 8 cadavers. In the first phase, the previously described technique was assessed. In the second phase, a modified set of techniques was created and evaluated. In the third phase, inter-user reliability of the modified set of techniques was assessed and calculated using Cohen's ĸ coefficient. In all three phases, methylene blue was injected through pressure monitoring needles into the gluteus maximus (GMax), gluteus medius/minimus (GMM), and the tensor fascia lata (TFL) compartments. Following dissection, rate of successful penetration into each targeted compartment and distance from the neurovascular structures was recorded.

RESULTS

The previously described set of techniques was found to be variable. The modified set of techniques was effective, successfully reaching the GMax, GMM, and TFL compartments in 100%, 100%, and 81% of attempts, respectively. Inter-user reliability was excellent (ĸ = 1) for the techniques to reach both the GMax and GMM compartments, and moderate (ĸ = 0.54) for the technique to reach the TFL compartment. Within the GMax, the pressure monitoring needle was at a mean of 5.4±0.6 cm, 4.1±0.7 cm, 6.4±0.5 cm from the sciatic nerve (SN), superior gluteal nerve (SGN), and inferior gluteal nerve (IGN), respectively. Within the GMM, the pressure monitoring needle was at a mean of 9.7±1.4 cm, 7.4±1.3 cm, 11.1±1.7 cm from the SN, SGN, and IGN, respectively.

CONCLUSION

The modified set of techniques presented allows the three gluteal compartments to be safely and reproducibly reached to measure intracompartmental pressures during the diagnosis of gluteal compartment syndrome.

Review article: A comprehensive review of unusual causes of acute limb compartment syndrome

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.

Acute compartment syndrome of the contralateral thigh following reconstructive shoulder surgery done for multidirectional shoulder instability in lateral decubitus position

A man in his early 40s had revision reconstructive surgery on his left shoulder while in a right lateral decubitus position. The prolonged surgery (7 hours) caused acute compartment syndrome (ACS) in the contralateral (right) thigh. Moderate pain and swelling of the contralateral thigh ('well limb') was first noted in the recovery room. After progression to severe swelling and numbness in his right toes, fasciotomies of the right thigh were performed, confirming ACS. Thirteen months later he returned to his prior work without lower extremity discomfort or limitations, and he reported a good result from the revision shoulder surgery. Non-traumatic ACS of a well limb is a rare complication of surgery performed in the lateral decubitus position. We suggest that moving the patient temporarily, or to a new position (eg, beach chair), should be considered when the duration of surgery approaches 4.5 hours.

Gluteal compartment syndrome after laparoscopic surgery in lateral jackknife position: a case report

We present a case of a 42-year-old obese female with a body mass index of 38.4 kg/m². Laparoscopic tumor resection of a left nonfunctioning adrenal tumor was performed in the lateral jackknife position, and the operative time was over 5 h. After awakening, she complained right buttock pain, and we suspected bursitis due to the surgical position and decided to follow up the patient. On the second postoperative day, spontaneous pain worsened, and the computed tomography scan of the hip showed significant swelling of the gluteal muscles, which led us to suspect a gluteal compartment syndrome. Intramuscular compartment pressure was measured under general anesthesia at 72 mmHg, and a fasciotomy was performed. The symptoms improved promptly after surgery and completely disappeared 2 months after surgery. Although the gluteal compartment syndrome is a rare condition in which circulation is impaired by compression of the gluteal muscles, treatment should be initiated promptly before serious complications arise.

Forearm Compartment Pressure Change in Children Operated for Supracondylar Humerus Fracture

BACKGROUND

The aim of this study is to examine the preoperative and postoperative forearm compartment pressures in patients treated operatively for Gartland type III extension type supracondyler humerus fractures and understand the course of these values over postoperative period.

METHODS

Deep volar compartment pressure of 31 patients were measured in the proximal one third of the forearm preoperatively, and measurements were continued every 4 hours for the first 24 hours after the operation with a catheter. Type of the reduction technique (open reduction vs. closed reduction), duration of surgery, the time from the injury to surgery were all evaluated.

RESULTS

In the measurements made immediately after the operation (0 h), a sudden increase in the compartment pressure was detected in all patients (15.0±5.9 to 27.9±7.5 mm Hg) independent of the reduction technique and gradually decreased over time. The mean compartment pressure at the 12th hour postoperatively was higher in the open reduction group than in the CR group (24.5±3.4, 20.7±6.7 mm Hg, respectively) ( P =0.044). The mean preoperative compartment pressure was 17.7±5.8 mm Hg in patients with a time from injury to surgery longer than 12 hours, and 12.4±4.8 mm Hg in patients with 12 hours or less ( P =0.006). The postoperative 0-, 12-, and 20-hour pressure values were higher in the >1 hour operation time group than in the ≤1 hour group and the differences were statistically significant ( P =0.046, 0.016, and 0.032, respectively).

CONCLUSIONS

In pediatric supracondylar humeral fractures, those who underwent open reduction had higher preoperative and postoperative compartment pressures. The reduction attempt was found to be a factor that increased the compartment pressure and after the operation, the compartment pressure values decrease gradually. Prolonged operative time (>1 h) and increased time from injury to operative fixation (>12 h) were associated with higher compartment pressures.

LEVEL OF EVIDENCE

Level II-prospective study.

Point of care ultrasound needle guidance to assist diagnosis of acute gluteal compartment syndrome

Gluteal compartments can be difficult to assess for acute compartment syndrome (ACS) compared to other fascial compartments due to their anatomy and rarity of presentation. Point-of-care ultrasound (POCUS) needle guidance may assist in obtaining accurate compartment pressure measurements within the gluteal compartments. We present a case in which a 69-year-old woman presented following a fall resulting in a superior prosthetic hip dislocation. One-hour post hip-reduction, the patient began to experience severe pain of the right leg, swelling to the gluteal region, and numbness to her foot. With consideration of a developing gluteal compartment syndrome in mind, POCUS was used to guide the needle of a compartmental pressure monitor system into the gluteal maximus and medius-minimus compartments which demonstrated elevated compartment pressures consistent with ACS. The patient was subsequently taken for emergent fasciotomy and hematoma evacuation. There has been limited investigation into compartment pressure measurement under US guidance versus a palpation/landmark-guided technique. This case shows the feasibility of US needle guidance when assessing compartment pressures for this uncommon diagnosis.

Novel digital continuous sensor for monitoring of compartment pressure: a case report

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.

Acute Hematogenous Osteomyelitis Resulting in Atraumatic Pediatric Forearm Compartment Syndrome

Acute hematogenous osteomyelitis is well described after minor trauma in the pediatric population, with an incidence of 1 to 13 cases per 100,000 individuals. Compartment syndrome (CS) in children is a rare, but potentially devastating disease, classified as “cannot miss diagnosis.” Compared with adults, CS may exhibit a variable presentation with a wide range of symptoms in children, often leading to delayed diagnosis. Expeditious diagnosis and treatment of CS is paramount in minimizing adverse sequelae and maximizing potential functional outcome, regardless of etiology. Here, we present a rare case of atraumatic CS resulting from ruptured subperiosteal abscess secondary to acute hematogenous osteomyelitis in a pediatric male patient with 2 weeks of forearm pain and evolving neurologic deficits with initial delay in presentation to our facility. The ramifications of delayed diagnosis or misdiagnosis of CS emphasize the importance of a high index of suspicion despite atypical presentations in the pediatric patient.

Intracranial pressure management: moving beyond guidelines

PURPOSE OF REVIEW

The aim of this study was to provide an overview on advances in intracranial pressure (ICP) protocols for care, moving from traditional to more recent concepts.

RECENT FINDINGS

Deep understanding of mechanics and dynamics of fluids and solids have been introduced for intracranial physiology. The amplitude or the harmonics of the cerebral-spinal fluid and the cerebral blood waves shows more information about ICP than just a numeric threshold. When the ICP overcome the compensatory mechanisms that maintain the compliance within the skull, an intracranial compartment syndrome (ICCS) is defined. Autoregulation monitoring emerge as critical tool to recognize CPP management. Measurement of brain tissue oxygen will be a critical intervention for diagnosing an ICCS. Surgical procedures focused on increasing the physiological compliance and increasing the volume of the compartments of the skull.

SUMMARY

ICP management is a complex task, moving far than numeric thresholds for activation of interventions. The interactions of intracranial elements requires new interpretations moving beyond classical theories. Most of the traditional clinical studies supporting ICP management are not generating high class evidence. Recommendations for ICP management requires better designed clinical studies using new concepts to generate interventions according to the new era of personalized medicine.

Gluteal compartment syndrome: A systematic review and meta-analysis

INTRODUCTION

Gluteal compartment syndrome is a rare but devastating condition with limited characterization in the literature. The purpose of our systematic review, case series, and meta-analysis is to synthesize the current literature and provide recommendations on how to prevent gluteal compartment syndrome, identify at-risk patients, and avoid delays in diagnosis and treatment.

METHODS

International Classification of Disease codes were used to identify patients at our institution. PubMed, MEDLINE, and the Cochrane Library were searched to identify case reports between 1972 and March 1st, 2018. Cases were analyzed based on demographics, etiology, presentation, symptoms, diagnosis, treatment, and outcomes.

RESULTS

139 cases - 13 from our institution and 126 previously published - were included. The most common etiologies were postoperative (41%), prolonged immobilization secondary to substance abuse or loss of consciousness (35%) and trauma (19%). 89% were male, mean age was 45 years (range, 16-74), and mean body mass index was 41 kg/m². Rhabdomyolysis and sciatic neuropathy were identified in 94% and 74% of patients, respectively. Fasciotomy was performed in 80% of patients. Overall, 93% of patients survived. However, 41% of patients suffered prolonged neurologic dysfunction. In patients with an initial neurologic deficit, there was a higher rate of permanent neurological deficit in patients treated medically than those treated surgically (12/14 vs 29/61, p=0.0153), but no statistical difference in mortality (0/14 vs 4/61, p=1). In patients without initial neurologic deficit, there were no statistical differences in rates of permanent neurological deficit (0/7 vs 2/20, p=1) or mortality (0/7 vs 3/20, p=0.545) between those receiving medical or surgical treatment.

DISCUSSION

Gluteal compartment syndrome is an orthopaedic emergency that may be more prevalent and associated with higher morbidity and mortality than previously recognized. Risk factors may include prolonged surgical duration, immobilization secondary to substance abuse, and pelvic trauma. Intraoperative precautions and postoperative surveillance are recommended in obese patients undergoing prolonged procedures. Fasciotomies improve neurologic outcomes in patients presenting with an initial neurologic deficit. In patients who are neurologically intact on presentation, medical management with neurologic function surveillance may be the optimal initial treatment. Fasciotomies do not impact mortality. Additionally, a treatment algorithm is provided.

Expanded dengue syndrome presented with rhabdomyolysis, compartment syndrome, and acute kidney injury: A case report

RATIONALE

Expanded dengue syndrome (EDS) is the phenomenon coined by the World Health Organization for cases of dengue fever (DF) with rare but dangerous consequences. EDS mainly leads to complications involving the vital organs, thus is also associated with a higher mortality rate. This case report presents the first-ever case where a patient developed EDS with both rhabdomyolysis-induced acute kidney injury and compartment syndrome of the limbs.

PATIENT CONCERNS

Our patient, an 18-year-old Pakistani male, presented with fever, colicky abdominal pain, vomiting, diarrhea, dark-colored urine, and oliguria.

DIAGNOSES

Dengue rapid NS-1 test came back positive. Along with myoglobinuria both serum creatine phosphokinase and creatine levels were abnormal. Hence, the patient was diagnosed with rhabdomyolysis-induced acute kidney injury. On physical examination, his right arm was painful and tender with restricted movement at the elbow. A Doppler ultrasound of the arm revealed thickening of the skin and underlying muscles, as well as edematous abnormalities affecting the entire right upper limb, both of which are indications of compartment syndrome.

INTERVENTIONS AND OUTCOME

The management included rehydration, administration of dextrose and bicarbonate (bicarbonate infusion) prepared by adding 150 mEq sodium bicarbonate in 850 mL dextrose 5%, pain killers, along with platelet, and packed red cell transfusions. Additionally, right upper limb was kept elevated at 90° for 30 minutes every 2 hours to reduce edema and crept bandages were applied. The patient was discharged after 11 days and the follow-up was uneventful.

LESSON

Physicians should be aware that rhabdomyolysis-induced acute kidney damage and limb compartment syndrome are also possible DF consequences, and they should be on the lookout for any indications pointing to these complications in DF. A prompt diagnosis can prevent further complications and fatality.

Ultrastructural Analysis of Volumetric Histotripsy Bio-effects in Large Human Hematomas

Large-volume soft tissue hematomas are a serious clinical problem, which, if untreated, can have severe consequences. Current treatments are associated with significant pain and discomfort. It has been reported that in an in vitro bovine hematoma model, pulsed high-intensity focused ultrasound (HIFU) ablation, termed histotripsy, can be used to rapidly and non-invasively liquefy the hematoma through localized bubble activity, enabling fine-needle aspiration. The goals of this study were to evaluate the efficiency and speed of volumetric histotripsy liquefaction using a large in vitro human hematoma model. Large human hematoma phantoms (85 cc) were formed by recalcifying blood anticoagulated with citrate phosphate dextrose/saline-adenine-glucose-mannitol solution. Typical boiling histotripsy pulses (10 or 2 ms) or hybrid histotripsy pulses using higher-amplitude and shorter pulses (0.4 ms) were delivered at 1% duty cycle while continuously translating the HIFU focus location. Histotripsy exposures were performed under ultrasound guidance with a 1.5-MHz transducer (8-cm aperture, F# = 0.75). The volume of liquefied lesions was determined by ultrasound imaging and gross inspection. Untreated hematoma samples and samples of the liquefied lesions aspirated using a fine needle were analyzed cytologically and ultrastructurally with scanning electron microscopy. All exposures resulted in uniform liquid-filled voids with sharp edges; liquefaction speed was higher for exposures with shorter pulses and higher shock amplitudes at the focus (up to 0.32, 0.68 and 2.62 mL/min for 10-, 2- and 0.4-ms pulses, respectively). Cytological and ultrastructural observations revealed completely homogenized blood cells and fibrin fragments in the lysate. Most of the fibrin fragments were less than 20 μm in length, but a number of fragments were up to 150 μm. The lysate with residual debris of that size would potentially be amenable to fine-needle aspiration without risk for needle clogging in clinical implementation.

Evidence-Based Approach to Timing of Nerve Surgery: A Review

ABSTRACT

Events causing acute stress to the health care system, such as the COVID-19 pandemic, place clinical decisions under increased scrutiny. The priority and timing of surgical procedures are critically evaluated under these conditions, yet the optimal timing of procedures is a key consideration in any clinical setting. There is currently no single article consolidating a large body of current evidence on timing of nerve surgery. MEDLINE and EMBASE databases were systematically reviewed for clinical data on nerve repair and reconstruction to define the current understanding of timing and other factors affecting outcomes. Special attention was given to sensory, mixed/motor, nerve compression syndromes, and nerve pain. The data presented in this review may assist surgeons in making sound, evidence-based clinical decisions regarding timing of nerve surgery.

Regional anesthesia and acute compartment syndrome: principles for practice

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.

Regional analgesia for lower leg trauma and the risk of acute compartment syndrome: Guideline from the Association of Anaesthetists

Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. We offer a multi-professional, consensus opinion based on an objective review of case reports and case series. The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party. Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other.

Sonographic Clues in Suspicion of Compartment Syndrome in a Lower Extremities Venous Study: A Case Study

Compartment syndrome occurs when excessive pressure builds up inside an enclosed muscle space in the body. The dangerously high pressure in compartment syndrome impedes the flow of blood to and from the affected tissues. It can be an emergency, requiring surgery to prevent a permanent injury. In this case study, a lower extremities venous examination was performed on a male patient suspected of having compartment syndrome, as an incidental finding. Sonographic evaluation of the right leg revealed the absence of popliteal and small saphenous veins, and acute thrombus in the posterior tibial veins. The evaluation further revealed an incidental finding of double pseudo-aneurysm in the popliteal fossa, which was suspected for increasing the excessive compartmental pressure. This unique case study presents sonographical evaluation strategies when compartment syndrome is suspected.

Photoacoustic imaging in monitoring of compartmental syndrome in rat extremities

Muscle ischemia injury is the essence of compartment syndrome (CS). Photoacoustic (PA) imaging can monitor hemoglobin concentration changes in ischemic tissue by determining the state of light-absorbing molecules. This study investigated whether PA imaging can provide accurate CS monitoring. Rats received compression on the lower hind limb for 3 h to induce ischemia injury, followed by PA imaging of desired muscles for 24 h. PA intensities of the injured group were significantly lower than that in the control group. Histology findings correlated well with the PA findings. The results demonstrated that PA imaging could be a noninvasive and timely tool for clinically monitoring CS.

Complications and Comorbidities in Hispanic Patients Who Develop Traumatic and Non-traumatic Acute Compartment Syndrome

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. 

The blister occurring in severe tibial plateau fractures (Schatzker V-VI) decreases the risk of acute compartment syndrome

BACKGROUND

Severe tibial plateau fractures may result in acute compartment syndrome (ACS) of the leg, which is always considered to be an orthopaedic emergency. Blistering is not an uncommon sign and may be related to decreased compartment pressure. No experiments on the risk of ACS based on the presence of blisters after tibial plateau fractures have been conducted, and controversies about the high rate of ACS in patients with tibial plateau fractures still exist.

QUESTIONS/PURPOSES

This research retrospectively followed the bicondylar tibial plateau fractures treated with locking plates and verified if the risk of ACS was decreased after a blister was observed.

METHODS

A total of 100 patients with closed tibial fractures (63 men and 37 women) were included and divided into with blister (group A, 40) and without blister groups (group B, 60). The creatine kinase (CK), BUN, and chloride levels were recorded on the first day after hospitalization. The hospitalization costs and injury to operation time were collected in the two groups. The Lysholm knee score and a visual analogue scale (VAS) for pain were used to assess the rehabilitation after follow-up. Clinical and serological results of ACS in the two groups were compared.

RESULTS

There was significant delay in the time from injury to operation (11.0 ± 3.5 VS 7.6 ± 7.2, Z = - 3.771, P < 0.001) in the with blister (group A) and without blister groups (group B). The levels of chloride and BUN were significantly lower in the with blister group than in the without blister group (102.7 ± 3.0 VS 104.7 ± 2.57 mg/dL, Z = - 3.33, P = 0.001) (10.3 ± 2.5 VS 10.3 ± 2.8 mg/dL, Z = - 2.366, P = 0.018). There were no significant differences in the CK levels in the with blister and without blister groups (285.8 ± 202.6 VS 408.4 ± 633.6 U/L, Z = - 1.379, P = 0.168), but a trend of decreasing to normal was obvious in patients with blisters. There were no significant differences in the Lysholm knee score (40 VS 60, 80 ± 4.9 VS 79.8 ± 3.0, Z = - 0.872, P = 0.383), or the VAS (40 VS 60, 1.6 ± 0.7 VS 2.2 ± 1.3, Z = - 1.568, P = 0.117) for pain compared with patients without blisters.

CONCLUSION

In conclusion, the presence of blisters in patients with severe tibial plateau fractures decreases the pressure in the compartment. There was a significant improvement in serological results after blisters appeared, which may be related to the reason for the decreased pressure decreased, and conservative management is recommended for these patients.

Síndrome compartimental agudo del miembro inferior: estado actual

El síndrome compartimental agudo del miembro inferior es una urgencia médica, que puede conllevar una importante morbilidad para el paciente y que puede tener implicaciones medicolegales para el personal médico. Afecta cerca de 3,1 por 100.000 habitantes en el mundo occidental, con predominio de hombres y jóvenes. Debido a una alteración de la perfusión tisular, por la disposición de los músculos de las extremidades en compartimientos compactos, con poca tolerancia a variaciones en la presión, puede causar isquemia, con cambios irreversibles a nivel muscular y nervioso, falla multiorgánica y la muerte, de no tratarse oportunamente. El trauma de la extremidad inferior asociado a fractura es la principal causa del síndrome compartimental agudo. El diagnóstico puede realizarse por evaluación clínica, mediante las clásicas seis “P” de la isquemia, u de manera objetiva, al medir la presión intracompartimental con dispositivos especializados. La fasciotomía descompresiva es un procedimiento quirúrgico mediante el cual se inciden las fascias de los compartimientos musculares, permitiendo la disminución de las presiones a ese nivel, y se constituye en el único tratamiento eficaz para el síndrome compartimental agudo. Las complicaciones posquirúrgicas no son infrecuentes, siendo la perdida de la extremidad la más grave de todas. Un correcto conocimiento y aplicación de la técnica quirúrgica evitará procedimientos inadecuados, que impliquen mayor riesgo de resultados adversos. Presentamos una revisión de los aspectos fundamentales de esta patología potencialmente catastrófica.

Institutional differences in management of compartment syndrome at academic and community-based trauma centers: A survey of Orthopaedic Trauma Association (OTA) members

OBJECTIVES

The purpose of this study was to compare management of compartment syndrome at academic and community trauma centers and to identify any institutional variables that influence the number of adverse events reported to the hospital's peer review process.

DESIGN

Web-based survey.

SETTING

N/A.

PARTICIPANTS

Orthopedic Trauma Association (OTA) members.

METHODS

A link to a 9-item web-based questionnaire was sent to members of the OTA.

RESULTS

Two hundred twenty-four (21%) of 1031 OTA members completed the survey. Respondents indicated that residents were primarily responsible for checking compartments at academic trauma centers (91%), while community trauma centers reported higher utilization rates of ortho attendings (81%), trauma attendings (26%), and nurses (27%). Seventy-five percent of respondents at academic trauma centers relied on intra-compartmental pressure monitoring to make the diagnosis in intubated/obtunded patients as opposed to just 56% of respondents at community centers. Seventy percent of all respondents utilizing prophylactic fasciotomies practiced at community trauma centers. Forty-four percent indicated that they had submitted cases involving management of compartment syndrome to their hospital peer review process. While most submitted only 1 or 2 cases (75% of positive replies), 5% had submitted 5 or more cases for peer review. Use of a pressure monitor and orthopaedic surgeons performing all fasciotomies were associated with a lower number of cases submitted to peer review (P < .02 and P < .04, respectively).

CONCLUSION

Academic and community trauma centers differ in their utilization of in-house staff for early assessment, in the diagnostic modalities employed in obtunded patients, and in their threshold for fasciotomy. Adverse events are regularly reported for peer review at both academic and community trauma centers. As there is great variability between institutions in terms of clinical practice as demonstrated by the responses to this survey, it is recommended that institutions devise their own written protocol based on the resources they have available to reduce adverse events.

LEVEL OF EVIDENCE

Therapeutic Level V.

Dichotomy in Fasciotomy: Practice Patterns Among Trauma/Acute Care Surgeons With Performing Fasciotomy With Peripheral Arterial Repair

INTRODUCTION

Failure to perform adequate fasciotomy for a presumed or diagnosed compartment syndrome after revascularization of an acutely ischemic limb is a potential cause of preventable limb loss. When required, outcomes are best when fasciotomy is conducted with the initial vascular repair. Despite over 100 years of experience with fasciotomy, the actual indications for its performance among acute care and trauma surgeons performing vascular repairs are unclear. The hypothesis of this study was that there are many principles of fasciotomy that are uniformly accepted by surgeons and that consensus guidelines could be developed.

METHODS

A 20-question survey on fasciotomy practice patterns was distributed to trauma and acute care surgeons of a major surgical society which had approved distribution.

RESULTS

The response to the survey was 160/1066 (15 %). 92.5% of respondents were fellowship trained in trauma and acute care surgery, and 74.9% had been in practice for fewer than 10 years. Most respondents (71.9%) stated that they would be influenced to perform a preliminary fasciotomy (fasciotomy conducted prior to planned exploration and arterial repair) based upon specific signs and symptoms consistent with compartment syndrome-including massive swelling (55.6%), elevated compartment pressures (52.5%), delay in transfer >6 hours (47.5%), or obvious distal ischemia (33.1%). 20.6% responded that they would conduct exploration and repair first, regardless of these considerations. Prophylactic fasciotomies (fasciotomy without overt signs of compartment syndrome) would be performed by respondents in the setting of the tense compartment (87.5%), ischemic time >6 hours (88.1%), measurement of elevated compartment pressures (66.9%), and in the setting of large volume resuscitation requirements (31.3%). 69.4% of respondents selectively measure compartment pressures, with nearly three-fourths utilizing a Stryker needle device (72.5%). The most common sequence of repairs following superficial femoral artery injury with a >6-hour limb ischemia was cited as the initial insertion of a shunt, followed by fasciotomy, then vein harvest, and finally interposition repair.

CONCLUSIONS

While there is some general consensus on indications for fasciotomy, there is marked heterogeneity in surgeons' opinions on the precise indications in selected scenarios. This is particularly surprising in light of the long history with fasciotomy in association with major arterial repairs and strongly suggests the need for a consensus conference and/or meta-analysis to guide further care.

Does a specialised orthopaedic trauma module utilising high fidelity simulation improve student nurses' perceptions of their competence? A pilot study

BACKGROUND

Trauma is the fourth leading cause of death in the western world, and traumatic injuries are recognised as clinically challenging to care for. Orthopaedic trauma care is not standard content in pre-qualifying nursing curriculums, compounded by a dearth in specialised post-qualifying education internationally. As a result, registered nurses may not have the clinical skill set to appropriately manage patients with traumatic conditions.

AIMS

To understand pre-qualifying student nurses' perceptions of their own competence in orthopaedic trauma care and understand if utilisation high fidelity simulation improves confidence, knowledge and application of theory.

METHODOLOGY

A small-scale qualitative pilot study utilising purposive sampling, designed to inform the development of a larger longitudinal study. A 5-point likert scale questionnaire with options for qualitative comments was administered after 8 weeks of a specialised module culminating in a high-fidelity simulation and in-depth debrief session. Thematic analysis was conducted.

FINDINGS

All students found that the module improved their confidence and knowledge in their skills set. The high-fidelity simulation was found to be an effective learning environment to translate theory to practice.

CONCLUSIONS

Specialised orthopaedic trauma training is effective in improving student nurses' knowledge and perceived competence in trauma care. High fidelity simulation is a valuable teaching tool to develop student's skill sets in complex scenarios and support application of theory to practice.

Unusual presentation of acute compartment syndrome of the forearm and hand

A 49-year-old man was referred to orthopaedics with an acute onset of left forearm and hand swelling, widespread blisters and erythema after lying face down on the floor for an unknown period of time. He also presented with left wrist stiffness due to pain and clawing of the fingers and glove-type loss of sensation in the whole hand. Any attempt to straighten the fingers or extend the wrist exacerbated the pain. Symptoms deteriorated rapidly. Compartment syndrome was diagnosed and surgical fasciotomies of his left forearm and left hand were performed following multidisciplinary urgent discussions between plastic surgeons, microbiologists, anaesthetists and orthopaedic surgeons. The left forearm and left hand underwent extensive decompression and subsequent skin grafting and had good healing despite the initial skin presentation. The patient has made a satisfactory recovery and has required extensive hand physiotherapy and social care.

Gluteal Compartment Syndrome After Prolonged Immobilization in Drug Abusers

Background

There has been an increasing incidence of drug abuse patients presenting with rhabdomyolysis after prolonged immobilization. Our study was to assess etiology and management challenges with patients presenting with gluteal compartment syndrome after drug abuse.

Methodology

We did a retrospective analysis of five patients who presented with gluteal compartment syndrome secondary to drug abuse over one year.

Results

We had a 100% association with rhabdomyolysis and acute renal injury necessitating hemodialysis. There was a frequent association with the involvement of additional compartments like thigh and leg.

Conclusion

Patients with drug overdose can present with unusual compartment syndrome involvement like the gluteal compartment. Compartment syndrome is a surgical emergency and needs multidisciplinary involvement. 

Bothrops atrox Snakebite: How a Bad Decision May Lead to a Chronic Disability: A Case Report

Snakebites are a neglected and underestimated global health hazard. In the Brazilian Amazon, Bothrops snakebites are the most prevalent and may lead to severe complications. Here we describe a severe case of Bothrops atrox snakebite that, owing to delayed medical assistance, presented with renal and respiratory failure, compartment syndrome, and tissue necrosis. After several fasciotomy surgeries, the patient survived; however, he showed significant functional disability. Prompt management of snake envenomation would aid in the early diagnosis of local and systemic complications and, consequently, would result in a better functional outcome with improved quality of life.

Risk factors for developing acute compartment syndrome in the pediatric population: a systematic review and meta-analysis

PURPOSE

Acute compartment syndrome (ACS) is often difficult to diagnose in pediatric patients due to their erratic symptomatology. Therefore, it is of paramount importance to identify at-risk patients to facilitate a prompt diagnosis. This study aims to identify risk factors for the development of ACS in the pediatric population.

METHODS

We included studies comprised of pediatric patients with traumatic ACS. We excluded studies evaluating compartment syndrome secondary to exertion, vascular insult, abdominal processes, burns, and snake bites. Heterogeneity was addressed by subgroup analysis, and whenever it remained significant, we utilized a random-effects meta-analysis for data pooling. The protocol has been registered at PROSPERO (ID = CRD42019126603).

RESULTS

We included nine studies with 380,411 patients, of which 1144 patients were diagnosed with traumatic ACS. The average age was 10 years old, and 67% of patients were male. Factors that were significantly associated with ACS were: open radius/ulna fractures (OR 3.56 CI 1.52-8.33, p = 0.003), high-energy trauma (OR 3.51 CI 1.71-7.21, p = 0.001), humerus fractures occurring concurrently with forearm fractures (OR 3.49 CI 1.87-6.52, p < 0.001), open tibia fractures (OR 2.29 CI 1.47-3.55, p < 0.001), and male gender (OR 2.06 CI 1.70-2.51, p < 0.001).

CONCLUSION

In the present study, open fractures, high-energy trauma, concurrent humerus and forearm fractures, and male gender significantly increased the risk of developing ACS in the pediatric population. Clinicians should raise their suspicion for ACS when one or multiple of these factors are present in the right clinical context.

TYPE OF STUDY

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

III.

Compartment syndrome: Neuromuscular complications and electrodiagnosis

Compartment syndrome (CS) is a treatable condition characterized by elevated intracompartmental pressure and may be acute or chronic in nature. Sustained elevated compartment pressure can lead to ischemia and necrosis of muscle as well as injury to peripheral nerves, creating a deficit that may be neuropathic, myopathic, or mixed. While electrodiagnostic assessments are of limited utility in the diagnosis of acute/traumatic CS, they can assist with prognosticating return of function after surgical fasciotomy or in clarifying the injury pattern in cases in which a traumatic injury results in subsequent neuromuscular deficits. They can also be used to rule out conditions that mimic chronic exertional CS. During electrodiagnostic assessment, clinicians should be aware of patterns associated with muscle fibrosis vs denervation and use this information to assist with prognostication and appropriate counseling for patients regarding any interventional or adaptive treatments that may help restore function.

Iatrogenic Compartment Syndrome Secondary to Burn Dressing in a 2-Year-Old Child

We report a severe case of compartment syndrome due to a compressive burn dressing. An otherwise healthy 2-year-old girl presented at her local health center with a superficial partial-thickness thermal burn on the dorsum of the mid phalanx of the second finger of her right hand. A compressive dressing was applied solely to the affected finger. Forty-eight hours afterward, the patient presented in the emergency room with severe pain of the finger. After removal of the dressing, a circular constrictive eschar was observed at the base of the finger, secondary to ischemia due to the compressive dressing. Emergent lateral escharotomies were performed, with immediate recovery of distal perfusion. One week afterward, the patient underwent surgical debridement of the burn on the dorsum of her finger and escharectomy of the ischemic eschar at the base. The lesions were covered with partial-thickness skin grafts. This case shows that acute compartment syndrome can lead to severe sequelae, such as the loss of an extremity or body segment. We must take utmost care in all our actions to avoid any (negligent) act that could lead to severe or permanent damage to our patients.

Diagnosing acute compartment syndrome-where have we got to?

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.

An Acute Paraspinal Compartment Syndrome: Anatomic Description of the Compartment and Surgical Technique

An acute paraspinal compartment syndrome (CS) is a rare condition and is only described in a few case reports. In our spine surgery department, a 16-year-old boy with severe low back pain due to a lumbar paraspinal CS. was treated with a paraspinal fasciotomy. After this case, we performed a cadaver study to determinate the compartment. The objective of this paper is to give a description of the anatomic lumbar paraspinal compartment and our surgical technique, a transmuscular paraspinal approach described by Wiltse and colleagues. The lumbar CS is most often seen in the lateral compartment where the erector spinae muscle, subdivided into the iliocostalis and the longissimus, is encased within a clear fascia. Lumbar paraspinal CS is a rare complication but should always be recognized. A thorough knowledge of the anatomy helps you to understand the clinical signs and start a correct treatment.

Noninvasive diagnostics for extremity compartment syndrome following traumatic injury: A state-of-the-art review

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.

Non-hip/non-vertebral fractures - How to treat best?

Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.

Acute compartment syndrome: An orthopedic emergency

Acute compartment syndrome (ACS) is a true orthopedic emergency. NPs in all settings should be able to recognize ACS to ensure swift surgical intervention is not delayed. This article highlights a systematic approach to exam and diagnosis.

Surgical management of acute compartment syndrome and sequential complications

Background

Acute compartment syndrome occurs when pressure within a compartment increases and affects the function of the muscle and tissues after an injury. Compartment syndrome is most common in lower leg and may lead to permanent injury to the muscle and nerves if left untreated.

Methods

46 patients with acute compartment syndrome were enrolled, including 8 cases with serious complications, between January 2008 and December 2012. The protocols combining early management and the correction of deformities were adjusted in order to attempt to enable full recovery of all patients.

Results

All patients had necrotic muscles and nerves, damaged vascular, and severe foot deformities. In the early stage, each patient received systemic support and wound debridement to promote wound healing. For patients with serious complications, a number of medical measures, including installation of Ilizarov external frames, arthrodesis, osteotomy fusion, arthroplasty, or tendon lengthening surgery, were performed to achieve satisfactory clinical outcomes. All the patients resumed weight-bearing walking and daily exercises.

Conclusion

Acute compartment syndrome and sequential complications could be managed using a number of medical procedures.