Spontaneous compartment syndrome in a patient on long-term anticoagulation

Compartment syndrome associations with drugs: a pharmacovigilance study of the FDA adverse event reporting system (FAERS)

BACKGROUND

Compartment syndrome is an uncommon but life-threatening condition. No study has comprehensively compared compartment syndrome (CS) association with available drugs. The objective of this study was to estimate the association between CS and drugs using the FDA Adverse Event Report System (FAERS).

RESEARCH DESIGN AND METHODS

FAERS reports from the first quarter of 2004 to the third quarter of 2023 were analyzed. The Medical Dictionary for Regulatory Activities (MedDRA) was used to identify CS cases. Reporting odds ratio (ROR), corresponding to 95% confidence intervals (95% CI) were calculated to detect a positive signal.

RESULTS

A total of 2197 reports were considered in the study after the inclusion criteria were applied. Totally 100 drugs were found to be associated with CS. The median time for drug-associated CS was 45 days.

CONCLUSIONS

By analyzing the FAERS database, the study revealed that certain drugs are significantly associated with compartment syndrome. Further studies are needed to verify whether these drugs are associated with such a risk.

Clinical Case of Acute Non-Traumatic Hand Compartment Syndrome and Systematic Review for the Upper Extremity

Background: While trauma to the upper extremity is known to cause acute compartment syndrome (ACS), nontraumatic causes of ACS of the upper extremity are rare. Nontraumatic ACS of the upper extremity can lead to adverse outcomes if not recognized early. There are limited reports of spontaneous ACS published in the literature. The aim of this comprehensive systematic review is to increase awareness among plastic surgeons and hand surgeons of this acute event and provide an algorithmic approach to management in the acute setting through an illustrative case example. Methods: A comprehensive systematic review of published literature was conducted in the Medline/PubMed database with the search terms, "compartment syndrome," "extremity," "spontaneous," "nontraumatic," and "atraumatic" without timeframe limitations. Articles were identified and included in this review based on ACS localization in the upper extremity and etiology of nontraumatic, spontaneous origin. Results: Sixteen publications and 19 total cases of nontraumatic ACS of the upper extremity from 1993 to 2016 met our search criteria. A bleeding disorder was the etiology in three cases, systemic anticoagulation in three cases, infection in six cases, and unknown in three cases. The remaining four cases included systemic sclerosis, Ehlers-Danlos syndrome, rhabdomyolysis, and McArdle disease. Conclusions: Nontraumatic causes of ACS of the upper extremity include infection, anticoagulation therapy, and bleeding disorders. Even though trauma is the most common cause of ACS, clinicians should be aware of these other potential causes of ACS in the nontraumatic setting. Appropriate medical and surgical intervention should be done to avoid potential adverse outcomes.

Acute Traumatic Compartment Syndrome of the Forearm: Literature Review and Unfavorable Outcomes Risk Analysis of Fasciotomy Treatment

Forearm compartment syndrome is a relatively underreported event compared with compartment syndrome of the lower extremity or trunk. The aim of this review of the literature was to provide insight into the potential consequences of certain treatment modalities in the control of acute compartment syndrome of the forearm based on data presented over the past 44 years. A comprehensive search was conducted across several databases including EMBASE, Ovid MEDLINE, Cochrane Database of Systematic Reviews, and Scopus, capturing studies published from 1973 to 2017 to identify potential articles for inclusion in the review. Outcomes data were evaluated for each of the studies included in this analysis on the basis of treatment utilized (fasciotomy vs. no fasciotomy) and respective outcome (favorable vs. unfavorable). Relative risk (RR) analysis was performed to determine risk factors for unfavorable outcomes from the pooled data. The analysis revealed a statistically significant higher likelihood of unfavorable outcomes resulting from performing fasciotomy in the event of forearm compartment syndrome compared with conservative management (RR = 4.82, p < .01). Fasciotomy treatment was associated with a higher likelihood of patients presenting with forearm compartment syndrome to experience unfavorable outcomes. The results of this study can help guide awareness of potential sequelae of treatment choices in forearm compartment syndrome, and clinical decision-making for wise patient selection for surgical intervention, when necessary.

Nontraumatic Compartment Syndrome in a Patient with Protein S Deficiency: A Case Report

CASE

Protein S deficiency, a hypercoagulable thrombophilia, often results in venous thromboembolism. Nontraumatic compartment syndrome in a patient with protein S deficiency has not been well publicized. Herein, we present a rare case of nontraumatic compartment syndrome of the hand and the thigh in a 48-year-old woman with a known history of protein S deficiency; emergency fasciotomies were needed.

CONCLUSION

Based on our patient and a review of the current literature, we advocate for a heightened awareness of compartment syndrome in patients with protein S deficiency.

Recurrent spontaneous compartment syndrome of the thigh

Acute comparment syndrome (ACS) is a surgical emergency, in which tissue pressure becomes greater than perfusion pressure leading to tissue ischaemia. It is typically a consequence of trauma. We present a case in which a patient suffers blunt trauma to the thigh, but develops ACS 2 years after this injury and consequently endures 10-episodes of ACS (no perciptating event or cause) in the same thigh over 10 years. On the 10th presentation the patient was found to have arteriovenous malformation on MR angiography which were embolised and the fasciotomy wound closed with a split-thickness skin graft. A thorough literature search deemed this case to be the first reported recurrent spontaneous ACS of the thigh. Prompt recognition and treatment of ACS is vital. Clinicians should thoroughly investigate such patients postoperatively and involve vascular/plastic surgeons and interventianal radiologist to provide optimum care and prevent recurrence.

Non-traumatic compartment syndrome secondary to deep vein thrombosis and anticoagulation

We describe an unusual case of non-traumatic compartment syndrome in three compartments of the left lower limb in a 57-year-old male inpatient. He had recently been started on anticoagulation therapy for multiple pulmonary emboli and deep vein thrombosis of the left posterior tibial and peroneal veins. Three of the four osteofascial compartments had pressures above 70 mm Hg, hence four compartment fasciotomies were performed. Postoperatively, intravenous heparin therapy was started resulting in a significant blood loss, but he had no neurovascular deficit. At reoperation, for primary wound closure, his tissues looked healthy. Non-traumatic causes of acute compartment syndrome, including deep venous thrombosis and anticoagulation, are considered.

Perioperative management of chronic anticoagulation in orthopaedic surgery

The orthopaedic patient on chronic anticoagulation therapy is at risk of thromboembolism and hemorrhage in the perioperative period. To establish the most effective anticoagulation regimen, patients should be stratified according to the risk of arterial or venous thromboembolism. Timing of surgery, thromboembolic risk, and bleeding risk should be considered when developing an anticoagulation protocol. Retrievable inferior vena cava filters may be a viable alternative to bridging therapy in patients at high risk of venous thromboembolism and/or bleeding.

Rare case of upper arm compartment syndrome following biceps tendon rupture

We present a case of upper arm compartment syndrome following a biceps tendon rupture in a 77-year old man on warfarin sodium. Compartment syndrome is common in the forearm and leg, but rare in the upper arm with only a handful of cases reported in the literature. Our patient's anticoagulated state predisposed him to the development of compartment syndrome. To the best of our knowledge there has been only one other case reported in the literature of upper arm compartment syndrome following biceps tendon rupture in a patient on warfarin sodium. Compartment syndrome of the upper arm is a rare occurrence. Previous cases have occurred due to malposition of blood pressure cuffs, injections, venepuncture, trauma, tourniquets, shoulder dislocation, surgical complication, subatmospheric pressure induced, biceps rupture, and triceps rupture. The fascia of the upper arm is relatively thinner and more distensible than the fascia of the leg or forearm. This creates more room for the compartment to swell before pressures builds up to a significant level. Thus, a significantly increased amount of pressure needs to build up before compartment syndrome will occur in the upper arm. Once the diagnosis was formed, the patient was treated with emergent fasciotomy and evacuation of hematoma. After a prolonged hospital stay, the patient was released with minor neurological deficits. At final follow-up, the patient was neurovascularly intact with no complaints of numbness or tingling, and he had regained full motor function throughout.

Posterior compartment syndrome associated with clopidogrel therapy following trivial trauma

Haematomata caused by blunt trauma may potentially induce a compartment syndrome by raising intra-compartmental pressure. We report a case of acute posterior compartment syndrome following minimal trauma to the leg of an elderly patient on the antiplatelet agent clopidogrel. This case highlights the high index of clinical suspicion required to detect compartment syndrome in those on long term antiplatelet therapy and prompt surgical decompression is recommended.

Acute compartment syndrome after rupture of the medial head of gastrocnemius in a child

Rupture of the gastrocnemius muscle is an uncommon injury, with most cases occurring in athletes and, typically, presenting with the acute onset of focal calf pain and ecchymosis after injury. Although gastrocnemius ruptures are usually treated symptomatically with good results, we present an unusual case of a medial head of gastrocnemius muscle tear complicated by acute compartment syndrome in a 7-year-old boy whose right calf was crushed in a fall. After confirmation of the diagnosis of compartment syndrome, the patient underwent emergency fasciotomy with evacuation of hematoma, and, thereafter, he recovered unremarkably. Clinicians and surgeons need to maintain a high index of suspicion for compartment syndrome associated with gastrocnemius muscle injury, so that timely surgical decompression can be undertaken and complications related to delayed diagnosis and treatment can be avoided.

Acute bilateral forearm compartment syndrome of unknown aetiology

This is the first reported case of non-traumatic, acute bilateral forearm compartment syndrome. Despite a delay of over 24 hours until surgical decompression and 50% muscle fibre necrosis in the histopathological examination, the clinical outcome was excellent after fasciotomy, delayed primary wound closure and early institution of a range of motion exercise programme. The literature on non-traumatic causes of compartment syndrome is reviewed.

Acute compartment syndrome secondary to diabetic muscle infarction: case report and literature review

Acute compartment syndrome has a multitude of aetiologies. Unfortunately, the diagnosis is often delayed, resulting in permanent functional loss. Although spontaneous muscle infarction is an uncommon, yet well-recognized complication of diabetes mellitus, subsequent development of compartment syndrome appears to be rare, with only five case reports identified in the literature. This condition has not been reported in the emergency medicine literature. We report a case of a diabetic gentleman who presented with lower limb pain significantly out of proportion to any obvious injury and had a subsequent diagnosis of acute compartment syndrome. Despite fasciotomies, he had a persistent foot drop. Nontraumatic acute compartment syndrome secondary to diabetic muscle infarction should be considered in any diabetic patient presenting with pain out of proportion to sustained injury.

Occult trauma in high-risk populations

Several groups of patients are at increased risk for traumatic injury that is "occult," or not apparent on initial presentation. Perhaps the most notorious are those who abuse alcohol, but other groups include the elderly, coagulopathic, those with neurological disease, and the mentally ill. Moreover, traumatic injury can coexist with (or be masked by) medical pathology, resulting in the disposition of injured patients to nonsurgical services where surveillance for traumatic injury diminishes. Because delays or failures in diagnosis might result in unnecessary pain, morbidity, and mortality, it is important for the emergency physician to identify occult presentations of trauma before disposition. This review highlights commonly missed traumatic injuries in adult patients.

Compartment syndrome after simple venipuncture in an anticoagulated patient

An excessively anticoagulated 52-year-old man on chronic warfarin therapy developed a forearm compartment syndrome after venipuncture in an antecubital vein. At fasciotomy, active venous bleeding into the forearm from the venipuncture site was noted, and a large forearm hematoma was evacuated. Anticoagulated patients or those with coagulopathies are at risk for compartment syndrome after percutaneous needle punctures and should be warned of this possibility. Such individuals should be instructed to seek immediate medical attention if any signs or symptoms of this complication occur.

Acute compartment syndrome in a hypothyroid patient

Acute compartment syndrome (ACS) is caused by conditions that either decrease the size of the compartment of increase the content of the compartment. Intracompartmental pressures are raised, thereby initiating a sequence of events that results in myoneural injury. Although limb trauma is the most common and well-organized etiology of ACS, the cause is frequently not readily apparent. Thyroid disease is not a commonly recognized cause of ACS; only one case of ACS associated with hypothyroidism has been previously reported. We now describe a second case of ACS in a patient with severe hypothyroidism and discuss the possible pathogenesis of this association.

Anatomic bases of the forearm compartment syndrome

One of the most common sites for the compartment syndrome (CS) is the forearm. Its compartments have been studied by injection of colored gelatin into the particular anatomical spaces. The three "pressure-measuring-points" recommended in the clinical literature to measure intracompartmental tissue pressure in equivocal diagnostic cases were used for the dye injections on the forearms of five preserved cadavers of adults. However, instead of the compartments especially affected in CS two adjacent spaces were revealed. In order to elucidate the clinical relevant spaces two additional approaches for the injection had been used. Cross-sections at 15 mm intervals of the injected forearms had been performed. Some of them are presented and schematically summarized in this article. Recent studies have suggested that there are different guidelines for description of the anatomically isolated spaces. However, especially one of these spaces seems to be responsible for the CS on the forearm. The remarkable features of this so called "deep flexor compartment" are its very restrictive envelopes, its rare fascial contacts, its impermeable seal in proximal-radial direction as well as the extremely endangered structures within the compartment. The flexor carpi ulnaris muscle is recommended to be the "primary structure" for measuring the tissue pressure as well as for surgical decompression. The article reviews the anatomical base of the CS.