Diagnostic techniques in acute compartment syndrome of the leg

[Diagnostics of acute compartment syndrome : Current gold standard and the state of science of noninvasive assessment methods]

Acute compartment syndrome (ACS) is defined by a disorder of the microcirculation due to a persistent pathological pressure increase within a muscle compartment. The ischemia of the tissue leads to an initially reversible functional impairment and finally irreversible damage of the musculature, nerves and other structures. Based on the understanding of the pathophysiology, the current diagnostic concepts and treatment using the so-called dermatofasciotomy of the affected muscle compartments can be derived. In addition to the suspicion of a possible ACS based on the medical history of the patient, the findings of the clinical examination are decisive. This review article gives a summary of all the essential aspects of the diagnostics. In clinically uncertain cases and for monitoring, an objectification of the findings using instrument-based techniques is increasingly required. Nowadays, invasive needle pressure measurement is available; however, due to limited reliability, specificity and sensitivity, these measurements only represent an aid to decision guidance supporting or advising against the indications for dermatofasciotomy. The increasing demands on making a certain diagnosis and justification of a surgical intervention from a legal point of view, substantiate the numerous scientific efforts to develop noninvasive instrument-based diagnostics. These methods are based either on detection of increasing intracompartmental pressure or decreasing perfusion pressure and microcirculation. The various measurement principles are summarized in a lucid form.

Blister formation in acute compartment syndrome: Unraveling the underlying predictors

Blisters are a common complication of orthopedic trauma and can cause surgery delay and increase the risk of infection. This study aims to identify risk factors for blisters in patients with acute compartment syndrome (ACS). Our study collected data from 206 ACS patients admitted to 2 hospitals between November 2013 and January 2021. Patients were divided into 2 groups: the blister group (BG) and the control group (CG), based on the presence or absence of blisters. We conducted univariate analysis, logistic regression analysis, and receiver operating characteristic (ROC) curve analysis to identify any significant differences in demographics, comorbidities, and admission laboratory test results between the 2 groups. Our study found that the incidence of blisters in ACS patients was 21.8% (45 out of 206). Univariate analysis identified several factors that were significantly associated with blister formation. Logistic regression analysis showed that patients who developed ACS in the winter or spring (P = .007, OR = 2.690, 95% CI [1.308-5.534]), patients who received a referral (the process whereby patients are transferred between medical facilities for further evaluation and treatment attempts prior to admission to our hospital) (P = .009, OR = 4.235, 95% CI [1.432-12.527]), and patients with higher PLR (P = .036, OR = 1.005, 95% CI [1.000-1.009]) were independent risk factors for blisters. Additionally, a history of drinking (P = .039, OR = 0.027, 95% CI [0.046-0.927]) was found to be a protective factor for blister formation in these patients. Moreover, ROC curve analysis showed that a PLR value of 138 was the cutoff point for predicting the development of blisters in ACS patients. Our study identified seasonal factors (refer to these months like winter or spring), referral, and patients with higher PLR as independent risk factors, and a history of drinking as a protective factor for blister formation in ACS patients. These findings allow clinicians to individualize the evaluation of blister risk and perform early targeted therapies.

Acute quadruple extremity compartment syndrome due to angio-oedema after polypharmacy overdose including olmesartan medoxomil, telmisartan and vildagliptin

This case report describes a rare manifestation of acute compartment syndrome (ACS) involving all four extremities, precipitated by angio-oedema in a middle-aged woman who consumed an overdose of multiple medications: nifedipine, azelnidipine, amlodipine besylate, olmesartan medoxomil, telmisartan, esaxerenone and vildagliptin. She presented with haemodynamic instability, necessitating intubation. Despite stabilising haemodynamic parameters within 24 hours, she manifested escalating extremity oedema. At 52 hours after ingestion, mottled skin was observed, along with necrotic alterations in the swollen hands and compartment pressures exceeding 30 mm Hg in all extremities. ACS was diagnosed, leading to fasciotomies. The aetiology is postulated to be drug-induced angio-oedema, possibly intensified by the concurrent overdose of olmesartan medoxomil, telmisartan and vildagliptin, each of which has a risk of angio-oedema even at standard dosages. This scenario is a very rare case caused by drug-induced angio-oedema, which underscores the importance of vigilant monitoring to detect ACS in patients with progressing limb oedema.

Telemedicine-Guided Two-Incision Lower Leg Fasciotomy Performed by Combat Medics During Tactical Combat Casualty Care: A Feasibility Study

INTRODUCTION

During tactical combat casualty care, life- and limb-saving procedures might also be performed by combat medics. This study assesses whether it is feasible to use a head-mounted display (HMD) to provide telemedicine (TM) support from a consulted senior surgeon for combat medics when performing a two-incision lower leg fasciotomy.

MATERIALS AND METHODS

Nine combat medics were randomized into groups to perform a two-incision lower leg fasciotomy. One group used the Vuzix M400 and the second group used the RealWear HMT-1Z1. A third, control, group received no guidance. In the Vuzix M400 group and RealWear HMT-1Z1 group, a senior surgeon examined the results after the two-incision lower leg fasciotomy was finished to assess the release of compartments, possible collateral damage, and performance of the combat medics. In the control group, these results were examined by a surgical resident with expertise in two-incision lower leg fasciotomies. The resident's operative performance questionnaire was used to score the performance of the combat medics. The telehealth usability questionnaire was used to evaluate the usability of the HMDs as perceived by the combat medics.

RESULTS

Combat medics using an HMD were considered competent in performing a two-incision lower leg fasciotomy (Vuzix: median 3 [range 0], RealWear: median 3 [range 1]). These combat medics had a significantly better score in their ability to adapt to anatomical variances compared to the control group (Vuzix: median 3 [range 0], RealWear: median 3 [range 0], control: median 1 [range 0]; P = .018). Combat medics using an HMD were faster than combat medics in the control group (Vuzix: mean 14:14 [SD 3:41], RealWear: mean 15:42 [SD 1:58], control: mean 17:45 [SD 2:02]; P = .340). The overall satisfaction with both HMDs was 5 out of 7 (Vuzix: median 5 [range 0], RealWear: median 5 [range 1]; P = .317).

CONCLUSIONS

This study shows that it is feasible to use an HMD to provide TM support performance from a consulted senior surgeon for combat medics when performing a two-incision lower leg fasciotomy. The results of this study suggest that TM support might be useful for combat medics during tactical combat casualty care when performing life- and limb-saving procedures.

Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach

BACKGROUND

Intramedullary tibial nailing (IMN) is the gold standard for stabilizing tibial shaft fractures. IMN can be performed through an infra- or suprapatellar approach.

PURPOSE

The aim of this study is to compare the rate of fasciotomies for acute compartment syndrome between infra- and suprapatellar approaches.

METHODS

A total of 614 consecutive patients who were treated with IMN for tibial fracture between October 2007 and February 2020 were included in the study. The approach used for IMN was determined by the operating surgeon. Infrapatellar IMN was performed with the knee in deep flexion position, with or without calcaneal traction. Suprapatellar IMN was performed in straight or semiflexed position. The diagnosis of compartment syndrome was based on clinical analysis, but for some patients, a continuous compartment pressure measurement was used. The primary outcome was the rate of peri- and postoperative compartment syndrome treated with fasciotomies.

RESULTS

The study sample included 513 patients treated with infrapatellar IMN and 101 patients treated with suprapatellar IMN technique. The mean age of the patients was 44.7 years (infrapatellar technique) and 48.4 years (suprapatellar technique). High energy trauma was seen in 138 (27%) patients treated with infrapatellar technique and in 39 (39%) patients treated with suprapatellar technique. In the suprapatellar group (n = 101), there were no cases of peri- or postoperative compartment syndrome treated with fasciotomies. In the infrapatellar group (n = 513), the need for fasciotomies was stated in 67 patients, 31 patients (6.0%) perioperatively and in 36 patients (7.0%) postoperatively. The rate of fasciotomies (0/101 versus 67/513 cases) differed significantly (p < 0.001). There were no significant differences in the fracture morphology or patient demographics between the study groups.

CONCLUSIONS

The suprapatellar technique is recommended over the infrapatellar approach in the treatment of tibial shaft fractures. The rate of peri- and postoperative compartment syndrome and the need for fasciotomies was significantly lower with the suprapatellar technique. The major cause of increased rate of peri- or postoperative acute compartment syndrome with infrapatellar IMN technique is presumably associated with the positioning of the patient during the operation.

LEVEL OF EVIDENCE: 3

Establishment and pathophysiological evaluation of a novel model of acute compartment syndrome in rats

BACKGROUND

Researches have used intra-compartmental infusion and ballon tourniquest to create high intra-compartmental pressure in animal models of Acute Compartment Syndrome (ACS). However, due to the large differences in the modeling methods and the evaluation criteria of ACS, further researches of its pathophysiology and pathogenesis are hindered. Currently, there is no ideal animal model for ACS and this study aimed to establish a reproducible, clinically relevant animal model.

METHODS

Blunt trauma and fracture were caused by the free falling of weights (0.5 kg, 1 kg, 2 kg) from a height of 40 cm onto the lower legs of rats, and the application of pressures of 100 mmHg, 200 mmHg, 300 mmHg and 400 mmHg to the lower limbs of rats using a modified pressurizing device for 6 h. The intra-compartmental pressure (ICP) and the pressure change (ΔP) of rats with single and combined injury were continuously recorded, and the pathophysiology of the rats was assessed based on serum biochemistry, histological and hemodynamic changes.

RESULTS

The ΔP caused by single injury method of different weights falling onto the lower leg did not meet the diagnosis criteria for ACS (< 30 mmHg). On the other hand, a combined injury method of a falling weight of 1.0 kg and the use of a pressurizing device with pressure of 300 mmHg or 400 mmHg for 6 h resulted in the desired ACS diagnosis criteria with a ΔP value of less than 30 mmHg. The serum analytes, histological damage score, and fibrosis level of the combined injury group were significantly increased compared with control group, while the blood flow was significantly decreased compared with control group.

CONCLUSION

We successfully established a new preclinical ACS-like rat model, by the compression of the lower leg of rats with 300 mmHg pressure for 6 h and blunt trauma by 1.0 kg weight falling.

Recurrent atraumatic compartment syndrome as a manifestation of genetic neuromuscular disease

Compartment syndrome (CS) is a medical emergency that occurs secondary to excessively high pressures within a confined fibro-osseous space, resulting in reduced perfusion and subsequent tissue injury. CS can be divided into acute forms, most commonly due to trauma and considered an orthopaedic emergency, and chronic forms, most commonly presenting in athletes with recurrent exercise-induced pain. Downstream pathophysiological mechanisms are complex but do share commonalities with mechanisms implicated in genetic neuromuscular disorders. Here we present 3 patients with recurrent CS in the context of a RYR1-related disorder (n = 1) and PYGM-related McArdle disease (n = 2), two of whom presented many years before the diagnosis of an underlying neuromuscular disorder was suspected. We also summarize the literature on previously published cases with CS in the context of a genetically confirmed neuromuscular disorder and outline how the calcium signalling alterations in RYR1-related disorders and the metabolic abnormalities in McArdle disease may feed into CS-causative mechanisms. These findings expand the phenotypical spectrum of RYR1-related disorders and McArdle disease; whilst most forms of recurrent CS will be sporadic, above and other genetic backgrounds ought to be considered in particular in patients where other suggestive clinical features are present.

A Comparative Analysis of Fasciotomy Results in Children and Adults Affected by Crush-Induced Acute Kidney Injury following the Kahramanmaraş Earthquakes

Background and Objectives: The current study aims to determine the impact of fasciotomy on mortality and morbidity in children and adults with crush-related AKI following the 2023 Kahramanmaraş earthquakes. Materials and Methods: The study included individuals who had suffered crush injuries after the 2023 Kahramanmaraş earthquakes and were identified as having an acute kidney injury (AKI). Patients with an AKI were divided into two groups based on age: those under 18 years and those over 18 years. A comparative analysis was conducted between the mortality and morbidity rates of patients who underwent fasciotomy and those who did not. Disseminated intravascular coagulopathy (DIC), sepsis, and adult respiratory distress syndrome (ARDS) have all been identified as contributors to morbidity. Results: The study was conducted with a total of 40 patients (21 males and 19 females) aged between 4 and 83 years. A total of 21 patients underwent fasciotomy, and the patients underwent varying numbers of fasciotomy, ranging from 0 to 11. The mortality rate was 12.5%, corresponding to five adult patients. No instances of mortality were reported in the paediatric cohort. The application of fasciotomy in instances of crush-induced AKI did not result in elevated levels of mortality in either the paediatric or adult demographic. Within the adult population, a substantial difference in the duration of dialysis was observed between individuals who underwent fasciotomy and those who did not. A statistically significant increase in the number of fasciotomy incisions was observed in patients diagnosed with sepsis compared with those without sepsis. The study found a significant positive correlation between the number of fasciotomy incisions and dialysis days. Conclusions: Neither adult nor paediatric patients with crush-induced AKI showed an increased risk of death after fasciotomy. The number of fasciotomy incisions significantly correlated with the development of sepsis. Despite experiencing delays in hospital admission for paediatric patients, the incidence of both crush syndrome and mortality rates among children remained relatively low.

Efficacy of a portable interface pressure sensor for robotic surgery in preventing compartment syndrome

BACKGROUND/OBJECTIVE

This study determines whether the use of a portable interface pressure sensor (Palm Q) for robotic surgery could prevent compartment syndrome.

METHODS

In the present single center, non-trial observational study, patients diagnosed with gynecological diseases between April 2015 and August 2020 treated with laparoscopic or robotic surgery were enrolled. We assessed 256 cases involving surgery performed in the lithotomy position with an operative time >4 h. The Palm Q device was placed preoperatively on both sides of the patients' lower legs. The pressure was measured every 30 min preoperatively and intraoperatively and adjusted to ≤30 mmHg. If the pressure reached ≥30 mmHg, the operation was stopped, the patient was repositioned, the leg position was released, the pressure was reduced to ≤30 mmHg, and the procedure was resumed. We compared the maximum creatine kinase levels of the Palm Q and non-Palm Q groups. We also analyzed the correlation between the patients' symptoms postoperatively (shoulder and leg pain) and compartment syndrome.

RESULTS

Our data showed that immediate postoperative creatine kinase levels predict compartment syndrome. Propensity score matching of the 256 enrolled patients resulted in 92 cases (46 per group), balanced for age, body mass index, and lifestyle disease. Creatine kinase levels differed significantly between the Palm Q and non-Palm Q groups (p = 0.041). None of the patients in the Palm Q group experienced well-leg compartment syndrome complications.

CONCLUSION

Palm Q can potentially help to prevent perioperative compartment syndrome.

Value of Multimodality Ultrasound in Quantitative Evaluation of the Intra-compartmental Pressure and Perfusion Pressure in Acute Compartment Syndrome in a Rabbit Model

OBJECTIVE

The aim of the work described here was to investigate the feasibility of using multimodality ultrasound in quantitative evaluation of the intra-compartmental pressure (ICP) and perfusion pressure (PP) changes in acute compartment syndrome (ACS).

METHODS

Infusion technique was used to increase the ICP of the anterior compartment of 10 rabbits from baseline to 20, 30, 40, 50, 60, 70 and 80 mmHg. The anterior compartment was evaluated with conventional ultrasound, shear wave elastography (SWE) and contrast-enhanced ultrasound (CEUS). The shape of the anterior compartment, shear wave velocity (SWV) of the tibialis anterior (TA) muscle and CEUS parameters of the TA muscle were measured.

RESULTS

When the ICP exceeded 30 mmHg, the shape of the anterior compartment did not expand significantly with increasing ICP. There was a strong correlation between the SWV of TA muscle and measured ICP (ρ = 0.927). Arrival time (AT), time to peak (TTP), peak intensity (PI) and area under the curve (AUC) were significantly correlated with PP (AT, ρ = -0.763; TTP, ρ = -0.900; PI, ρ = 0.665; AUC, ρ = 0.706), whereas mean transit time (MTT) was not.

CONCLUSION

Multimodality ultrasound can be used to quantitatively evaluate ICP and PP and, thus, could provide more information for the rapid diagnosis and monitoring of ACS.

Acute Extremity Compartment Syndrome and (Regional): Anesthesia: The Monster Under the Bed

Acute compartment syndrome (ACS) is a potential orthopedic emergency that leads, without prompt diagnosis and immediate treatment with surgical fasciotomy, to permanent disability. The role of regional anesthesia (RA) for analgesia in patients at risk for ACS remains unjustifiably controversial. This critical review aims to improve the perception of the published literature to answer the question, whether RA techniques actually delay or may even help to hasten the diagnosis of ACS. According to literature, peripheral RA alone does not delay ACS diagnosis and surgical treatment. Only in 4 clinical cases, epidural analgesia was associated with delayed ACS diagnosis.

Lumbar Paraspinal Compartment Syndrome: Case Report and Critical Evaluation of the Literature

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).

Extremity compartment syndrome: A review with a focus on non-invasive methods of diagnosis

The article deals with an overview of acute extremity compartment syndrome with a focus on the option of non-invasive detection of the syndrome. Acute extremity compartment syndrome (ECS) is an urgent complication that occurs most often in fractures or high-energy injuries. There is still no reliable method for detecting ECS. The only objective measurement method used in clinical practice is an invasive measurement of intramuscular pressure (IMP). The purpose of this paper is to summarize the current state of research into non-invasive measurement methods that could allow simple and reliable continuous monitoring of patients at risk of developing ECS. Clinical trials are currently underway to verify the suitability of the most studied method, near-infrared spectroscopy (NIRS), which is a method for measuring the local oxygenation of muscle compartments. Less explored methods include the use of ultrasound, ultrasound elastography, bioimpedance measurements, and quantitative tissue hardness measurements. Finding a suitable method for continuous non-invasive monitoring of the syndrome would greatly improve the quality of care for patients at risk. ECS must be diagnosed quickly and accurately to prevent irreversible tissue damage that can occur within hours of syndrome onset and may even warrant amputation if neglected.

BioFACTS: biomarkers of rhabdomyolysis in the diagnosis of acute compartment syndrome - protocol for a prospective multinational, multicentre study involving patients with tibial fractures

INTRODUCTION

The ischaemic pain of acute compartment syndrome (ACS) can be difficult to discriminate from the pain linked to an associated fracture. Lacking objective measures, the decision to perform fasciotomy is based on clinical findings and performed at a low level of suspicion. Biomarkers of muscle cell damage may help to identify and monitor patients at risk, similar to current routines for patients with acute myocardial infarction. This study will test the hypothesis that biomarkers of muscle cell damage can predict ACS in patients with tibial fractures.

METHODS AND ANALYSIS

Patients aged 15-65 years who have suffered a tibial fracture will be included. Plasma (P)-myoglobin and P-creatine phosphokinase will be analysed at 6-hourly intervals after admission to the hospital (for 48 hours) and-if applicable-after surgical fixation or fasciotomy (for 24 hours). In addition, if ACS is suspected at any other point in time, blood samples will be collected at 6-hourly intervals. An independent expert panel will assess the study data and will classify those patients who had undergone fasciotomy into those with ACS and those without ACS. All primary comparisons will be performed between fracture patients with and without ACS. The area under the receiver operator characteristics curves will be used to identify the success of the biomarkers in discriminating between fracture patients who develop ACS and those who do not. Logistic regression analyses will be used to assess the discriminative abilities of the biomarkers to predict ACS corrected for prespecified covariates.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Ethical Review Boards in Linköping (2017/514-31) and Helsinki/Uusimaa (HUS/2500/2000). The BioFACTS study will be reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology recommendations.

TRIAL REGISTRATION NUMBER

NCT04674592.

Factors Associated With Surgical Site Infections After Fasciotomy in Patients With Compartment Syndrome

Fasciotomy is the standard of care to treat acute compartment syndrome (ACS). Although fasciotomies often prevent serious complications, postoperative complications can be notable. Surgical site infection (SSI) in these patients is as high as 30%. The objective of this study was to determine factors that increase the risk of SSI in patients with ACS.

Developing an in-vivo physiological porcine model of inducing acute atraumatic compartment syndrome towards a non-invasive diagnosis using shear wave elastography

Compartment syndrome (CS) is a pathological event caused by elevated intracompartmental pressure (ICP); however, changes from the onset of inducing atraumatic CS remained unclear. The study aimed to investigate the physiological changes in a newly developed in vivo porcine acute atraumatic CS model. CS was induced by ischemia–reperfusion injury in the left hind leg of fourteen pigs divided into an echogenicity group (EG) and a shear wave elastography group (SEG). Echogenicity was measured in EG, and shear elastic modulus (SEM) was measured in SEG seven times before, at the onset of inducing CS, and every 30 min after the onset over eight hours. Simultaneously, ICP, blood pressure, and muscle perfusion pressure (MPP) were also measured in both groups. Our results indicate that SEM of the experimental leg in SEG significantly increased as CS developed compared to the control leg (p = 0.027), but no statistical difference in the echogenicity in EG was found between the experimental leg and control leg. There were also significant correlations between SEM and ICP (p < 0.001) and ICP and MPP (p < 0.001). Our method and findings can be a basis to develop a non-invasive diagnostic tool using a shear wave elastography for atraumatic CS.

'Well-leg' compartment syndrome associated with gynaecological surgery: a perioperative risk-reduction protocol and checklist

'Well-leg' compartment syndrome (WLCS) is an uncommon, but potentially devastating, complication associated with prolonged patient positioning for abdomino-pelvic surgery. Gynaecologists, anaesthetists and the wider theatre team share a responsibility to minimise the risk of this highly morbid, and even fatal, postoperative complication. This article provides an overview of WLCS related to gynaecological surgery - raising awareness amongst gynaecologists and highlighting the time-critical nature of diagnosis and management. Given the potential litiginous nature of this complication, we also present a perioperative checklist and risk-reduction protocol to suggest a standardised approach to prevention and relevant documentation. TWEETABLE ABSTRACT: Gynaecologists share a responsibility to minimise the risk of postoperative 'well-leg' compartment syndrome.

Utilizing Dynamic Phosphorous-31 Magnetic Resonance Spectroscopy for the Early Detection of Acute Compartment Syndrome: A Pilot Study on Rats

INTRODUCTION

Disasters, including terrorism and earthquakes, are significant threats to people and may lead to many people requiring rescue. The longer the rescue takes, the higher the chances of an individual contracting acute compartment syndrome (ACS). ACS is fatal if diagnosed too late, and early diagnosis and treatment are essential.

OBJECTIVE

To assess the ability of dynamic phosphorus magnetic resonance spectroscopy (31P-MRS) in the early detection of muscular damage in ACS.

MATERIALS AND METHODS

Six ACS model rats were used for serial 31P-MRS scanning (9.4 Tesla). Skeletal muscle metabolism, represented by the levels of phosphocreatine (PCr), inorganic phosphate (Pi), and adenosine triphosphate (ATP), was assessed. The PCr/(Pi + PCr) ratio, which decreases with ischemia, was compared with simultaneously sampled plasma creatine phosphokinase (CPK), a muscle damage marker.

RESULTS

The PCr/(Pi + PCr) ratio significantly decreased after inducing ischemia (from 0.86 ± 0.10 to 0.18 ± 0.06; p < 0.05), while CPK did not change significantly (from 89 ± 29.46 to 241.50 ± 113.28; p > 0.05). The intracellular and arterial pH index decreased over time, revealing significant differences at 120 min post-ischemia (from 7.09 ± 0.01 to 6.43 ± 0.13, and from 7.47 ± 0.03 to 7.39 ± 0.04, respectively). In the reperfusion state, the spectra and pH did not return to the original values.

CONCLUSIONS

The dynamic 31P-MRS technique can rapidly detect changes in muscle bioenergetics. This technique is a promising non-invasive method for determining early muscular damage in ACS.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Necrosis in the flexor hallucis longus muscle after subclinical leg compartment syndrome and tibial fracture: A case report

•

Undetected compartment syndrome can cause disabling complications.

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In untreated compartment syndrome, nerve and vascular injury results in motor weakness, contractures, or muscle necrosis.

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Thorough examination must be done to identify the affected stuctures.

•

The treatment should be based on functional outcomes, e.g., a stable foot for pain-free, plantigrade gait.

•

Surgical therapy is indicated if the ankle joint cannot be restored to a functional position with conservative methods.

Introduction

Compartment syndrome is a condition in which an increased pressure within one compartment results in decreased blood flow, preventing nutrition and blood supply from reaching nerve and muscle cells. Ongoing physiological cascades can progress to local and systemic manifestations. This article presents a case of subclinical compartment syndrome resulting in muscle necrosis and contracture. More specifically, this article highlights the presentation of a complicated and neglected case of subclinical compartment syndrome with a subsequent fixed equinus deformity and its management.

Presentation of case

A 15-year-old high school student sustained a proximal tibia fracture during a motor vehicle accident. The compartment was not recognized until a period of follow-up. The patient later presented to our clinic with ankle equinus deformity. Further exploration found the contracture and necrosis of flexor hallucis longus (FHL) muscle. We excised the necrotic wound and performed an ankle fusion.

Discussion

The patient had developed subclinical localized deep posterior compartment syndrome in the distal portion of the FHL muscle. As only a small portion of the muscle was involved, there was no retraction of the main muscle belly; however, the necrotic part can become fibrotic and adhere to the surrounding tissues. While subclinical compartment syndrome is not uncommon, the finding of isolated FHL muscle necrosis is rare. Thus, the management is still debatable.

Conclusion

This article emphasized that neglecting compartment syndrome may result in undesired complications, which emphasizes the importance of an early diagnosis and treatment.

Diagnostic Modalities for Acute Compartment Syndrome of the Extremities: A Systematic Review

Importance

Acute compartment syndrome (ACS) can cause catastrophic tissue damage leading to permanent muscle and nerve loss. Acute compartment syndrome is a clinical diagnosis, with intracompartmental pressure (ICP) used in equivocal cases. There are no reliable diagnostic methods. The clinical evaluation is impossible to standardize, and the threshold for ICP has been known to be unreliable; thus, guidelines for diagnosis can result in overtreatment or delayed diagnosis.

Objective

To present and review the advantages and disadvantages of each diagnostic modality and identify gaps that need to be addressed in the future and to review the most used and appropriate animal and human ACS models.

Evidence Review

We included clinical studies and animal models investigating diagnostic modalities for ACS of the extremities. A MEDLINE and Web of Science search was performed. The protocol for the study was registered on PROSPERO (CRD42017079266). We assessed the quality of the clinical studies with Newcastle-Ottawa scale and reported level of evidence for each article.

Findings

Fifty-one articles were included in this study, reporting on 38 noninvasive and 35 invasive modalities. Near-infrared spectroscopy and direct ICP measurement using a Stryker device were the most common, respectively. Cadaveric studies used saline infusions to create an ACS model. Most studies with human participants included injured patients with acquired ACS or at risk of developing ACS. In healthy human participants, tourniquets formed the most commonly used ACS model. Application of tourniquets and infusion of saline or albumin were the most used ACS models among animal studies.

Conclusions and Relevance

This article reports on the most common as well as many new and modified diagnostic modalities, which can serve as inspiration for future investigations to develop more effective and efficient diagnostic techniques for ACS. Future studies on diagnostic modalities should include the development of tools for continuous assessment of ICP to better identify the earliest alterations suggestive of impending ACS. With the advent of such technologies, it may be possible to develop far less aggressive and more effective approaches for early detection of ACS.

Non-invasive measurement of muscle compartment elasticity in lower limbs to determine acute compartment syndrome: Clinical results with pressure related ultrasound

PURPOSE

Close monitoring of patients at risk to develop an acute compartment syndrome (ACS) is well known to be essential. There is a relevant risk that clinical assessment alone is not reliable enough. Reliable assessment of the elasticity of the muscle compartment might represent a helpful tool to assess the pressure in this enclosed space. Therefore, the purpose of this study was to determine the feasibility of muscle elasticity measurements by a non-invasive device.

METHODS

In a prospective study, patients with elevated intra-compartmental pressure (ICP) were included. An ultrasound-based measurement approach was used to determine the relative elasticity (RE) of both, the affected and unaffected limb. A pressure transducing ultrasonic probe head was combined with the probe to obtain cross section views of the anterior tibial compartment and to detect the observer´s amount of pressure applied on the limb surface. The compartment depth without compression (P₀) corresponds to 100%. The difference to the compartment depth with a probe pressure of 80mmHg (P₈₀) on the limb (delta) related to P₀ resulted in a value of relative elasticity (%). These values were compared with the invasive needle measurement (mmHg) regarding their intra-individual difference and correlation of the compartmental pressure.

RESULTS

In six trauma patients the relative elasticity in their paired limbs showed a significant difference. The RE in the healthy compartments revealed a level of 17.95% (SD+/-5,4), whereas the RE of the affected limbs significantly decreased to a mean of 5,14% (SD+/-2,1) (p < 0,0001). The average values of the repetitively measured RE and the ICP showed a high level of correlation (spearman correlation coefficient: roh = 0,929). The RE less than 10,5% of the anterior tibial compartment had a sensitivity of 95,8% and a specificity of 87,5% to an appropriate diagnosis of ACS.

DISCUSSION

The presented study appears to represent a promising approach to reliably assess the pressure in a muscle compartment. In this first clinical study, our measurement method represents a low cost, easy and secure approach that has the potential to substitute invasive measurement. Further investigations and development in lager cohorts are required to improve its practicality and to confirm the reliability.

Selective fasciotomy for acute traumatic lower leg compartment syndrome: is it feasible?

INTRODUCTION

The standard treatment for an acute compartment syndrome (ACS) of the lower leg is a four compartment fasciotomy. It can be performed through either one lateral or a lateral and medial incision. Selective fasciotomy, only opening the compartments with elevated pressure, is a less invasive procedure. The aim of this study was to describe a procedure of selective fasciotomy after pressure measurement and to determine its feasibility in a retrospective cohort study.

METHODS

All patients with an ACS of the lower leg due to a proximal or tibia shaft fracture (AO 41 or 42) who received either a four compartment fasciotomy or a selective fasciotomy after pressure measurement between 2006 and 2016 were included. Every compartment with an intracompartment pressure of more than 30 mmHg was opened. The primary outcome was any missed compartment syndrome after selective fasciotomy. Secondary outcomes were reoperations for completing four compartment fasciotomy and persistent sensomotoric deficits.

RESULTS

Fifty-one patients with a mean age of 43 years (6-76) were included. Of these, 41 (80%) had a selective fasciotomy. There was no missed compartment syndrome. One patient had a reoperation 8 h after primary selective fasciotomy due to ACS of the superficial and deep flexor compartment. The anterior compartment had to be released in all patients. In 67%, the release of 2 compartments was sufficient. Six patients had postoperative sensomotoric deficits at discharge with full recovery during follow-up.

CONCLUSION

Selective fasciotomy is feasible and seems to be safe. Future comparative studies will have to focus on possible benefits of this less invasive treatment.

Ultrasound shear wave elastography for measuring intracompartmental pressure of compartment syndrome using a turkey hind limb model

Diagnosis and treatment of acute compartment syndrome are quite challenging. It is well known that compartment pressure is an important factor for diagnosing fasciotomy. However, the current technology to measure the pressure using a needle-catheter is invasive and painful. Recently ultrasound elastography has been used to measure soft tissue elasticity based on shear wave propagation speed. Because the muscle's elasticity is affected by the pressure within the compartment, ultrasound elastography might be a possible tool for the compartment pressure evaluation. Ultrasound shear wave elastography and pressure were simultaneously measured using a clinical ultrasound system and clinically used catheter in a turkey anterior-lateral and anterior-deep compartment under elevated pressures of baseline, 10, 20, 30, 40, and 50 mmHg using vascular infusion technique. Shear wave propagation speed increased linearly in proportion to the increase in intra-compartmental pressure. Strong correlation was observed between measured pressure and mean shear wave speed in each compartment (anterior-lateral compartment, mean R² = 0.929, P < 0.001; anterior-deep compartment, mean R² = 0.97, P < 0.001). Compared with anterolateral compartment pressure, anterior-deep compartment pressure was the same at the baseline; however, it was significantly higher at intended anterolateral compartment pressures of 20 and 30 mmHg (P = 0.008, P = 0.016). By using ultrasound shear wave elastography, the compartment pressure can be accurately measured. This noninvasive technology can potentially help surgeons for the early detection, monitoring, and prognosis of intra-compartmental pressure.

Guidewire perforation and compartment syndrome after lower extremity angioplasty

Chronic total occlusion remains one of the most challenging lesions to treat despite continuing developments in medical devices and increasing operator experience. Guidewire perforation complications are being increasingly observed. Early recognition and timely institution of appropriate treatment are essential to prevent potentially devastating sequelae.

An implanted pH sensor read using radiography

A biomedical sensor was developed to measure local pH near orthopedic implants to detect and study implant-associated infection. The sensor is read using plain radiography, a technique which is noninvasive, inexpensive, ubiquitously available in medical facilities, and routinely used in diagnosis and follow-up. The sensor comprises a radiopaque tungsten indicator pin embedded within a chemically responsive hydrogel that exhibits a pH-dependent swelling. A stainless steel well holds this hydrogel and attaches to an orthopedic plate. The local pH may be determined from the extent of hydrogel swelling by radiographically measuring the indicator position relative to the well. We calibrated the sensor in a series of standard pH buffers and tested it during bacterial growth in culture. The sensor was robust: its response was negligibly affected by changes in temperature, ionic strength within the normal physiological range, or long-term incubation with reactive oxygen species generated from hydrogen peroxide and copper. Pooled data from several sensors fabricated at different times and tested in different conditions had a root-mean-square deviation from a pH electrode reading of 0.24 pH units. Radiographic measurements were also performed in cadaveric tissue with the sensor attached to an orthopedic plate fixed to a tibia. Pin position readings varied by 100 μm between observers surveying the same radiographs, corresponding to 0.065 pH units precision in the range pH 4-8. The sensor was designed to augment standard radiographs of tissue, bony anatomy, and hardware by also indicating local chemical concentrations.

Acute compartment syndrome: Cause, diagnosis, and new viewpoint

BACKGROUND

Acute compartment syndrome (ACS) is defined as a clinical entity originated from trauma or other conditions, and remains challenging to diagnose and treat effectively. The review was aim to present the controversy in diagnosing, treating ACS. It was found that there was no criterion about the ACS, and result unnecessary osteotomy. The presence of clinical assessment (5P) always means the necrosis of muscles and was the most serious or irreversible stage of ACS. Besides pressure methods, the threshold of pressure identifying ACS was also controversial.

METHODS

Immediate surgical fasciotomy was important to prevent severe suquelae of the ACS. However, there was still controversy about the right time that fasciotomy should be done to avoid irreversible ischemic changes. The most important thing to treat ACS was comprehension to the true injury mechanism, but a systemic classification about traumatic mechanism in most literature was not clear.

RESULTS

After observations to fracture patients with blister, we recommended that surgeons dealing with such emergencies should be vigilant, and the indication for fasciotomy should be strictly controlled following with injury mechanism especially for patients without severe soft tissue injury.

CONCLUSION

For those crushing and soft tissue injuries, the current evidence based strategies for managing patients was useful, but for those fracture related injury, more examination was necessary to avoid overtreatment especially for those patients with blister observed. In facing patients, medical history, injured mechanism should be paid special attention, and rigorous classification about traumatic etiology was the key for the treatment of these patients.

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

Acute compartment syndrome (ACS) is a serious medical condition that can occur following traumatic injury to an extremity. If left undiagnosed, ACS can eventuate in amputation of the limb or even death. Because of this, fasciotomy to release the pressure within the muscle and restore tissue perfusion is often performed upon suspicion of ACS, as the sequelae to fasciotomy are less severe than those associated with not performing the fasciotomy. Currently, the "gold standard" of diagnosis is based on clinical assessment of such symptoms as pain out of proportion to the injury, obvious high pressure and swelling, pain on passive stretch of the muscles in the affected compartment, and deficits in sensory and/ormotor functions. Diagnosis is often confirmed using invasive measurements of intramuscular pressure (IMP); however, controversy exists as to how direct IMP measurement should be accomplished and threshold pressures for accurate diagnosis. Because of this and the attendant issues with invasive measurements, investigators have been searching over the last 25 years for a noninvasive means to quantitatively measure IMP or perfusion to the limb. The purpose of this review is to summarize the current state of the art of noninvasive devices that could potentially be used to diagnose ACS accurately and objectively. To do this, we divide the discussion into those medical devices that primarily measure mechanical surrogates of IMP (e.g., tissue hardness or myofascial displacement) and those that primarily measure indices of tissue perfusion (e.g., tissue oxygen saturation via near-infraredspectroscopy). While near-infrared spectroscopy-basedtechnologies have shown the most promise, whether such technologies will be of diagnostic benefit await the completion of ongoing clinical trials. LEVEL OF EVIDENCE: Systematic Review, level II.

Surgical management of acute compartment syndrome and sequential complications

Background

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

Methods

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

Results

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

Conclusion

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

Feasibility of ultrasound measurement in a human model of acute compartment syndrome

Background

Early diagnosis of acute compartment syndrome (ACS) of the leg is essential to improve the outcome. Direct invasive measurement is currently recommended to measure intracompartmental pressure. A non-invasive and reproducible means of making the diagnosis would be a step forward. The purpose of this exploratory study was to investigate the feasibility of non-invasive ultrasound-guided angle measurement as a surrogate of increased pressure in a model of ACS.

Methods

A model of ACS was generated by infusion of saline into the anterior compartment of the leg of human cadavers to incrementally increase the intracompartmental pressure from 10 to 100 mmHg. In 40 legs (20 cadavers), the angle (TFA, tibia-fascia angle) between the anterolateral cortex of the tibia and the fascia of the anterior compartment was measured at each 10 mmHg pressure increase using ultrasound in a standardized transversal plane. A multilevel linear regression model was used to estimate intracompartmental pressure from delta TFA (ΔTFA).

Results

TFA (mean [± SD]) increased from 61.0° (± 12.0°) at 10 mmHg up to 81.1° (± 11.1°) at 100 mmHg compartment pressure. Each increase ΔTFA by one degree was associated with an increase in pressure by 3.9 mmHg (95% CI, 3.8–4.0, p < 0.001).

Conclusions

We found that intracompartmental pressure of the anterior compartment of the calf can be well estimated by ultrasound-based ΔTFA in this post mortem experiment. Our findings indicate that non-invasive TFA measurement is feasible and it is reasonable that this will hold true in real life, but the findings are too preliminary to be used in clinical practice now.

A cadaveric model of anterior compartment leg syndrome: Subcutaneous minimally invasive fasciotomy versus open fasciotomy

OBJECTIVE

Because of disabling sequelae of open fasciotomy in anterior compartment syndrome (ACS) of the leg, we wanted to describe and validate a cadaveric model of ACS. We hypothesized that, first, anterior compartment syndrome (ACS) could be reproduced in cadaveric leg and, second, fasciotomy without complete skin incision could lower the intramuscular pressure (IMP) in an equivalent range to complete dermatofasciotomy.

MATERIALS AND METHODS

Lower limb ACS was reproduced by progressive injection of physiologic serum in the anterior compartment of 23 fresh frozen cadaveric legs with monitoring of IMP, in order to reach a maximal stabilised IMP higher than 30mmHg. Subcutaneous minimally invasive fasciotomy was performed on 14 legs through 5 transversal mini-incisions of the skin (2cm) along the axis from the tibial tuberosity to the posterior aspect of the lateral malleolus. Standard open fasciotomy of the anterior compartment was performed on the remaining 9 legs as control. IMP was measured after the skin incisions and after every fasciotomy through skin incisions in the first group and after skin and fascia incisions in the control group.

RESULTS

A maximal IMP of 43±2mmHg was obtained by injection of 177±9ml physiologic serum into the anterior compartment of the leg. In the control open fasciotomy group, the skin incision alone did not lower IMP significantly, whereas fasciotomy lowered IMP to 10±1mmHg, which is statistically different from maximal IMP (p<0.001). In the subcutaneous fasciotomy group, complete fasciotomy lowered significantly the IMP to 11±4mmHg (p<0.001), without statistical difference with the control group.

DISCUSSION

This cadaveric model is effective to reproduce the hyperpressure encountered in ACS. In this model, IMP release after fasciotomy is as efficient through minimally invasive subcutaneous incision as with control open fasciotomy. This in vitro technique appears as an attractive alternative treatment in anterior compartment syndrome of the leg. It should be tested in the other compartments of the leg and its in vivo feasibility in acute conditions has to be clarified.

LEVEL OF EVIDENCE

III, control laboratory study.

Low compartment pressure and myoglobin levels in tibial fractures with suspected acute compartment syndrome

BACKGROUND

The intense ischemic pain of acute compartment syndrome can be difficult to discriminate from the pain related to an associated fracture. Lacking objective measures, the decision to perform fasciotomy is often only based on clinical findings and performed at a low threshold. Biomarkers of muscle cell damage might help to identify and monitor patients at risk. In patients with fractures, however, markers of muscle cell damage could be elevated because of other reasons associated with the trauma, which would make interpretation difficult. In a review of all patients who underwent emergency fasciotomy in our health care district we aimed to investigate the decision-making process and specifically the use of biomarkers in patients with and without fractures.

METHODS

In the southeast health care region of Sweden 79 patients (60 men) with fractures (median age 26 years) and 42 patients (34 men) without associated fractures (median age 44 years) were treated with emergency fasciotomy of the lower leg between 2007 and 2016. Differences in clinical findings, p-myoglobin and p-creatine phosphokinase as well as pressure measurements were investigated.

RESULTS

P-myoglobin was analyzed preoperatively in 20% of all cases and p-creatine phosphokinase in 8%. Preoperative levels of p-myoglobin were lower in patients with fractures (median 1065 μg/L, range 200-3700 μg/L) compared with those without fractures (median 7450 μg/L, range 29-31,000 μg/L), p < 0.05. Preoperative intracompartmental pressure was lower in the fracture group (median 45 mmHg, range 25-90 mmHg) compared with those without fractures (median 83 mmHg, range 18-130 mmHg), p < 0.05.

CONCLUSIONS

Biomarkers are seldom used in the context of acute fasciotomy of the lower leg. Contrary to our expectations, preoperative levels of p-myoglobin and intracompartmental pressures were lower in fracture patients. These findings support differences in the underlying pathomechanism between the groups and indicate that biomarkers of muscle cell necrosis might play a more important role in the diagnosis of acute compartment syndrome than previously thought.

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.

Compartment Pressure Monitoring After Thyroid Surgery: A Possible Method to Detect a Rebleeding

BACKGROUND

Postoperative rebleeding after thyroid surgery is a rare but a serious complication. The aim of this study was to ascertain the extent to which postoperative pressure could be used as detector for rebleeding after thyroid surgery.

METHODS

Thirty-two patients with thyroidectomy or hemithyroidectomy were considered prospectively. In the course of surgery, a pressure microsensor (3PN Probe Spiegelberg) was implanted into the postoperative cavity and data were collected for special activities and stress situations over the first 48 h postoperatively. Additional endpoint was the influence of drains on the determined values.

RESULTS

The overall mean pressure (MP) at rest on both postoperative days for all patients with and without drain was 0.36 ± 2.84 mmHg (range -6.7 to 6.7). The MP in all activity and stress situations on the first day was with 0.23 ± 3.71 mmHg, and on the second day, the MP was 1.33 ± 4.50. 92.13% of our values were below 7 mmHg. One patient had a hemorrhage. The pressure increases continuously up to 36 mmHg, before the patient was transferred to the operating theater.

CONCLUSIONS

This is the first pilot study to consider continuous pressure measurement to be a potential tool for early detection of a postoperative rebleeding in thyroid surgery. In the strictest sense, postoperative intra-cervical pressure at rest ranges from subatmospheric to 7 mmHg. The elevation of pressure in case of a rebleeding up to 36 mmHg differs dramatically from normal postoperative pressure. The collected data will warrant further validation to be able to recommend threshold values for an early treatment decisions in rebleeding.

OTA/AO Classification Is Highly Predictive of Acute Compartment Syndrome After Tibia Fracture: A Cohort of 2885 Fractures

OBJECTIVE

To determine the correlation between the OTA/AO classification of tibia fractures and the development of acute compartment syndrome (ACS).

DESIGN

Retrospective review of prospectively collected database.

SETTING

Single Level 1 academic trauma center.

PATIENTS

All patients with a tibia fracture from 2006 to 2016 were reviewed for this study. Three thousand six hundred six fractures were initially identified. Skeletally mature patients with plate or intramedullary fixation managed from initial injury through definitive fixation at our institution were included, leaving 2885 fractures in 2778 patients.

METHODS

After database and chart review, univariate analyses were conducted using independent t tests for continuous data and χ tests of independence for categorical data. A simultaneous multivariate binary logistic regression was developed to identify variables significantly associated with ACS.

RESULTS

ACS occurred in 136 limbs (4.7%). The average age was 36.2 years versus 43.3 years in those without (P < 0.001). Men were 1.7 times more likely to progress to ACS than women (P = 0.012). Patients who underwent external fixation were 1.9 times more likely to develop ACS (P = 0.003). OTA/AO 43 injuries were at least 4.0 times less likely to foster ACS versus OTA/AO 41 or 42 injuries (P < 0.007). OTA/AO 41-C injuries were 5.5 times more likely to advance to ACS compared with OTA/AO 41-A (P = 0.03). There was a significantly higher rate of ACS in OTA/AO 42-B (P = 0.005) and OTA/AO 42-C (P = 0.002) fractures when compared with OTA/AO 42-A fractures. In the distal segment, fracture type did not predict the risk of ACS (P > 0.15). Group 1 fractures had a lower rate of ACS compared with group 2 (P = 0.03) and group 3 (P = 0.003) fractures in the middle segment only. Bilateral tibia fractures had a 2.7 times lower rate of ACS (P = 0.04). Open injury, multiple segment injury, fixation type, and concurrent pelvic or femoral fractures did not predict ACS.

CONCLUSIONS

In this large cohort of tibia fractures, we found that the age, sex, and OTA/AO classification were highly predictive for the development of ACS.

LEVEL OF EVIDENCE

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

Different effect of percutaneous plate insertion via anteromedial vs anterolateral approach on intracompartmental pressure of the leg: A cadaveric study

BACKGROUND

Currently Minimally Invasive Plate Osteosynthesis (MIPO) technique for tibial shaft fracture management has gained wide attention. However, an increased intracompartmental pressure after the plate insertion may result in postoperative acute compartment syndrome. We reported the difference of immediate effect of percutaneous plate insertion using 2 approaches of MIPO technique on anterior compartment pressure of the legs.

MATERIALS AND METHODS

Eight soft cadaveric legs (one female and three males) without previous history of skeletal trauma or surgery were infused with normal saline to create the sustained intracompartmental pressure of 20mm Hg in all four compartments. The Synthes^® 4.5mm 11-hole Narrow Locking Compression Plate was inserted via anteromedial and anterolateral approach. Anterior compartment pressure was measured by portable digital monitoring device through side-port needle (Stryker^® Intracompartmental Monitoring Device) before and after plate insertion for each approach.

RESULTS

By using anteromedial approach, a mean of anterior compartment pressure was increased by 0.375mm Hg after plate insertion (5 of 8 legs had no change in pressure and the remaining 3 resulted in 1mm Hg pressure elevation). For anterolateral plate insertion, all of the 8 legs had an elevation of anterior compartment pressure with a mean of 3.5mmHg (ranged from 2 to 6mm Hg).

CONCLUSIONS

When both approaches were compared to each other, the anterolateral plate insertion resulted in higher intracompartmental pressure elevation of the anterior compartment than the anteromedial approach. Surgeon should be more aware of acute compartment syndrome when considering the anterolateral approach in treating close tibial fracture. However, in patients with suspected acute compartment syndrome, close observation and continuous monitoring of the intracompartmental pressure is still imperative for all healthcare provider.

Functional outcome of tibial fracture with acute compartment syndrome and correlation to deep posterior compartment pressure

AIM

To measure single baseline deep posterior compartment pressure in tibial fracture complicated by acute compartment syndrome (ACS) and to correlate it with functional outcome.

METHODS

Thirty-two tibial fractures with ACS were evaluated clinically and the deep posterior compartment pressure was measured. Urgent fasciotomy was needed in 30 patients. Definite surgical fixation was performed either primarily or once fasciotomy wound was healthy. The patients were followed up at 3 mo, 6 mo and one year. At one year, the functional outcome [lower extremity functional scale (LEFS)] and complications were assessed.

RESULTS

Three limbs were amputated. In remaining 29 patients, the average times for clinical and radiological union were 25.2 ± 10.9 wk (10 to 54 wk) and 23.8 ± 9.2 wk (12 to 52 wk) respectively. Nine patients had delayed union and 2 had nonunion who needed bone grafting to augment healing. Most common complaint at follow up was ankle stiffness (76%) that caused difficulty in walking, running and squatting. Of 21 patients who had paralysis at diagnosis, 13 (62%) did not recover and additional five patients developed paralysis at follow-up. On LEFS evaluation, there were 14 patients (48.3%) with severe disability, 10 patients (34.5%) with moderate disability and 5 patients (17.2%) with minimal disability. The mean pressures in patients with minimal disability, moderate disability and severe disability were 37.8, 48.4 and 58.79 mmHg respectively (P < 0.001).

CONCLUSION

ACS in tibial fractures causes severe functional disability in majority of patients. These patients are prone for delayed union and nonunion; however, long term disability is mainly because of severe soft tissue contracture. Intra-compartmental pressure (ICP) correlates with functional disability; patients with relatively high ICP are prone for poor functional outcome.

Extremity compartment syndrome following blunt trauma: a level I trauma center's 5-year experience

BACKGROUND

Extremity compartment syndrome is a recognized complication of trauma. We evaluated its prevalence and outcomes at a suburban level 1 trauma center.

METHODS

The trauma registry was reviewed for all blunt trauma patients aged ≥18 years, admitted between 2010 and 2014. Chart review of patients with extremity compartment syndrome was performed.

RESULTS

Of 6180 adult blunt trauma admissions, 83 patients developed 86 extremity compartment syndromes; two patients had compartment syndromes on multiple locations. Their (n = 83) median age was 44 years (interquartile range: 31.5-55.5). The most common mechanism of injury was motor vehicle/motor cycle accident (45.8%) followed by a fall (21.7%). The median injury severity score was 9 (interquartile range: 5-17); 65.1% had extremity abbreviate injury score ≥3. Notably, 15 compartment syndromes did not have an underlying fracture. Among patients with fractures, the most commonly injured bone was the tibia, with tibial plateau followed by tibial diaphyseal fractures being the most frequent locations. Fasciotomies were performed, in order of frequency, in the leg (n = 53), forearm (n = 15), thigh (n = 9), foot (n = 5), followed by multiple or other locations.

CONCLUSIONS

Extremity compartment syndrome was a relatively uncommon finding. It occurred in all extremity locations, with or without an associated underlying fracture, and from a variety of mechanisms. Vigilance is warranted in evaluating the compartments of patients with extremity injuries following blunt trauma.

[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.

Intracompartmental Sepsis With Burn: A Case Report

Intracompartmental sepsis (IS) is a rare complication in patients with burns. Intracompartmental sepsis presents in patients with inadequate perfusion of intracompartmental tissues and subsequent ischemic necrosis and infection. Contributing factors include high-volume resuscitation, delayed escharotomies, and previous bacteremia. We describe a case of massive burns from a gas explosion and the subsequent development of IS in our intensive care burn unit. The patient presented with a 75% total body surface area burn on admission, with 39% superficial, deep partial-thickness and 26% full-thickness burns. Intracompartmental sepsis was diagnosed 45 days after admission. Anterior compartment muscles, including the tibialis anterior, extensor hallucis longus, and extensor digitorum longus, were necrotic with relatively fair nerve and vascular structures. Intracompartmental sepsis is an overwhelming, infectious complication that appears late and can occur easily in patients with major burns. Early diagnosis and management are a must for improving outcomes.

Acute Compartment Syndrome

Acute compartment syndrome (ACS) is a well-known pathophysiologic complication of trauma or tissue ischemia. ACS affects the appearance, function, and even the viability of the involved limb, and demands immediate diagnosis and treatment. However, ACS is difficult to diagnose and the only effective treatment is decompressive surgical fasciotomy. The clinical signs and symptoms may easily be attributed to other aspects of the injury, which further complicates the diagnosis. This article highlights the latest information regarding the diagnosis of ACS, how to perform fasciotomies, how to manage fasciotomy wounds, and also reviews complications and outcomes of ACS.

Exercise-induced acute compartment syndrome in a young man, occurring after a short race

We describe a case of exercise-induced acute compartment syndrome (ACS) in a 23-year-old man who presented to his primary care physician 48 hours after he attempted to run a 5K race. He noticed searing pain in his left leg after the first half mile but had no other symptoms. He was referred to the emergency department and diagnosed with ACS, and a fasciotomy was done. A presentation of limb pain that is out of proportion to a known or suspected injury should prompt consideration of ACS. Early recognition and surgical management are essential to achieving the best possible outcome.