1
|
Dlott CC, Metcalfe T, Khunte A, Jain S, Bahel A, Hsiang WR, Donnelley CA, Kayani J, Wiznia DH. Evaluating musculoskeletal urgent care center triage and transfer of emergency conditions for emergency surgical assessment and intervention. Medicine (Baltimore) 2022; 101:e32519. [PMID: 36595864 PMCID: PMC9794202 DOI: 10.1097/md.0000000000032519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Musculoskeletal urgent care centers (MUCCs) are an alternative to emergency departments (EDs) for patients to seek care for low acuity orthopedic injuries such as ankle sprains or joint pain, but are not equipped to manage orthopedic emergencies that require a higher level of care provided in the ED. This study aims to evaluate telephone and online triage practices as well as ED transfer procedures for MUCCs for patients presenting with an orthopedic condition requiring urgent surgical intervention. We called 595 MUCCs using a standardized script presenting as a critical patient with symptoms of lower extremity compartment syndrome. We compared direct ED referral frequency and triage frequency for MUCCs for patients insured by either Medicaid or by private insurance. We found that patients presenting with an apparent compartment syndrome were directly referred to the ED by < 1 in 5 MUCCs. Additionally, < 5% of patients were asked additional triage questions that would increase clinician suspicion for compartment syndrome and allow MUCCs to appropriately direct patients to the ED. MUCCs provide limited telephone and online triage for patients, which may result in delays of care for life or limb threatening injuries that require ED resources such as sedation, reductions, and emergency surgery. However, when MUCCs did conduct triage, it significantly increased the likelihood that patients were appropriately referred to the ED. Level of Evidence: Level II, prognostic study.
Collapse
Affiliation(s)
- Chloe C. Dlott
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
- * Correspondence: Chloe C. Dlott, Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, 800 Howard Avenue, New Haven, CT 06519, United States (e-mail: )
| | - Tanner Metcalfe
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Akshay Khunte
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Sanjana Jain
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Anchal Bahel
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Walter R. Hsiang
- University of California San Francisco, Department of Urology, San Francisco, CA, United States
| | - Claire A. Donnelley
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Jehanzeb Kayani
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| | - Daniel H. Wiznia
- Yale University School of Medicine, Department of Orthopaedics & Rehabilitation, New Haven, CT, United States
| |
Collapse
|
2
|
Sonawane K, Dhamotharan P, Dixit H, Gurumoorthi P. Coping With the Fear of Compartment Syndrome Without Compromising Analgesia: A Narrative Review. Cureus 2022; 14:e30776. [DOI: 10.7759/cureus.30776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 11/06/2022] Open
|
3
|
Ilyas H, Fagan C, Roser F, Hebela NM. Lumbar Paraspinal Compartment Syndrome: Case Report and Critical Evaluation of the Literature. Clin Spine Surg 2022; 35:301-309. [PMID: 34654777 DOI: 10.1097/bsd.0000000000001254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lumbar compartment syndrome is a recognized clinical phenomenon, despite receiving less attention as a clinical entity. Given its rarity, the definitive presentation, diagnosis, and management strategies are not completely agreed upon. MATERIALS AND METHODS A literature search on PubMed of all case reports of lumbar paraspinal compartment syndromes was conducted. All case reports and reviews were analyzed for patient demographic data, presentation, diagnostic evaluation, treatment, and clinical follow-up. RESULTS A total of 37 cases of lumbar compartment syndrome were identified. Overall, 91.9% occurred in men with an average age of 30.9 years. Weightlifting (n=18, 48.6%) and physical exertion (n=7, 18.9%) accounted for the majority of presentations. In all, 37.8% of cases occurred unilaterally. Creatinine kinase, aspartate aminotransferase, and alanine aminotransferase were notably elevated. Compartment pressure was elevated with an average of 91.8 mm Hg (SD: 44.8 mm Hg). Twenty-two cases were treated operatively (59.5%) and 15 (40.5%) were treated nonoperatively. In total, 19/20 (95.0%) of cases treated operatively reported either resolution of pain or return to baseline activities without limitation, compared with 1/11 (9.1%) treated nonoperatively. This difference between the operative and nonoperative cohort was statistically significant ( P <0.0001). CONCLUSIONS Lumbar paraspinal compartment syndrome is a rare, but well-documented clinical entity. In all, 67.5% of cases occurred after weightlifting or physical exertion. Overall, 40.5% of cases in the literature were treated nonoperatively. Per our analysis, there is a clinically and statistically significant difference in cases treated operatively versus nonoperatively (95.0% vs. 9.1%, P <0.0001).
Collapse
Affiliation(s)
- Haariss Ilyas
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Claire Fagan
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Florian Roser
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Nader M Hebela
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| |
Collapse
|
4
|
Schupbach D, Honjol Y, Bouklouch Y, Merle G, Harvey EJ. Acute Compartment Syndrome Modeling with Sequential Infusion Shows the Deep Posterior Compartment Is Not Functionally Discrete. J Bone Joint Surg Am 2022; 104:813-820. [PMID: 35041625 DOI: 10.2106/jbjs.21.00291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Clinical case series have indicated that 1 or 2-compartment decompression of the anterior or lateral leg may be sufficient for release, but, currently, no cadaveric model has verified that approach. The objective of this study was to investigate the functional relationship between compartments by alternating sequences of infusion and fasciotomy release. METHODS This study utilized multicompartment sequential pressurization with simultaneous monitoring by continuous pressure sensors to model compartment syndrome in a human cadaver leg. Subsequent sequential release of compartments and continuous streaming of pressure readings permitted unique insights. RESULTS A leg model allowed the examination of pressure changes in all 4 compartments as treated with sequential fasciotomies. The successful modeling of lower-leg pressures consistent with compartment syndrome showed that discrepancies relative to accepted concepts were seen when the deep posterior compartment was pressurized in isolation. Also, release of 1 of the 2 of either the anterior or lateral compartments seems to be sufficient for decompression to acceptable pressure levels. CONCLUSIONS The deep posterior compartment does not appear to be completely discrete and instead follows the pressurization curve of the posterior muscle group. This indicates that release of the deep posterior compartment may not be needed in all acute compartment syndrome scenarios. CLINICAL RELEVANCE Surgical techniques can be modified for treatment of acute compartment syndrome to avoid large scar lengths, deep dissection, and multiple exposures that could improve patient outcomes.
Collapse
Affiliation(s)
- Drew Schupbach
- Department of Surgery, Injury Repair Recovery Program, McGill University Health Center Research Institute, McGill University, Montreal, Quebec, Canada.,Experimental Surgery Program, McGill University, Montreal, Quebec, Canada
| | - Yazan Honjol
- Experimental Surgery Program, McGill University, Montreal, Quebec, Canada
| | - Yasser Bouklouch
- Department of Surgery, Injury Repair Recovery Program, McGill University Health Center Research Institute, McGill University, Montreal, Quebec, Canada
| | - Geraldine Merle
- Department of Surgery, Injury Repair Recovery Program, McGill University Health Center Research Institute, McGill University, Montreal, Quebec, Canada
| | - Edward J Harvey
- Department of Surgery, Injury Repair Recovery Program, McGill University Health Center Research Institute, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
5
|
Powell-Bowns MF, Littlechild JE, Yapp LZ, Faulkner AC, White TO, McQueen MM, Duckworth AD. Tibial shaft fractures - to monitor or not? a multi-centre 2 year comparative study assessing the diagnosis of compartment syndrome in patients with tibial diaphyseal fractures. Injury 2021; 52:3111-3116. [PMID: 34246477 DOI: 10.1016/j.injury.2021.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 06/01/2021] [Accepted: 06/12/2021] [Indexed: 02/02/2023]
Abstract
AIMS The aim of this study was to compare the outcome in patients who did and did not undergo continuous compartment pressure monitoring (CCPM) following a tibial diaphyseal fracture. PATIENTS AND METHODS We performed a retrospective cohort study of 287 patients with an acute tibial diaphyseal fractures who presented to three centres over a two-year period. Demographic data, diagnosis, management, wound closure, complications, and subsequent surgeries were recorded. The primary outcome measure was the rate of short-term complications. Secondary outcomes were time to fasciotomy and split-skin grafting rates. RESULTS Of the 287 patients in the study cohort, 171 patients underwent CCPM (monitored group; MG) and 116 did not (non-monitored group; NMG). There were 21 patients who developed ACS and underwent fasciotomy, with comparable rates in both groups (n=13 in the MG vs n=8 in NMG; p=0.82). There was no difference in the rate of complications between groups (all p>0.05). The mean time from admission to fasciotomy was 22.1hrs, with a mean time of 19.8hrs in the MG and 25.8hrs in the NMG (mean difference, 6hrs; p=0.301). One patient in the NMG required a below-knee amputation. There was a trend towards a reduced requirement for split-skin grafting post decompression in the MG (15% vs 50%; p=0.14). CONCLUSION This study found no difference in the short-term complication rates in those patients that underwent CCPM and those that did not following a fracture of the tibial diaphysis. CCPM does appear to be safe with no increase in the rate of fasciotomies performed. There was a trend towards a reduced time to fasciotomy and a reduced rate of split skin grafting for wound closure with CCPM. LEVEL OF EVIDENCE Level III (Diagnostic: Retrospective cohort study).
Collapse
Affiliation(s)
| | | | - Liam Z Yapp
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | | | - Timothy O White
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Margaret M McQueen
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Andrew D Duckworth
- Edinburgh Orthopaedics - Trauma, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Centre for Population Health Sciences, Usher Institute, University of Edinburgh.
| |
Collapse
|
6
|
Klima M. Institutional differences in management of compartment syndrome at academic and community-based trauma centers: A survey of Orthopaedic Trauma Association (OTA) members. OTA Int 2020; 3:e090. [PMID: 33937713 PMCID: PMC8078146 DOI: 10.1097/oi9.0000000000000090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/13/2020] [Indexed: 10/25/2022]
Abstract
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.
Collapse
|
7
|
Hill KL, Wu VJ, Kusumoto H, Sherman WF, Savoie FH. Management of Orthopaedic Emergencies During a Pandemic: Compartment Syndrome of the Hand in a Patient with COVID-19: A Case Report. JBJS Case Connect 2020; 10:e2000377. [PMID: 32960013 DOI: 10.2106/jbjs.cc.20.00377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
CASE A 58-year-old man presented with acute respiratory distress syndrome and coagulopathy secondary to COVID-19. He developed acute compartment syndrome (ACS) of the left hand. He underwent a bedside 10-compartment decompression of the hand with volar forearm and carpal tunnel release while in the ICU. This report adds to the scarce body of literature regarding orthopaedic complications related to COVID-19. CONCLUSION Coagulopathy secondary to COVID-19 can be a risk factor for the development of ACS. Frequent examinations of lines, restraints, and extremities are recommended. The COVID-19 pandemic presents unique challenges, necessitating clinical adjustments to best care for patients.
Collapse
Affiliation(s)
- Kelly L Hill
- 1Department of Orthopaedics, Tulane University, New Orleans, Louisiana
| | | | | | | | | |
Collapse
|
8
|
Venous Thromboembolism Prophylaxis After Pelvic and Acetabular Fractures: A Survey of Orthopaedic Surgeons' Current Practices. J Am Acad Orthop Surg 2020; 28:750-755. [PMID: 32235242 DOI: 10.5435/jaaos-d-19-00409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The goal of this study was to identify the current practices and rationale of orthopaedic surgeons regarding venous thromboembolism (VTE) prophylaxis for pelvic and acetabular (P&A) fractures. METHODS A 25-item web-based questionnaire was made available to all Orthopaedic Trauma Association (OTA) members on the OTA website. Analysis of data was performed after the three-month study period. RESULTS One hundred three active OTA members completed the survey. Most respondents practiced at an academic level I trauma centers. The most important factor in selecting a VTE regimen was its effectiveness, whereas cost was the least important. Low-molecular-weight heparin (LMWH) remains the preferred agent for VTE prophylaxis after P&A trauma. Factors such as surgical intervention and weight-bearing had a variable effect on surgeons' opinions regarding the type and duration of VTE prophylaxis. CONCLUSION Most surgeons treating P&A fractures use LMWH for VTE prophylaxis, but the decision on which agent to use and duration of treatment is multifactorial. Published VTE prophylaxis literature and guidelines provide some guidance, but there is no consensus. Overall, LMWH appears to be the VTE prophylaxis agent of choice for most orthopaedic trauma surgeons, irrespective of nonsurgical or surgical management of these fractures.
Collapse
|
9
|
Walters TJ, Kottke MA, Hargens AR, Ryan KL. Noninvasive diagnostics for extremity compartment syndrome following traumatic injury: A state-of-the-art review. J Trauma Acute Care Surg 2019; 87:S59-S66. [PMID: 31246908 DOI: 10.1097/ta.0000000000002284] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Thomas J Walters
- From the US Army Institute of Surgical Research (T.J.W., M.A.K., K.L.R.), Fort Sam Houston, San Antonio, Texas; and Department of Orthopaedic Surgery, Altman Clinical and Translational Research Institute (A.R.H.), University of California San Diego, San Diego, California
| | | | | | | |
Collapse
|
10
|
Acute compartment syndrome: An orthopedic emergency. Nurse Pract 2019; 44:23-28. [PMID: 30865061 DOI: 10.1097/01.npr.0000554087.90202.2b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
11
|
Crush Injury and Extremity Compartment Syndromes. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0141-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|