Acute compartment syndromes

Do Widespread or Selective Invasive Monitoring Increase the Rate of Fasciotomies for Tibial Shaft and Plateau Fractures, or Affect the Incidence of Possible Missed Compartment Syndrome?

INTRODUCTION

To report the incidence of lower leg fasciotomies in tibial shaft and plateau fractures and explore the incidence of potential missed acute compartment syndrome (ACS) with widespread, selective, or no invasive monitoring (IM).

METHODS

This is a retrospective review of adult patients with diaphyseal tibial fractures (Orthopaedic Trauma Association 42A-C), and proximal tibial fractures (Orthopaedic Trauma Association 41A-C) treated surgically at a Level 1 trauma center from 2001 to 2020. Main outcomes of interest include lower extremity fasciotomy rates and incidence of potential missed ACS (abnormal neurovascular examination, sensory changes, chronic pain, claw toes, or amputation) in diaphyseal and proximal tibial fractures at three time intervals: widespread use of IM (w-IM) (2000 to 2010), selective IM (s-IM) (2011 to 2015), and clinical examination with a high index of suspicion alone without IM (CES), 2016 to 2020.

RESULTS

Fasciotomy rates decreased from 4.96% (93 in 1,873) in 2001 to 2010 (w-IM) to 2.61% (32 in 1,226) in 2011 to 2015 (s-IM) and to 1.11% (16 in 1,438) in 2016 to 2020 (CES) (P < 0.001). Random samples of 317 patients with tibial shaft and plateau fractures that did not undergo fasciotomy from 2001 to 2010 (w-IM), 304 patients from 2011 to 2015 (s-IM), and 285 patients from 2016 to 2020 (CES) found that 96.5% had a normal neurovascular examination in the w-IM group, 98.4% in the s-IM group, and 96.8% in the CES group, P = 0.210. No differences were found in sensory changes in the three groups (0.6% for w-IM vs. 1.6% for s-IM vs. 0.4% for CES, P = 0.235) or severe pain (0.6% vs. 0.3% vs. 0.7%, P = 0.589). No patients had late amputation or claw toes in any group. The combined complication rate was slightly lower in the s-IM group (2.0%) and the CES group (2.8%) compared with the w-IM group (4.4%) (P = 0.214).

CONCLUSIONS

The rate of fasciotomy for ACS in proximal and diaphyseal tibial fractures has declined over time at our center coinciding with the decreased use of IM with no apparent increase in missed ACS.

LEVEL OF EVIDENCE

Diagnostic Level III.

Reperfusion injury or cytokine storm? Utilizing plasmapheresis in severe trauma-induced multiorgan failure: a case report

Reperfusion injury can cause tissue damage due to ischemia, with severe cases potentially resulting in multiorgan failure. Cytokine storm, a life-threatening systemic inflammatory state characterized by elevated levels of circulating cytokines and hyperactive immune cells, can also lead to tissue damage and multiorgan failure. Reperfusion injury and cytokine storm sometimes exhibit similar clinical features, necessitating specific treatment in severe cases. A 31-year-old man sustained a stab wound to his left knee. Computed tomography angiography and surgical exploration revealed a transection of the left popliteal artery and vein. Both vessels were revascularized via end-to-end anastomosis approximately 3 hours after the injury. On postoperative day 2, marked increases were observed in levels of aspartate aminotransferase (8,600 U/L), alanine transaminase (6,690 U/L), creatine phosphokinase (26,817 U/L), and lactate dehydrogenase (7,398 U/L) levels. Elevated levels of interleukin 6 (178 pg/mL) and ferritin (41,079 ng/mL) were also noted. Given the possibility of either reperfusion injury or cytokine storm, plasmapheresis was initiated. Following two rounds of plasmapheresis, the patient's condition rapidly improved, and he was discharged without complications. Reperfusion injury can arise when a target blood vessel is revascularized, particularly during severe stages of ischemia. Cytokine storm represents a life-threatening systemic inflammatory state characterized by high levels of circulating cytokines and overactive immune cells. Both reperfusion injury and cytokine storm can cause systemic inflammation and multiorgan failure. These two conditions may exhibit similar clinical features, necessitating supportive care primarily to prevent organ dysfunction. However, plasmapheresis may represent an effective treatment option in cases of severe progression.

Bilateral lower extremity compartment syndrome after prolonged gynecological surgery in lithotomy position: a case report

BACKGROUND

Acute compartment syndrome is a rare but serious complication following gynecological surgery in the lithotomy position, potentially resulting in permanent neuromuscular dysfunction or limb loss, making early recognition and prompt management essential.

CASE PRESENTATION

A 41-year-old woman underwent a laparoscopic myomectomy for uterine fibroids, during which she was positioned in the high lithotomy and head-down position for 118 min. Six hours post-surgery, she experienced spasmodic pain and swelling in both lower extremities. Thirteen hours after surgery, her symptoms worsened, leading to the diagnosis of acute compartment syndrome in both legs. An emergency bilateral fasciotomy was performed, and the patient fully recovered within two months without any neuromuscular dysfunction.

CONCLUSIONS

ACS should be an important differential diagnosis for lower extremity pain after gynecologic surgery, especially with prolonged lithotomy positioning. Gynecologists should be vigilant for ACS signs and symptoms to prevent delayed diagnosis.

Acute Limb Ischemia Management and Complications: From Catheter-Directed Thrombolysis to Long-Term Follow-up

Acute limb ischemia (ALI) is a vascular emergency that needs to be diagnosed and treated quickly to prevent permanent tissue damage and amputation. Catheter-directed thrombolysis is a possible treatment option for mild to moderate ALI, with improved results from endovascular procedures and thrombolytic drugs. However, patients receiving thrombolysis may experience higher rates of distal embolization, serious bleeding events, and stroke than those undergoing surgery. The review article emphasizes the need for postoperative and extended management of ALI patients, including monitoring for compartment syndrome, managing reperfusion damage, and reducing changeable cardiovascular risk factors such as lipid-lowering therapy, diabetes management, and smoking cessation. Complications that can arise from thrombolytic therapy are also discussed, including hemorrhagic complications, minor bleeding, and reperfusion damage, with recommendations to monitor patients closely during treatment and discontinue therapy immediately if any abnormalities are detected. Follow-up evaluations for patients, including Doppler ultrasound, ankle brachial index, pulse volume recordings, and laboratory tests, are recommended to ensure the best possible outcome for patients with ALI.

Treatment strategy for compartment syndrome at multiple regions due to injuries caused by a tree fall: a case report

BACKGROUND

Compartment syndrome commonly occurs in patients with forearm and lower leg fractures. Compartment syndromes of the gluteal and thigh muscles are less common. It is imperative that compartment syndrome be diagnosed and treated with fasciotomy as soon as possible. However, there are few reports on the diagnosis and treatment strategies for compartment syndromes that occur simultaneously in multiple anatomical regions or in the ipsilateral gluteal region and thigh.

CASE PRESENTATION

We report on a 76-year-old man who was obliquely crushed under a tree extending from the right forearm to the left groin. He was brought to our emergency room, where he was diagnosed with compartment syndrome of the right forearm and left lower leg and crush syndrome. Emergency fasciotomy was performed. On the day after admission, swelling and tightness of the left gluteal thigh became apparent, and intracompartmental pressures were elevated, which led to an additional diagnosis of these compartment syndromes. A fasciotomy was performed, the gluteal skin incision was made according to the Kocher-Langenbeck approach (one of the posterior approaches for hip fractures), and the thigh was approached by extending the incision laterally. This surgical approach enabled the decompression of the compartments through a single incision and allowed for easier wound treatment and closure.

CONCLUSION

This case highlights the diagnosis and treatment of compartment syndrome in four anatomical regions. Extension of the Kocher-Langenbeck approach to the lateral thigh can be a useful surgical approach for ipsilateral gluteal and thigh compartment syndrome.

Patient positioning in minimally invasive gynecologic surgery: strategies to prevent injuries and improve outcomes

Effective patient positioning is a critical factor influencing surgical outcomes, mainly in minimally invasive gynecologic surgery (MIGS) where precise positioning facilitates optimal access to the surgical field. This paper provides a comprehensive exploration of the significance of strategic patient placement in MIGS, emphasizing its role in preventing intraoperative injuries and enhancing overall surgical success. The manuscript addresses potential complications arising from suboptimal positioning and highlights the essential key points for appropriate patient positioning during MIGS, encompassing what the surgical team should or shouldn't do. In this perspective, the risk factors associated with nerve injuries, sliding, compartment syndrome, and pressure ulcers are outlined to guide clinical practice. Overall, this paper underscores the critical role of precise patient positioning in achieving successful MIGS procedures and highlights key principles for the gynecological team to ensure optimal patient outcomes.

Clinical characteristics of snakebite patients attending a tertiary hospital in Hangzhou, southeast China

BACKGROUND

Venomous snakebite is a neglected yet an important public health problem in China, and few studies have focused on them so far. The aim of this study is to investigate clinical characteristics of snakebites patients in a tertiary hospital in Hangzhou, southeast China.

METHODS

A total of 416 snakebite cases were included in this retrospective study. The data were collected from the medical records including demographics, clinical manifestations, management and outcomes.

RESULTS

Of the 416 patients with venomous snakebites, 248 were male, and the average age was 54.6 years. The majority of cases occurred in rural in May to September. Out of all the venomous bites, Gloydius brevicaudus accounted for the highest percentage (55.3%). Hands were the most vulnerable site to snakebites (47.4%). Patients had clinical manifestations of pain (100%), swelling (100%), wound necrosis (25.7%), hemorrhagic blister (18.3%), and blister (8.7%). Three hundred and ninety-two patients received antivenom administration, and most were treated within six hours after bites. Twenty-six patients received surgical treatments, and 90 patients developed venom-induced consumption coagulopathy. No deaths have occurred in this study.

CONCLUSION

Hangzhou is one of the regions with high affecting of snakebites in China. The results of this study will increase the understanding of the clinical characteristics of venomous snakebites in Hangzhou area.

Gluteal compartment syndrome secondary to prolonged immobilization following carbon monoxide poisoning associated with leukoencephalopathy: A case report

Introduction

Gluteal compartment syndrome (GCS) is a rare diagnosis that results mostly from a non-traumatic etiology. We describe a case of a gluteal compartment syndrome, complicated with sciatic nerve palsy.

Case presentation

This paper reported a case of gluteal compartment syndrome caused by prolonged immobilization due to carbon monoxide poisoning. The case was complicated with sciatic nerve palsy and a sequala of leukoencephalopathy.

Discussion and conclusion

This case report highlighted the importance of having a high suspicion for gluteal compartment syndrome in patients with history of lying down with prolonged immobilization. The diagnosis can be made solely on clinical examination and a fasciotomy must be performed with no delay.

Gluteal compartment syndrome: who is most at risk?

PURPOSE

Gluteal compartment syndrome (GCS) is a rare but devastating condition with a paucity of literature to help guide diagnosis and management. This study aims to identify and describe the risk factors and patient characteristics associated with GCS to facilitate early diagnosis.

METHODS

This is a retrospective case series of patients undergoing gluteal compartment release between 2015 and 2022 at an academic Level I trauma center. Chart reviews were performed to extract data on patient demographics, presenting symptoms, risk factors, operative findings, and postoperative outcomes.

RESULTS

14 cases of GCS were identified. 12 (85.7%) were male, with a mean age of 39.4 ± 13 years and a mean BMI of 25.1 ± 4.1 kg/m2. 12 (85.7%) patients did not present as traumas and only 3 had ≥ 1 fracture. 9 patients reported drug use. Hemoglobin (Hgb) (11.7 ± 4 g/dL) was generally low (5 had Hgb < 10 g/dL). Creatine kinase (49,617 ± 60,068 units/L) was consistently elevated in all cases, and lactate (2.8 ± 1.6 mmol/L) was elevated in 9. 13 had non-viable muscle requiring debridement. Postoperatively, the mean ICU length of stay was 12 ± 23 days. 2 patients died during admission and all remaining patients required discharge to rehabilitation facilities.

CONCLUSION

GCS is more likely to present in a young to middle-aged, otherwise healthy, male using drugs who is either found down or experienced an iatrogenic injury. Recognizing that GCS is different from that of the leg, in terms of etiology, may help avoid delays in diagnosis and treatment.

Extracellular vesicles derived from human ESC-MSCs target macrophage and promote anti-inflammation process, angiogenesis, and functional recovery in ACS-induced severe skeletal muscle injury

BACKGROUND

Acute compartment syndrome (ACS) is one of the most common complications of musculoskeletal injury, leading to the necrosis and demise of skeletal muscle cells. Our previous study showed that embryonic stem cells-derived mesenchymal stem cells (ESC-MSCs) are novel therapeutics in ACS treatment. As extracellular vesicles (EVs) are rapidly gaining attention as cell-free therapeutics that have advantages over parental stem cells, the therapeutic potential and mechanisms of EVs from ESC-MSCs on ACS need to be explored.

METHOD

In the present study, we examined the protective effects in the experimental ACS rat model and investigated the role of macrophages in mediating these effects. Next, we used transcriptome sequencing to explore the mechanisms by which ESC-MSC-EVs regulate macrophage polarization. Furthermore, miRNA sequencing was performed on ESC-MSC-EVs to identify miRNA candidates associated with macrophage polarization.

RESULTS

We found that intravenous administration of ESC-MSC-EVs, given at the time of fasciotomy, significantly promotes the anti-inflammation process, angiogenesis, and functional recovery of muscle in ACS. The beneficial effects were associated with ESC-MSC-EVs affecting macrophage polarization by delivering various miRNAs which regulate NF-κB, JAK/STAT, and PI3K/AKT pathways. Our data further illustrate that ESC-MSC-EVs mainly modulate macrophage polarization via the miR-21/PTEN, miR-320a/PTEN, miR-423/NLRP3, miR-100/mTOR, and miR-26a/TLR3 axes.

CONCLUSION

Together, our results demonstrated the beneficial effects of ESC-MSC-EVs in ACS, wherein the miRNAs present in ESC-MSC-EVs regulate the polarization of macrophages.

Acute Compartment Syndrome in the Athlete

In sports, acute compartment syndrome (ACS) develops following lower limb fracture, with subsequent high intracompartmental pressures and pain out of proportion to the physical examination. A prompt diagnosis is the key to a successful outcome in patients with ACS. The goal of treatment of ACS, namely decompressive fasciotomy, is to reduce intracompartmental pressure and facilitate reperfusion of ischemic tissue before onset of necrosis. A delay in diagnosis and treatment may result in devastating complications, including permanent sensory and motor deficits, contractures, infection, systemic organ failure, limb amputation, and death.

Acute ischemia of the upper and lower limbs: Tailoring the treatment to the underlying etiology

Acute limb ischemia (ALI) can be a devastating clinical emergency with potentially limb- or life-threatening consequences. It is defined as a quickly developing or sudden decrease in limb perfusion producing new or worsening symptoms and signs, often threatening limb viability. ALI is commonly related to an acute arterial occlusion. Rarely, extensive venous occlusion can lead to upper and lower extremities ischemia (ie, phlegmasia). The incidence of acute peripheral arterial occlusion causing ALI is approximately 1.5 cases per 10,000 people per year. The clinical presentation depends on the etiology and whether the patient has underlying peripheral artery disease. Except for traumas, the most common etiologies are embolic or thrombotic events. Peripheral embolism, likely related to embolic heart disease, is the most common cause of acute upper extremity ischemia. However, an acute thrombotic event may occur in native arteries, at the site of a pre-existing atherosclerotic plaque, or as a failure of previous vascular interventions. The presence of an aneurysm may predispose to ALI for both embolic and thrombotic mechanisms. Immediate diagnosis, accurate assessment of limb viability, and prompt intervention, when needed, play important roles in salvaging the affected limb and preventing major amputation. Severity of symptoms is usually dependent on the amount of surrounding arterial collateralization, which may often reflect a pre-existing chronic vascular disease. For this reason, early recognition of the underlying etiology is crucial for choice of best management and definitely for treatment success. Any error in the initial evaluation may negatively affect the functional prognosis of the limb and endanger the patient's life. The aim of this article was to discuss diagnosis, etiology, pathophysiology, and treatment of patients with acute ischemia of the upper and lower limbs.

Compartment syndrome following snakebite in a boy: A case report and literature review

INTRODUCTION AND IMPORTANCE

Snake bites represent a significant public health issue worldwide, as venomous snake bites can result in lethal consequences if not treated promptly, including both local and systemic effects. The local symptoms of a snake bite commonly include tissue necrosis, edema, and compartment syndrome (CS). While CS is a rare complication following a snake bite, it may be more pronounced in children who typically have lower total dilution volume. Currently, the administration of anti-snake venom and prompt fasciotomy are the only specific treatments available for CS.

CASE PRESENTATION

The present report details a case of CS of the right upper extremity in a three-year-old boy who suffered a snake bite on his right hand and was brought to the emergency department of a hospital in northern Iran after a lapse of 14 h.

CLINICAL DISCUSSION

Snakebites frequently occur in the extremities, with about two thirds of them happening in the upper extremities. The skin of the dorsum is extremely thin, there is essentially little subcutaneous fat tissue, and there are numerous superficial veins in this area, particularly the hand.

CONCLUSIONS

Following snake bites, the use of proximal tourniquets should be avoided, and the public's awareness of this need should be encouraged through health education. The prognosis for recovery following fasciotomy and the significance of follow-up and rehabilitation should also be explained to patients.

Clinical predictors of early surgical intervention in patients with venomous snakebites

BACKGROUND

Venomous snakebites induce tissue destruction and secondary infection; however, the optimal timing of surgical intervention for these complications remains unknown. This study assessed the clinical predictors of early surgical intervention in patients with snakebites.

METHODS

This retrospective study included 63 patients (45 men and 18 women) with venomous snakebites. In addition to the snake species, the demographics, affected body parts, clinical characteristics, and ultrasound findings of the patients in the surgical (32 patients) and nonsurgical (31 patients) groups were analyzed and compared.

RESULTS

A higher incidence of acute compartment syndrome, local ecchymosis, skin necrosis, bullae, blisters, and fever was found in the surgical group than in the nonsurgical group, and ultrasound findings of the absence of Doppler flow were more frequently noted in the surgical group than in the nonsurgical group. After adjustment using a multivariate logistic regression model, only advanced age, Naja atra bite, local ecchymosis, and bulla or blister formation remained significant factors for surgical intervention. Furthermore, comparison of the outcomes of patients who received early (≤ 24 h) and late (> 24 h) surgical intervention revealed that the duration of continuous negative pressure wound therapy (6 vs. 15 days; P = 0.006), duration of hospital stay (13 vs. 26 days; P = 0.002), and duration of outpatient follow-up (15 vs. 36 days; P < 0.001) were significantly lower in patients who received early surgical intervention. The final reconstructive surgery was simple among the patients who received surgical intervention within 24 h of being bitten (P = 0.028).

CONCLUSION

In patients with snakebites, advanced age, high-risk clinical manifestations (e.g., local ecchymosis and bulla or blister formation), and Naja atra envenomation are predictors of surgical intervention within 24 h.

The development of surgical risk score and evaluation of necrotizing soft tissue infection in 161 Naja atra envenomed patients

BACKGROUND

Naja atra bites cause wound necrosis, secondary infection, and necrotizing soft tissue infection (NSTI) requiring repetitive surgeries. Little information is known about the predictors for surgery after these bites.

MATERIALS AND METHODS

We retrospectively evaluated 161 patients envenomed by N. atra, 80 of whom underwent surgery because of wound necrosis and infection. We compared the patients' variables between surgical and non-surgical groups. To construct a surgical risk score, we converted the regression coefficients of the significant factors in the multivariate logistic regression into integers. We also examined the deep tissue cultures and pathological findings of the debrided tissue.

RESULTS

A lower limb as the bite site, a ≥3 swelling grade, bullae or blister formation, gastrointestinal (GI) effects, and fever were significantly associated with surgery in the multivariate logistic regression analysis. The surgical risk scores for these variables were 1, 1, 2, 1, and 2, respectively. At a ≥3-point cutoff value, the model has 71.8% sensitivity and 88.5% specificity for predicting surgery, with an area under the receiver operating characteristic curve of 0.88. The histopathological examinations of the debrided tissues supported the diagnosis of snakebite-induced NSTI. Twelve bacterial species were isolated during the initial surgery and eleven during subsequent surgeries.

DISCUSSION AND CONCLUSIONS

From the clinical perspective, swelling, bullae or blister formation, GI effects, and fever appeared quickly after the bite and before surgery. The predictive value of these factors for surgery was acceptable, with a ≥3-point risk score. The common laboratory parameters did not always predict the outcomes of N. atra bites without proper wound examination. Our study supported the diagnosis of NSTI and demonstrated the changes in bacteriology during the surgeries, which can have therapeutic implications for N. atra bites.

Compartment Syndrome After Hip and Knee Arthroplasty

Early diagnosis and prompt definitive management of acute compartment syndrome (ACS) are paramount in preventing the significant morbidity associated with compartment syndrome. The diagnosis of compartment syndrome can be difficult, given the pain associated with the procedure in the immediate postoperative period. Obesity, anticoagulation, postoperative epidural infusion, and prolonged operative time have been reported as risk factors for ACS. In addition to maintaining high clinical suspicion in patient with risk factors for ACS after joint replacement, emphasis on limiting modifiable risk factors should be practiced, including meticulous hemostasis, careful patient positioning, and limiting prolonged postoperative regional anesthesia when not required.

The Role of the Ilizarov Ring External Fixator in the Management of Tibial Fractures with Impending/Incomplete Compartment Syndrome

Objective  The management of tibia fractures complicated by compartment syndrome affects the treatment and functional outcome of patients due to the complications associated with fasciotomy. The purpose of the present study is to differentiate impending/incomplete compartment syndrome (ICS) from established acute compartment syndrome (ACS) in tibial fractures, and to assess the outcome of the fixation of the Ilizarov apparatus in patients with these fractures presenting with ICS, who were not submitted to fasciotomy.

Methods  After the establishment of the inclusion and exclusion criteria, 19 patients were included in the study from January 2007 to December 2017. All patients were male, with an average age of 42.3 ± 11.38 years. All of these patients were managed with Ilizarov ring fixation as per the medical and surgical protocol established in the present study.

Results  The average follow-up obtained for our 18 patients was of 47 ± 41.5 months, with one patient being lost to follow-up. The average time for ring application was of 3.7 ± 1.7 days. In total, 3 (16.7%) of these patients had nonunion. There were no soft-tissue or neurovascular complications in the immediate postoperative period. All of the patients eventually united and were independently mobile without any sequelae of compartment syndrome.

Conclusion  The Ilizarov ring external fixator can be used in the management of tibial fractures with ICS, avoiding fasciotomy with its various complications of infection and nonunion, resulting in fewer surgeries and faster rehabilitation. Surgeons should carefully differentiate ACS and ICS in these patients, as the clinical and functional results vary significantly. Unnecessary fasciotomies should be avoided.

A Pain in the Butt: A Case Series of Gluteal Compartment Syndrome

INTRODUCTION

Gluteal compartment syndrome is a rare and difficult-to-diagnose form of compartment syndrome.

CASE SERIES

We present three patients with gluteal compartment syndrome and review the clinical presentation, imaging, and laboratory findings that assist in diagnosis. Suggestions for more readily diagnosing gluteal compartment syndrome are provided.

CONCLUSION

Emergency physicians must be familiar with the diagnosis and management of gluteal compartment syndrome to prevent the significant associated morbidity and mortality.

Compartment Syndrome in Children With a Supracondylar Fracture: Not Everyone has Risk Factors

OBJECTIVES

To clarify the incidence, associated conditions, and timing of fasciotomy for compartment syndrome (CS) in children with a supracondylar (SC) fracture of the humerus.

DESIGN

A retrospective trauma system database study.

SETTING

Accredited trauma centers in Pennsylvania.

PATIENTS

A statewide trauma database was searched for children 2-13 years of age admitted with a SC fracture between January 2001 and December 2015. Four thousand three hundred eight children met inclusion criteria.

INTERVENTION

Treatment of a SC fracture.

MAIN OUTCOME MEASUREMENT

Diagnosis of CS/performance of a fasciotomy.

RESULTS

During the study period, 21 (0.49%) children admitted with a SC fracture of the humerus were treated with fasciotomy. CS/fasciotomy was more likely in males (P = 0.031), those with a nerve injury (P = 0.049), and/or ipsilateral forearm fracture (P < 0.001). Vascular procedure, performed in 18 (0.42%) children, was strongly associated with CS/fasciotomy (P < 0.001). Closed reduction and fixation of a forearm fracture was associated with CS (P = 0.007). Timing of SC fracture treatment did not influence outcome. Fasciotomy was performed subsequent to reduction in 13 subjects; mean interval between procedures was 23.4 hours (r = 4.5-51.3).

CONCLUSIONS

Risk factors for CS exist; however, they are not required for the condition to develop. CS may develop subsequent to admission and/or SC fracture treatment. In timing of operative management and hospitalization, the results support contemporary practice.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive measurement of orbital compartment pressure and implications for orbital compartment syndrome: a pilot study

BACKGROUND

Diagnosis of orbital compartment syndrome is mainly based on clinical findings, such as intraocular pressure and proptosis, which try to estimate the orbital compartment pressure. However, the reliability of these surrogates is unclear. Current techniques for the direct measurement of orbital compartment pressure are widely experimental and impractical in the clinical setting. Our aim was to explore the feasibility of minimally invasive needle manometry for direct measurement of orbital compartment pressure under reproducible conditions in an in vivo model of orbital congestion. We further sought to evaluate intraocular pressure and proptosis as indicators for elevated orbital compartment pressure.

METHODS

A total of 7 ml of mepivacaine 2% solution was injected into the orbital compartment in 20 patients undergoing cataract surgery under local anesthesia. A commercially available single-use manometer device was inserted between the syringe and the injection needle to measure the orbital compartment pressure for each milliliter of intraorbital volume increment. Additionally, intraocular pressure (subgroup A; n = 10) or axial globe position (subgroup B; n = 10) were measured.

RESULTS

Needle manometry allowed for rapid and continuous measurement of orbital compartment pressure. Overall mean orbital compartment pressure increased from 2.5 mmHg pre- to 12.8 mmHg post-interventionally. Both, intraocular pressure (Spearman's correlation coefficient rs = 0.637, p < 0.0001) and proptosis (rs = 0.675, p < 0.0001) correlated strongly with the orbital compartment pressure.

CONCLUSIONS

Needle manometry appears to be a feasible minimally invasive instrument to directly measure orbital compartment pressure, showing promises for a more routine application in managing orbital compartment syndrome. The results further suggest that both elevated intraocular pressure and proptosis are valuable indicators for orbital compartment syndrome.

Acute Abdominal Compartment Syndrome complicating a chronic mesenteric ischemia revascularization

BACKGROUND

Abdominal Compartment Syndrome (ACS) is a pathological condition that results from an increase in pressure within the abdomen associated with organ failure. It can be acute or chronic, primary or secondary. ACS poses a serious diagnostic challenge for physicians as the clinical presentation is varied and can mimic other medical pathologies. To prevent a multi-organ failure and ultimately death due to this disease, the World Society of Abdominal Compartment Syndrome (WSACS) suggested clinical criteria and biology tests to facilitate an early diagnosis of acute ACS.

CASE PRESENTATION

We report a case of 61 year-old man diagnosed with chronic mesenteric ischemia that has been successfully treated by prosthetic bypass. The postoperative period was eventual, the patient presented complications corresponding essentially to a manifest acute ACS. The treatment consisted on abdominal decompression and resuscitation measures.

CONCLUSIONS

An early diagnosis of ACS disease for an appropriate therapeutic initiation is mandatory to prevent its complications and save the patient's life prognosis.

Envenomation by Trimeresurus stejnegeri stejnegeri: clinical manifestations, treatment and associated factors for wound necrosis

Background

Trimeresurus stejnegeri stejnegeri bite induces tissue swelling, pain, thrombocytopenia, rhabdomyolysis, and acute renal failure. However, the incidence of coagulopathy, factors associated with wound necrosis, and the appropriate management of this condition have not been well characterized yet.

Materials

This study included patients bitten by T. s. stejnegeri that were admitted to the study hospitals from 2001 to 2016. Patient characteristics, laboratory data, and management approaches were compared in victims with and without wound necrosis.

Results

A total of 185 patients were evaluated: three patients (1.6%) were asymptomatic; whereas tissue swelling and pain, local ecchymosis, wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and renal impairment were present in 182, 53, 13, 15, 10, 1, and 3 patients, respectively. One patient died from coagulopathy and hemorrhagic shock. Antivenom was administered to all envenomed patients at a median time of 1.8 h after the bite. The median total dose of antivenom was five vials. Chi-square analysis showed that bitten fingers, using cold packs during first aid, presence of bullae or blisters, lymphangitis or lymphadenitis, local numbness and suspected infection to be significantly associated with wound necrosis. After adjustment using a multivariate logistic regression model, only cold packs as first aid, bulla or blister formation, and wound infection remained significant.

Conclusions

The main effects of T. s. stejnegeri envenomation are tissue swelling, pain, and local ecchymosis. We do not recommend the use of cold packs during first aid to reduce wound pain, as this may be a risk factor for wound necrosis. In addition, patients with bulla or blister formation should be carefully examined for subsequent wound necrosis. Antiplatelet use may worsen systemic bleeding. No severe rhabdomyolysis or renal failure was observed in this large case series, we therefore considered that they were not prominent effects of T. s. stejnegeri bite.

Sciatic Nerve Injury Secondary to a Gluteal Compartment Syndrome

Gluteal compartment syndrome (GCS) is extremely rare, with a low index of suspicion among physicians, hence, it is highly overlooked. The underdiagnosis can lead to irreversible tissue ischemia and severe neurological deficits. GCS is a surgical emergency and requires immediate surgical intervention given its high morbidity and mortality. Based on the limited available literature, multiple etiologies have been postulated including traumatic and nontraumatic causes. This article presents a complex and unusual case of GCS after prolonged immobilization in an IV drug abuser who was subjected to initial missed diagnosis.

Clinical manifestations and treatments of Protobothrops mucrosquamatus bite and associated factors for wound necrosis and subsequent debridement and finger or toe amputation surgery

INTRODUCTION

Protobothrops mucrosquamatus bite induces wound necrosis, coagulopathy, thrombocytopenia, rhabdomyolysis, and acute renal failure. The severity of the hematological derangements and associated factors for wound necrosis and subsequent surgery and the appropriate management of these conditions have not been well characterized. Although severe renal failure requiring hemodialysis has been reported following P. mucrosquamatus bite, the culprit snake may be erroneously classified.

MATERIALS AND METHODS

A total of 186 patients with P. mucrosquamatus bites were retrospectively evaluated. They were categorized into group 1 (patients receiving debridement or finger/toe amputation) and group 2 (all other patients) to identify the associated factors for surgery. Characteristic data were compared between groups 1 and 2 and between definite and suspected cases.

RESULTS

No differences were observed between definite and suspected cases in terms of symptomatology and management. Of the 186 patients, 7 (3.8%) were asymptomatic, 179 (96.2%) experienced tissue swelling and pain, and 107 (57.5%) had local ecchymosis. Coagulopathy, thrombocytopenia, and renal impairment were found in 13 (7%), 19 (10.2%), and 7 (3.8%) patients, respectively. None of the patients required transfusion therapy or hemodialysis. Furthermore, no systemic bleeding or death occurred. Antivenom was administered to all 179 envenomed patients at a median of 1.5 h post-bite. The median total dose of the specific antivenom was 5.5 vials. In multivariate logistic regression analysis, finger as the bite site, bullae and blister formation, and wound infection were significantly associated with wound necrosis; whereas finger as the bite site and bullae and blister formation were related to debridement or finger/toe amputation.

DISCUSSION AND CONCLUSIONS

Protobothrops mucrosquamatus envenomation mainly exerts effects on local tissue. Systemic effects are uncommon and generally nonsevere and transient after the treatment with the specific antivenom. We speculated that severe renal failure requiring hemodialysis is not a typical finding of P. mucrosquamatus envenomation. Patients with finger as the bite site and bullae or blister formation should be carefully examined for wound necrosis, secondary infection, and subsequent surgery. Further evaluations of the efficacy of antivenom against local tissue effects and the effect of selective antibiotics in the management of bite wound infection are urgently required. Although the antivenom manufacturer suggested a skin test prior to use, we believed that it could be omitted because it does not accurately predict the allergic responses.

Acute Bilateral Compartment Syndrome of the Forearms

A 43-year-old woman presented to our emergency department with severe bilateral forearm pain. On examination, both forearms were tense and swollen and the patient had excruciating pain, made much worse on passive extension of the fingers. The pain did not resolve with analgesia. The symptoms and clinical examination were highly suspicious for compartment syndrome. However, there was no history of trauma, strenuous physical activity, or any other obvious factor that might have precipitated the onset of a compartment syndrome. The serum creatinine kinase at presentation was greater than 37,000. The patient, however, did have a history of hypertension and was taking losartan, an angiotensinogen II antagonist that has been associated with rhabdomyolysis. The patient was brought to surgery for emergency fasciotomies and made an excellent recovery after surgery. The etiology of this patient's bilateral compartment syndrome is uncertain but may be a manifestation of drug-induced rhabdomyolysis.

Risk Factors for Compartment Syndrome in Pediatric Trauma Patients

OBJECTIVE

This study aimed to identify risk factors for compartment syndrome (CS) in pediatric trauma populations.

METHODS

We included patients younger than 19 years treated at trauma centers contributing to the National Trauma Data Bank between 2009 and 2012. Multivariable logistic regression was used to examine the association between risk factors and the development of CS. The final model adjusted for age, sex, race, number of comorbidities, Glascow Coma Scale, Injury Severity Score, mechanism of injury, and fracture of the lower limb.

RESULTS

A total of 341,238 patients were eligible for analysis, and 896 patients developed CS (0.3%). In adjusted regression models, older patients had significantly higher odds of CS compared with patients 1 years or younger (odds ratio [OR], 3.29 [95% confidence interval [CI], 1.29-8.37; 2-6 years]; OR, 7.55 [95% CI, 3.08-18.55 [7-12 years]; OR, 10.34 [95% CI, 4.26-25.09 [13-18 years]). Male patients had significantly increased odds of CS compared with female patients, as did patients with lower limb fractures compared with patients without lower limb fractures (OR, 1.93 [95% CI, 1.56-2.40]; OR, 7.61 [95% CI, 6.48-8.94]; respectively). Finally, patients with a firearm injury had higher odds of CS compared with other mechanisms of injury (OR, 3.51 [95% CI, 2.70-4.56]).

CONCLUSIONS

Older pediatric trauma patients, male patients, and those with lower limb fractures and firearm injuries have increased odds of CS. Information on risk factors can be used to help identify patients most likely to develop CS, facilitating timely diagnosis and treatment.

Primary Closure of Wide Fasciotomy and Surgical Wounds Using Rubber Band-Assisted External Tissue Expansion: A Simple, Safe, and Cost-effective Technique

BACKGROUND

Although decompressive fasciotomy is a limb-saving procedure in the setting of acute compartment syndrome, it leaves a large wound defect with tissue edema and skin retraction that can preclude primary closure. Numerous techniques have been described to address the challenge of closing fasciotomy wounds. This study reports our experience with fasciotomy closure using rubber bands (RBs) for external tissue expansion.

METHODS

Patients were informed about RB closure and split-thickness skin graft options. Only patients who opted for RB closure and had wounds that could not be approximated using the pinch test underwent the procedure. Starting from the apex and progressively advancing, the RBs were applied to the skin edges at 3 to 4 mm intervals using staples. The RBs were advanced by twisting back-and-forth to create a criss-cross pattern. One week after application, fasciotomy wounds were closed primarily or underwent further RB application, based on clinical assessment of adequacy of skin advancement, compartment tension, and perfusion. Review of a prospectively maintained database was performed, including demographics, comorbidities, etiology, wound and operative details, hospital stay, and complications.

RESULTS

Seventeen consecutive patients with 25 wounds (22 fasciotomy and 3 other surgical wounds) were treated using the RB technique. Average wound length and width measured 15.7 cm (range, 5-32 cm) and 5.2 cm (range, 1-12 cm), respectively. Locations of wounds included forearm (n = 12, 48.0%), leg (n = 7, 28.0%), hand (n = 4, 16.0%), elbow (n = 1, 4.0%), and hip (n = 1, 4.0%). Eighteen of 25 wounds (72.0%) were closed primarily after 1 RB application. Additional RB application was required for 5 wounds to achieve primary closure. Between stages, patients were discharged home if they did not have other conditions requiring in-hospital stay. No complications were observed, and no revision surgeries were required. Patient satisfaction was 100%, and all indicated that they would choose the RB technique over skin grafting.

CONCLUSIONS

The modified RB technique is a simple, safe, and cost-effective alternative for treating fasciotomy and other surgical defects resulting in high patient satisfaction and good cosmetic outcome, without the need for split-thickness skin graft or flap coverage.

Acute Limb Ischemia: An Update on Diagnosis and Management

This review presents an update on the diagnosis and management of acute limb ischemia (ALI), a severe condition associated with high mortality and amputation rates. A comprehensive spectrum of ALI etiology is presented, with highlights on embolism and in situ thrombosis. The steps for emergency diagnosis are described, emphasizing the role of clinical data and imaging, mainly duplex ultrasound, CT angiography and digital substraction angiography. The different therapeutic techniques are presented, ranging from pharmacological (thrombolysis) to interventional (thromboaspiration, mechanical thrombectomy, and stent implantation) techniques to established surgical revascularization (Fogarty thrombembolectomy, by-pass, endarterectomy, patch angioplasty or combinations) and minor or major amputation of necessity. Postprocedural management, reperfusion injury, compartment syndrome and long-term treatment are also updated.

Aetiology of trauma-related acute compartment syndrome of the leg: A systematic review

BACKGROUND

Acute compartment syndrome (ACS) is characterised by abnormal pressure inside a compartment, resulting in ischemia of muscles and nerves. Most orthopaedic surgeons, especially those who work in major trauma centres, have been or will be facing a case of ACS in their clinical activity. Fortunately, complications related to untreated compartment syndrome have become less frequent thanks to a better understanding of pathogenesis and to early recognition and prompt surgical treatment. The aim of this study is to identify the existing evidence regarding aetiology of trauma-related ACS of the leg.

METHODS

A systematic review of the literature was undertaken using PubMed Medline, Ovid Medline and the Cochrane library, extended by a manual search of bibliographies. Retrieved articles were eligible for inclusion if they reported data about aetiology of trauma-related compartment syndrome of the tibia.

RESULTS

Ninety-five studies that fulfilled the inclusion criteria were identified. By dividing the studies into three groups according to the traumatic aetiology, we were able to classify traumatic ACS as fracture related, soft tissue injury related and vascular injury related. Fracture related was the most represented group, comprising 58 papers, followed by the soft tissue injury related group which includes 44 articles and vascular injury related group with 24 papers.

CONCLUSIONS

Although traditionally ACS has been associated mainly with fractures of tibial diaphysis, literature demonstrates that other localisations, in particular in the proximal tibia, are associated with an increased incidence of this serious condition. The forms of ACS secondary to soft tissues injuries represent an extremely variable spectrum of lesions with an insidious tendency for late diagnosis and consequently negative outcomes. In the case of vascular injury, ACS should always be carefully considered as a priority, given the high incidence reported in the literature, as a result of primitive vascular damage or as a result of revascularisation of the limb. Knowledge of aetiology of this serious condition allows us to stratify the risk by identifying a population of patients most at risk, together with the most frequently associated traumatic injuries.

Influence of probe pressure on the pulsatile diffuse correlation spectroscopy blood flow signal on the forearm and forehead regions

In a pilot study of 11 healthy adults (24 to 39 years, all male), we characterize the influence of external probe pressure on optical diffuse correlation spectroscopy (DCS) measurements of pulsatile blood flow obtained on the forearm and forehead. For external probe pressure control, a hand inflatable air balloon is inserted between the tissue and an elastic strap. The air balloon is sequentially inflated to achieve a wide range of external probe pressures between 20 and 250 mmHg on the forearm and forehead, which are measured with a flexible pressure sensor underneath the probe. At each probe pressure, the pulsatility index (PI) of arteriole blood flow on the forehead and forearm is measured with DCS (2.1-cm source-detector separation). We observe a strong correlation between probe pressure and PI on the forearm ( R = 0.66 , p < 0.001 ), but not on the forehead ( R = - 0.11 , p = 0.4 ). The forearm measurements demonstrate the sensitivity of the DCS PI to skeletal muscle tissue pressure, whereas the forehead measurements indicate that DCS PI measurements are not sensitive to scalp tissue pressure. Note, in contrast to pulsatility, the time-averaged DCS blood flow index on the forehead was significantly correlated with probe pressure ( R = - 0.55 , p < 0.001 ). This pilot data appears to support the initiation of more comprehensive clinical studies on DCS to detect trends in internal pressure in brain and skeletal muscle.

Epidemiology, treatment and outcome after compartment syndrome of the thigh in 69 cases - Experiences from a level I trauma centre

BACKGROUND

Compartment syndrome of the thigh (CST) is a rare condition, and its delayed diagnosis and therapy may lead to devastating adverse effects. Thus, the aim of this study was to present the amassed clinical experiences, regarding diagnosis and treatment of CST at a level I trauma centre.

MATERIALS AND METHODS

The database was reviewed for all patients with a manifest CST treated surgically between 1995 and 2014.

RESULTS

69 patients (61 males and 8 females) met the inclusion criteria, with a mean age of 42.9 years (range: 11-87 years). Forty-four patients (64%) presented with an isolated CST. There was a significant association between complication rates and high impact vs. blunt trauma (12/32, 38% vs. 0/20, 0%; p = 0.0022; Fisher's exact test). The number of surgeries in patients with a concomitant femur fracture was significantly increased (in mean: 2.8 vs. 4.9 surgical interventions; p < 0.001; U test).

CONCLUSION

Patients after high impact trauma showed the highest complication rate. Concomitant femur fractures were associated with an increased number of surgical interventions. The synopsis of trauma mechanism, clinical presentation, age, anticoagulation status and clinical experience of the trauma surgeon seem to be the best tools to correctly diagnose CST.

Persistent Knee Pain After Falling Off a Bicycle

We present the case of an 18-year-old young man with severe persistent knee pain secondary to a popliteal artery thrombosis. This occurred as a result of a fall from a bicycle. Acute compartment syndrome refers to the sequelae that can occur because of increased fascial compartment pressures, such as crush injuries, burns, traumatic or spontaneous hemorrhage, or constrictive casts. Increased pressures in nonelastic fascial compartments result in decreased perfusion distally, leading to ischemia of muscles and neurovascular tissue. In addition to highlighting recognition of the classic signs and symptoms of this limb-threatening condition, this case illustrates the importance of obtaining a thorough history; this is necessary in order to have a high index of suspicion for this diagnosis. A significant degree of clinical insight and prompt surgical intervention may save the functions of both the muscles and the nerves. These are at risk of permanent damage due to possible elevated compartment pressures.

The First Aid and Hospital Treatment of Gunshot and Blast Injuries

BACKGROUND

When gunshot and blast injuries affect only a single person, first aid can always be delivered in conformity with the relevant guidelines. In contrast, when there is a dynamic casualty situation affecting many persons, such as after a terrorist attack, treatment may need to be focused on immediately life-threatening complications.

METHODS

This review is based on pertinent publications retrieved by a selective search in Medline and on the authors' clinical experience.

RESULTS

In a mass-casualty event, all initial measures are directed toward the survival of the greatest possible number of patients, in accordance with the concept of "tactical abbreviated surgical care." Typical complications such as airway obstruction, tension pneumothorax, and hemorrhage must be treated within the first 10 minutes. Patients with bleeding into body cavities or from the trunk must be given priority in transport; hemorrhage from the limbs can be adequately stabilized with a tourniquet. In-hospital care must often be oriented to the principles of "damage control surgery," with the highest priority assigned to the treatment of life-threatening conditions such as hemodynamic instability, penetrating wounds, or overt coagulopathy. The main considerations in initial surgical stabilization are control of bleeding, control of contamination and lavage, avoidance of further consequences of injury, and prevention of ischemia. Depending on the resources available, a transition can be made afterward to individualized treatment.

CONCLUSION

In mass-casualty events and special casualty situations, mortality can be lowered by treating immediately life-threatening complications as rapidly as possible. This includes the early identification of patients with lifethreatening hemorrhage. Advance preparation for the management of a masscasualty event is advisable so that the outcome can be as favorable as possible for all of the injured in special or tactical casualty situations.

Management of Postfasciotomy Wounds and Skin Defects Following Complex Vascular Trauma to the Extremities Using the External Tissue Extender System

Management of large postfasciotomy wounds and/or skin and soft tissue defects after major vascular trauma to the extremities can be challenging. The External Tissue Extender (Blomqvist; ETE), a skin-stretching device, which consists of silicone tapes and plastic stoppers, approximates wound margins and facilitates delayed primary closure. We describe our experience with the use of ETE in 5 patients (4 males) with a total of 8 wounds (7 postfasciotomy, 1 soft tissue defect) over the past 12 years. The mean patient age was 32 (range 17-61) years. The wounds involved the lower limb in 3 patients and the upper limb in 2, whereas the injured arteries were the popliteal in 3, the axillary in 1, and the brachial in 1. The mean wound length was 24 cm (range 9-37 cm), and the mean number of ETE silicone tapes used per wound was 13 (range 5-19). The median duration of ETE therapy was 7 days (range 4-7). ETE therapy resulted in sufficient wound approximation to allow complete closure with conventional suturing in 7 out of the 8 wounds. Of these, one developed infection that required drainage, debridement, and resuturing. All wounds achieved satisfactory healing status and all limbs had been salvaged. In conclusion, the ETE is a useful, easy-to-use, and simple adjunct that may facilitate delayed primary closure of large postfasciotomy wounds or extensive skin and soft tissue defects following complex vascular trauma to the extremities.

Acute Exertional Compartment Syndrome with Rhabdomyolysis: Case Report and Review of Literature

Patient: Male, 17

Final Diagnosis: Acute exertional compartment syndrome

Symptoms: Foot drop • leg pain • paresthesia

Medication: —

Clinical Procedure: Fasciotomy

Specialty: Orthopedics and Traumatology

Orthopaedic traumatology: fundamental principles and current controversies for the acute care surgeon

Multiply injured patients with fractures are co-managed by acute care surgeons and orthopaedic surgeons. In most centers, orthopaedic surgeons definitively manage fractures, but preliminary management, including washouts, splinting, reductions, and external fixations, may be performed by selected acute care surgeons. The acute care surgeon should have a working knowledge of orthopaedic terminology to communicate with colleagues effectively. They should have an understanding of the composition of bone, periosteum, and cartilage, and their reaction when there is an injury. Fractures are usually fixed urgently, but some multiply injured patients are better served with a damage control strategy. Extremity compartment syndrome should be suspected in all critically injured patients with or without fractures and a low threshold for compartment pressure measurements or empiric fasciotomy maintained. Acute care surgeons performing rib fracture fixation and other chest wall injury reconstructions should follow the principles of open fracture reduction and stabilization.

Association between kidney intracapsular pressure and ultrasound elastography

Background

Kidney congestion is a common pathophysiologic pathway of acute kidney injury (AKI) in sepsis and heart failure. There is no noninvasive tool to measure kidney intracapsular pressure (KIP) directly.

Methods

We evaluated the correlation of KIP with kidney elasticity measured by ultrasound surface wave elastography (USWE). We directly measured transcatheter KIP in three pigs at baseline and after bolus infusion of normal saline, norepinephrine, vasopressin, dopamine, and fenoldopam; infiltration of 2-L peritoneal dialysis solution in the intra-abdominal space; and venous, arterial, and ureteral clamping. KIP was compared with USWE wave speed.

Results

Only intra-abdominal installation of peritoneal dialysis fluid was associated with significant change in KIP (mean (95% CI) increase, 3.7 (3.2–4.2)] mmHg; P < .001). Although intraperitoneal pressure and KIP did not differ under any experimental condition, bladder pressure was consistently and significantly greater than KIP under all circumstances (mean (95% CI) bladder pressure vs. KIP, 3.8 (2.9–4.) mmHg; P < .001). USWE wave speed significantly correlated with KIP (adjusted coefficient of determination, 0.71; P < .001). Estimate (95% CI) USWE speed for KIP prediction stayed significant after adjustment for KIP hypertension (−0.8 (− 1.4 to − 0.2) m/s; P = .008) whereas systolic and diastolic blood pressures were not significant predictors of KIP.

Conclusions

In a pilot study of the swine model, we found ultrasound surface wave elastography speed is significantly correlated with transcatheter measurement of kidney intracapsular and intra-abdominal pressures, while bladder pressure overestimated kidney intracapsular pressure.

Naja atra snakebite in Taiwan

BACKGROUND

Naja atra snakebite is uncommon in Taiwan and causes distinct effects on its victims. Although the Taiwan government produces its own specific antivenom, little information on the management of N. atra snakebite is available.

MATERIALS AND METHODS

We retrospectively evaluated 183 patients admitted to two medical centers. Of these, 45 were identified as definite cases of N. atra snakebite, 86 as suspected cases, and 52 as clinical cases. Demographic data, symptomatology, and management were compared between these case groups.

RESULTS

Symptomatology and management were similar in the three groups. Among the 183 patients, 10 (5.5%) were asymptomatic and nine (4.9%) had transient and partial ptosis or body weakness. The principal effects were local tissue swelling and pain in 173 patients (94.5%), followed by clinically suspected wound infection in 148 (80.9%), skin necrosis in 120 (65.6%), necrotizing soft tissue infection in 77 (42.1%), fever in 59 (32.2%), and gastrointestinal effects in 53 (29%). The median total dose of specific antivenom needed to treat N. atra envenoming was 10 vials. In the envenomed patients, debridement was required in 74 patients (42.8%), fasciotomy/fasciectomy in 46 (26.6%), and finger or toe amputation in seven (4%). The first operation was performed at a median of 3.5 days after the bite.

DISCUSSION AND CONCLUSIONS

Based on these typical manifestations, clinical diagnosis of N. atra snakebites may be feasible and practical. In contrast to other snakes of Elapidae family, N. atra bite did not cause serious neurological effects. Early surgical consultation should be obtained because half of the patients underwent surgery due to infectious complications. Acute compartment syndrome was the surgical indication in rare cases; however, overestimation of the incidence may have occurred. This syndrome should be confirmed by serial intracompartmental pressure monitoring instead of only physical examination, and a sufficient dose of antivenom should be given prior to surgical decompression.

Compartment and Crush Syndromes After Sleep Deprivation and a Therapeutic Dose of Zolpidem

Despite extensive review in the literature, compartment syndrome and crush syndrome remain difficult to diagnose. Trauma, toxins and reperfusion have been associated with these syndromes. Cases involving alcohol and drug abuse have described patients “found down” compressing an extremity. We present a case of a registered nurse who developed compartment syndrome in multiple limbs due to prolonged sleep after sleep deprivation and zolpidem use. To our knowledge, this is the first case of compartment syndrome or crush syndrome to have occurred in the setting of zolpidem use. Sleep disruption in healthcare workers represents a public health issue with dangerous sequelae, both acute and chronic.

Timing of Presentation of Pediatric Compartment Syndrome and Its Microsurgical Implication: A Retrospective Review

BACKGROUND

Pediatric forearm compartment syndrome can lead to severe functional disability. Although it is known that earlier presentation with decompression leads to better outcomes, it is not known when presentation after injury leads to significant loss of function requiring microsurgical intervention. The authors describe the rate of microsurgical reconstruction after pediatric forearm compartment syndrome as related to timing of presentation.

METHODS

A retrospective chart review was conducted of pediatric patients with forearm compartment syndrome between January 1, 2000, and March 22, 2013, after a traumatic upper extremity injury. Demographic information, cause, time to decompression, complications, and functional outcome were recorded.

RESULTS

Thirty-five patients aged between 2 and 16 years (8.97 ± 4.12 years) met inclusion criteria. The majority (74 percent) were boys. The right upper extremity was predominantly involved (54 percent), with a predilection for ulnar fractures (66 percent). Fasciotomies were completed for 32 patients (91 percent). Two patients had no decompression (6 percent) because of late presentation. The average time to fasciotomy was less than 12 hours after injury in 16 patients (46 percent), 12 to 48 hours in 15 patients (43 percent), and greater than 48 hours in four patients (11 percent). Complications (63 percent) included nerve injury (40 percent), skin graft (37 percent), scar revision (11 percent), and long flexor tightness requiring serial casting (17 percent). Forearm muscle necrosis requiring microsurgical reconstructive surgery with a gracilis muscle flap occurred in two patients (6 percent). Increased time to decompression was statistically associated with long flexor tightness and gracilis reconstructive surgery.

CONCLUSION

Presentation after 48 hours resulted in significant functional deficits requiring reconstructive surgery (gracilis muscle flap reconstruction) or long-term conservative management (serial casting).

Gluteal compartment syndrome with sciatic nerve palsy caused by traumatic rupture of the inferior gluteal artery: a successful surgical treatment

Gluteal compartment syndrome is a rare entity, usually caused by direct trauma. This occurrence with sciatic nerve palsy caused by inferior gluteal artery laceration and compressive haematoma has not been reported in the literature. We describe such a case treated successfully by urgent surgical decompression and resolution of the sciatic nerve palsy. A man aged 41 years sustained blunt trauma to the right gluteal region causing a rupture of the inferior gluteal artery, gluteal compartment syndrome and rapidly progressive sciatic nerve palsy. The condition was treated urgently with interventional radiology, open surgical decompression and debridement. Recovery was complicated by recurrent haematoma formation, treated successfully with subsequent complete resolution of the sciatic nerve palsy. A review of the literature of traumatic gluteal compartment syndrome is presented with discussion of the clinical diagnosis, multidisciplinary treatment and recommendations for treatment of this injury.

[Diagnostics and treatment decisions in acute compartment syndrome. Results of a survey in German hospitals]

BACKGROUND AND OBJECTIVES

The presented survey was intended to evaluate whether a standardization of diagnostics and therapy for acute compartment syndrome has been achieved.

MATERIALS AND METHODS

University hospitals, academic teaching hospitals, and county hospitals in Germany were included.

RESULTS

A total of 38% (n=120) of all contacted hospitals participated in this study with questions mainly answered by consulting physicians (68%). In general the importance of the clinical examination was considered as being more important than other diagnostic measures. In cases where further diagnostics were necessary, the intramuscular pressure measurement was used most frequently. Of the participants 50% performed surgical fasciotomy based on the clinical examination in combination with the intramuscular pressure measurement; however, there were considerable differences between the participating hospitals with respect to the anatomical position of intramuscular measurements, the limiting value of the intramuscular pressure and the surgical technique for performing fasciotomy.

CONCLUSION

According to the presented analysis the diagnosis and indications for surgical treatment in patients developing an acute compartment syndrome do not seem to be sufficiently clarified. The establishment of unified treatment guidelines could help to reduce the number of delayed diagnoses of compartment syndrome.

Predictive Factors for Post-Ischemic Compartment Syndrome in Non-Traumatic Acute Limb Ischemia in a Lower Extremity

Objective: Compartment syndrome (CS) is serious complication following revascularization of acute limb ischemia (ALI). However, predictive factors associated with CS remain unclear. This study aimed to identify these predictive factors. Materials and Methods: Twenty-two patients who presented with non-traumatic ALI between November 2013 and October 2015 were enrolled and monitored for CS in this prospective cohort study. Predictive factors were compared between the CS and non-CS groups. Results: There were 5 patients in the CS group and 17 patients in the non-CS group. Four predictive factors were associated with CS: (1) inadequate backflow (80% and 12% in the CS and non-CS groups, respectively; P=.001); (2) serum creatine kinase (CK) level (20,683 U/L and 911 U/L in the CS and non-CS groups, respectively; P<.001); (3) positive fluid balance after admission (4,324 mL and 1,223 mL in the CS and non-CS groups, respectively; P<.001); and (4) Rutherford category IIB (100% and 18% in the CS and non-CS groups, respectively; P=.0002). Conclusion: Inadequate backflow, high serum CK level, positive fluid balance, and advanced-stage ALI were associated with CS. This information may be useful in identification of high-risk patients for CS prevention and in early detection of CS following the revascularization procedure.