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Mun F, Kim AH, Fleuriscar J, Bronheim RS, Choi A, Sotsky RB, Hughes AJ, Aiyer AA. Risk factors for amputation in opioid-related compartment syndrome. Arch Orthop Trauma Surg 2024; 144:3091-3094. [PMID: 38739154 DOI: 10.1007/s00402-024-05360-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 04/30/2024] [Indexed: 05/14/2024]
Affiliation(s)
- Frederick Mun
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N Caroline St 5th Floor, Baltimore, MD, 21205, USA.
| | - Andrew H Kim
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N Caroline St 5th Floor, Baltimore, MD, 21205, USA
| | - Jean Fleuriscar
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N Caroline St 5th Floor, Baltimore, MD, 21205, USA
| | - Rachel S Bronheim
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N Caroline St 5th Floor, Baltimore, MD, 21205, USA
| | - Ahnryul Choi
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N Caroline St 5th Floor, Baltimore, MD, 21205, USA
| | - Rachel B Sotsky
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N Caroline St 5th Floor, Baltimore, MD, 21205, USA
| | - Alice J Hughes
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N Caroline St 5th Floor, Baltimore, MD, 21205, USA
| | - Amiethab A Aiyer
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N Caroline St 5th Floor, Baltimore, MD, 21205, USA
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Shujauddin M, Hantouly AT, Moghamis I, Alzobi O, Mazhar FV, Mekhaimar MM. Gluteal compartment syndrome secondary to prolonged immobilization following carbon monoxide poisoning associated with leukoencephalopathy: A case report. Heliyon 2024; 10:e26217. [PMID: 38439871 PMCID: PMC10909629 DOI: 10.1016/j.heliyon.2024.e26217] [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: 12/24/2022] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 03/06/2024] Open
Abstract
Introduction Gluteal compartment syndrome (GCS) is a rare diagnosis that results mostly from a non-traumatic etiology. We describe a case of a gluteal compartment syndrome, complicated with sciatic nerve palsy. Case presentation This paper reported a case of gluteal compartment syndrome caused by prolonged immobilization due to carbon monoxide poisoning. The case was complicated with sciatic nerve palsy and a sequala of leukoencephalopathy. Discussion and conclusion This case report highlighted the importance of having a high suspicion for gluteal compartment syndrome in patients with history of lying down with prolonged immobilization. The diagnosis can be made solely on clinical examination and a fasciotomy must be performed with no delay.
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Affiliation(s)
- Mohammad Shujauddin
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ashraf T. Hantouly
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Isam Moghamis
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Osama Alzobi
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Fuad Vayalil Mazhar
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Maged Mekhaimar
- Department of Orthopedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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Gluteal compartment syndrome: A systematic review and meta-analysis. Injury 2022; 53:1209-1217. [PMID: 34602242 DOI: 10.1016/j.injury.2021.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/27/2021] [Accepted: 09/12/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Gluteal compartment syndrome is a rare but devastating condition with limited characterization in the literature. The purpose of our systematic review, case series, and meta-analysis is to synthesize the current literature and provide recommendations on how to prevent gluteal compartment syndrome, identify at-risk patients, and avoid delays in diagnosis and treatment. METHODS International Classification of Disease codes were used to identify patients at our institution. PubMed, MEDLINE, and the Cochrane Library were searched to identify case reports between 1972 and March 1st, 2018. Cases were analyzed based on demographics, etiology, presentation, symptoms, diagnosis, treatment, and outcomes. RESULTS 139 cases - 13 from our institution and 126 previously published - were included. The most common etiologies were postoperative (41%), prolonged immobilization secondary to substance abuse or loss of consciousness (35%) and trauma (19%). 89% were male, mean age was 45 years (range, 16-74), and mean body mass index was 41 kg/m2. Rhabdomyolysis and sciatic neuropathy were identified in 94% and 74% of patients, respectively. Fasciotomy was performed in 80% of patients. Overall, 93% of patients survived. However, 41% of patients suffered prolonged neurologic dysfunction. In patients with an initial neurologic deficit, there was a higher rate of permanent neurological deficit in patients treated medically than those treated surgically (12/14 vs 29/61, p=0.0153), but no statistical difference in mortality (0/14 vs 4/61, p=1). In patients without initial neurologic deficit, there were no statistical differences in rates of permanent neurological deficit (0/7 vs 2/20, p=1) or mortality (0/7 vs 3/20, p=0.545) between those receiving medical or surgical treatment. DISCUSSION Gluteal compartment syndrome is an orthopaedic emergency that may be more prevalent and associated with higher morbidity and mortality than previously recognized. Risk factors may include prolonged surgical duration, immobilization secondary to substance abuse, and pelvic trauma. Intraoperative precautions and postoperative surveillance are recommended in obese patients undergoing prolonged procedures. Fasciotomies improve neurologic outcomes in patients presenting with an initial neurologic deficit. In patients who are neurologically intact on presentation, medical management with neurologic function surveillance may be the optimal initial treatment. Fasciotomies do not impact mortality. Additionally, a treatment algorithm is provided.
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Tobarran N, Wolf C, Cumpston KL, Wills BK. Pressure Necrosis Requiring Fasciotomy After Kratom Overdose. J Addict Med 2022; 16:252-253. [PMID: 34001773 DOI: 10.1097/adm.0000000000000873] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Kratom (Mitragyna speciosa) is a popular plant-based extract that has dose-dependent stimulatory and sedative effects. It has been used for self-treatment of opioid withdrawal and can result in seizures, hepatotoxicity, and infectious complications from bacterial contamination. Reports of morbidity and mortality associated with Kratom may be confounded by coingestants. We report a case of severe rhabdomyolysis and pressure necrosis leading to fasciotomy in a patient who was using Kratom. CASE REPORT A 31-year-old male with substance use presented to the emergency department after loss of consciousness for 6 hours after smoking Kratom. He was found to have rhabdomyolysis, acute renal and hepatic injury, and electrolyte disturbances. No ethanol was detected, and urine drug screen was negative. Over the next 3 hours, the patient developed signs of compartment syndrome and he was transferred to the operating room for fasciotomy. He required continuous renal replacement therapy for 48 hours and his labs and clinical status improved. He was discharged 18 days later. A serum and urine sample from the first day of presentation were analyzed for mitragynine and 7-hydroxymitragynine using an Ultra Performance Liquid Chromatography-Tandem Mass Spectrometer (UPLC-MSMS) method. The serum mitragynine was 5 ng/mL and the urine mitragynine 6 ng/mL. CONCLUSIONS Although there are numerous reports of opioids resulting in prolonged periods of immobilization and rhabdomyolysis, this is not commonly reported in Kratom overdoses.This case report highlights the profound sedative effect of Kratom and the potential of pressure necrosis injury resulting in rhabdomyolysis and compartment syndrome requiring fasciotomy.
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Affiliation(s)
- Natasha Tobarran
- Department of Emergency Medicine, Division of Clinical Toxicology, Virginia Commonwealth University Health System, Richmond, VA (NT, KLC, BKW); Forensic Toxicology and Specialty Testing, Department of Pathology, Virginia Commonwealth University Health System, Richmond, VA (CW)
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5
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McNamee M, Wolfers M, Faour M, Montorfano L, Bordes SJ. Concomitant Gluteal and Thigh Compartment Syndrome Following Atraumatic Injury. Cureus 2021; 13:e17009. [PMID: 34540410 PMCID: PMC8423593 DOI: 10.7759/cureus.17009] [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] [Accepted: 08/08/2021] [Indexed: 11/13/2022] Open
Abstract
Gluteal compartment syndrome is a rare diagnosis associated with pelvic trauma and subsequent surgical intervention. Herein, we discuss the case and management of gluteal and thigh compartment syndrome following prolonged immobilization secondary to alcohol. To our knowledge, we present the first case of concomitant gluteal and thigh compartment syndrome following atraumatic injury.
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Affiliation(s)
- Molly McNamee
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | | | | | | | - Stephen J Bordes
- Surgery, Louisiana State University Health Sciences Center, New Orleans, USA
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Winstanley EL, Mahoney JJ, Castillo F, Comer SD. Neurocognitive impairments and brain abnormalities resulting from opioid-related overdoses: A systematic review. Drug Alcohol Depend 2021; 226:108838. [PMID: 34271512 PMCID: PMC8889511 DOI: 10.1016/j.drugalcdep.2021.108838] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Non-fatal opioid-related overdoses have increased significantly over the past two decades and there have been increasing reports of brain injuries and/or neurocognitive impairments following overdose events. Limited preclinical research suggests that opioid overdoses may cause brain injury; however, little is known about such injuries in humans. The purpose this systematic review is to summarize existing studies on neurocognitive impairments and/or brain abnormalities associated with an opioid-related overdose in humans. METHODS PubMed, Web of Science, Ovid MEDLINE and PsyINFO were searched, without year restrictions, and identified 3099 articles. An additional 24 articles were identified by reviewing references. Articles were included if they were published in English, reported study findings in humans, included individuals 18 years of age or older, and reported an objective measure of neurocognitive impairments and/or brain abnormalities resulting from an opioid-related overdose. Six domains of bias (selection, performance, attrition, detection (two dimensions) and reporting were evaluated and themes were summarized. RESULTS Seventy-nine journal articles, published between 1973-2020, were included in the review. More than half of the articles were case reports (n = 44) and there were 11 cohort studies, 18 case series, and 6 case-control studies. All of the studies were categorized as at-risk of bias, few controlled for confounding factors, and methodological differences made direct comparisons difficult. Less than half of the studies reported toxicology results confirming an opioid-related overdose; 64.6 % reported brain MRI results and 27.8 % reported results of neuropsychological testing. Only two studies had within subject comparative data to document changes in the brain possibly associated with an overdose. Despite these limitations, existing publications suggest that brain injuries and neurocognitive impairments are associated with opioid overdose. Additional research is needed to establish the incidence of overdose-related brain injuries and the potential impact on functioning, as well as engagement in treatment of substance use disorders. CONCLUSIONS Respiratory depression is a defining characteristic of opioid overdose and prolonged cerebral hypoxia may cause brain injuries and/or neurocognitive impairments. The onset, characteristics, and duration of such injuries is variable and additional research is needed to understand their clinical implications.
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Affiliation(s)
- Erin L. Winstanley
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA,Department of Neuroscience, West Virginia University, Morgantown, WV, USA,Corresponding author at: West Virginia University, School of Medicine, Rockefeller Neuroscience Institute, Department of Behavioral Medicine and Psychiatry, 930 Chestnut Ridge Road, Morgantown, WV 26505, USA. (E.L. Winstanley)
| | - James J. Mahoney
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, USA,Department of Neuroscience, West Virginia University, Morgantown, WV, USA
| | - Felipe Castillo
- Columbia University, Department of Psychiatry and New York State Psychiatric Institute, New York, NY, USA
| | - Sandra D. Comer
- Columbia University, Department of Psychiatry and New York State Psychiatric Institute, New York, NY, USA
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Kitchen SA, McCormack D, Werb D, Caudarella A, Martins D, Matheson FI, Gomes T. Trends and outcomes of serious complications associated with non-fatal opioid overdoses in Ontario, Canada. Drug Alcohol Depend 2021; 225:108830. [PMID: 34182376 DOI: 10.1016/j.drugalcdep.2021.108830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/29/2021] [Accepted: 05/10/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Non-fatal opioid overdoses can lead to serious complications and consequently, long-term health effects. We sought to characterize trends of hospitalizations for serious complications associated with opioid overdoses in Ontario, Canada and report health services utilization and mortality in the year following hospital discharge. METHODS We conducted a cross-sectional study in Ontario among individuals who experienced a hospitalization for a serious complication (required intubation, rhabdomyolysis, or a brain injury) associated with an opioid overdose between 2010 and 2019. We examined inpatient characteristics at the time of hospital admission, and health services utilization and mortality rates in the year following hospital discharge. RESULTS The rate of hospitalizations for serious complications associated with opioid overdoses increased by 66.7 % from 1.8 per 100,000 population in 2010 to 3.0 per 100,000 population in 2019 in Ontario. Individuals that were discharged alive from hospital experienced high health services utilization in the following year; 71.2 % (N = 953 of 1,338) visited the emergency department (ED), 34.2 % (N = 458) were admitted to hospital, and 16.4 % (N = 219) were treated in hospital for an opioid overdose. However only a quarter of individuals (N = 332; 24.8 %) initiated on opioid agonist therapy within 90 days. Additionally, 8.0 % (N = 127) of hospitalizations resulted in death within 1 year. CONCLUSIONS This study highlights increasing rates of serious complications associated with opioid overdoses, with a high demand of health services and a high mortality rate in the following year. These findings highlight an ongoing need for support and harm reduction services to allow for early intervention and follow-up care.
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Affiliation(s)
- Sophie A Kitchen
- Unity Health Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Ontario Drug Policy Research Network, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada
| | - Daniel McCormack
- Ontario Drug Policy Research Network, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada
| | - Dan Werb
- Unity Health Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Division of Infectious Diseases and Global Public Health, UC San Diego, 9500 Gilman Dr, San Diego, CA, 92161, USA; Centre on Drug Policy Evaluation, UC San Diego, 9500 Gilman Dr, San Diego, CA, 92161, USA
| | - Alexander Caudarella
- Mental Health and Addictions Service, St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada
| | - Diana Martins
- Unity Health Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Ontario Drug Policy Research Network, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada
| | - Flora I Matheson
- Unity Health Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada
| | - Tara Gomes
- Unity Health Toronto and Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Ontario Drug Policy Research Network, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada; Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada.
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8
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Mortensen SJ, Smith RDJ, von Keudell GR, Smith MR, Weaver MJ, Nazarian A, von Keudell AG. Substance-Related Found-Down Compartment Syndrome: A Systematic Review. J Orthop Trauma 2021; 35:e247-e253. [PMID: 33177431 DOI: 10.1097/bot.0000000000002001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To characterize the patient population with substance-related found-down extremity compartment syndrome (FDECS) and report on their treatment and outcome. DATA SOURCE This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Articles in English language were identified by searching 3 online databases, EMBASE, PubMed Publisher, and Cochrane Central, in September 2019. STUDY SELECTION Studies involving substance-related FDECS were included. Exclusion criteria were as follows: patient age <18 years, not original studies, no full text available, technical reports, traumatic acute extremity compartment syndrome, chronic exertional compartment syndrome, and vascular acute extremity compartment syndrome. DATA EXTRACTION There were 61 studies included with 166 cases of FDECS. Two investigators screened and extracted data independently according to a standardized template. Disagreements were addressed by an attempt to reach a consensus, and involvement of a third reviewer. Studies were quality assessed with "Quality Assessment tool for Case Series Studies." DATA SYNTHESIS Descriptive statistics were reported using Excel. CONCLUSION Substance-related FDECS is often occurring in young adults. Data from this review found that most of the patients were already diagnosed with substance use disorders and/or psychiatric disorders. There should be a high index of suspicion of FDECS in patients presenting after prolonged immobilization. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sharri J Mortensen
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Harvard Medical School, Boston, MA
| | - Richard D J Smith
- Harvard Medical School, Boston, MA
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA
| | | | - Malcolm R Smith
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael J Weaver
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and
| | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA
- Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
| | - Arvind G von Keudell
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and
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Gupta AK, Burgos MI, Lopez-Viego M, Hus N. Gluteal Compartment Syndrome After Prolonged Immobilization in Drug Abusers. Cureus 2020; 12:e9847. [PMID: 32953354 PMCID: PMC7497769 DOI: 10.7759/cureus.9847] [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] [Indexed: 11/10/2022] Open
Abstract
Background There has been an increasing incidence of drug abuse patients presenting with rhabdomyolysis after prolonged immobilization. Our study was to assess etiology and management challenges with patients presenting with gluteal compartment syndrome after drug abuse. Methodology We did a retrospective analysis of five patients who presented with gluteal compartment syndrome secondary to drug abuse over one year. Results We had a 100% association with rhabdomyolysis and acute renal injury necessitating hemodialysis. There was a frequent association with the involvement of additional compartments like thigh and leg. Conclusion Patients with drug overdose can present with unusual compartment syndrome involvement like the gluteal compartment. Compartment syndrome is a surgical emergency and needs multidisciplinary involvement.
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Affiliation(s)
- Anupam K Gupta
- Minimally Invasive Surgery, University of Miami Hospital, Miami, USA
| | - Monica I Burgos
- Internal Medicine, Universidad Autonoma de Guadalajara, Guadalajara, MEX
| | | | - Nir Hus
- Surgery, Delray Medical Center, Delray Beach, USA.,Surgery, Florida Atlantic University, Boca Raton, USA
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Hanandeh A, Shamia AA, Ramcharan MM. Sciatic Nerve Injury Secondary to a Gluteal Compartment Syndrome. Cureus 2020; 12:e9012. [PMID: 32775092 PMCID: PMC7405969 DOI: 10.7759/cureus.9012] [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] [Indexed: 11/05/2022] Open
Abstract
Gluteal compartment syndrome (GCS) is extremely rare, with a low index of suspicion among physicians, hence, it is highly overlooked. The underdiagnosis can lead to irreversible tissue ischemia and severe neurological deficits. GCS is a surgical emergency and requires immediate surgical intervention given its high morbidity and mortality. Based on the limited available literature, multiple etiologies have been postulated including traumatic and nontraumatic causes. This article presents a complex and unusual case of GCS after prolonged immobilization in an IV drug abuser who was subjected to initial missed diagnosis.
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Affiliation(s)
- Adel Hanandeh
- General Surgery, Columbia University College of Physicians and Surgeons at Harlem Hospital Center, New York, USA
| | | | - Max Murray Ramcharan
- General Surgery, Columbia University College of Physicians and Surgeons at Harlem Hospital Center, New York, USA
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11
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Broadhurst PK, Robinson LR. Compartment syndrome: Neuromuscular complications and electrodiagnosis. Muscle Nerve 2020; 62:300-308. [PMID: 31944307 DOI: 10.1002/mus.26807] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 01/07/2020] [Accepted: 01/11/2020] [Indexed: 11/10/2022]
Abstract
Compartment syndrome (CS) is a treatable condition characterized by elevated intracompartmental pressure and may be acute or chronic in nature. Sustained elevated compartment pressure can lead to ischemia and necrosis of muscle as well as injury to peripheral nerves, creating a deficit that may be neuropathic, myopathic, or mixed. While electrodiagnostic assessments are of limited utility in the diagnosis of acute/traumatic CS, they can assist with prognosticating return of function after surgical fasciotomy or in clarifying the injury pattern in cases in which a traumatic injury results in subsequent neuromuscular deficits. They can also be used to rule out conditions that mimic chronic exertional CS. During electrodiagnostic assessment, clinicians should be aware of patterns associated with muscle fibrosis vs denervation and use this information to assist with prognostication and appropriate counseling for patients regarding any interventional or adaptive treatments that may help restore function.
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Affiliation(s)
- Peter Kaas Broadhurst
- Department of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence R Robinson
- Department of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
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12
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Parzych L, Jo J, Diwan A, Swart E. "Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic. J Bone Joint Surg Am 2019; 101:1569-1574. [PMID: 31483400 DOI: 10.2106/jbjs.18.01307] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome. METHODS We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups. RESULTS Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function. CONCLUSIONS Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lydia Parzych
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Jacob Jo
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Amna Diwan
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Eric Swart
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts
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Diagnosing acute compartment syndrome-where have we got to? INTERNATIONAL ORTHOPAEDICS 2019; 43:2429-2435. [PMID: 31468110 PMCID: PMC6848051 DOI: 10.1007/s00264-019-04386-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/29/2019] [Indexed: 12/17/2022]
Abstract
Purpose Acute compartment syndrome is a condition whereby tissue ischaemia occurs due to increased pressure in a closed myofascial compartment. It is a surgical emergency, with rapid recognition and treatment—the keys to good outcomes. Methods The available literature on diagnostic aids was reviewed by one of the senior authors 15 years ago. Now, we have further reviewed the literature, to aim to ascertain what progress has been made. Results In this review, we present the evidence around a variety of available diagnostic options when investigating a potential case of acute compartment syndrome, including those looking at pressure changes, localised oxygenation, perfusion, metabolic changes and available blood serum biomarkers. Conclusions A significant amount of work has been put into developing modalities of diagnosis for acute compartment syndrome in the last 15 years. There is a lot of promising outcomes being reported; however, there is yet to be any conclusive evidence to suggest that they should be used over intracompartmental pressure measurement, which remains the gold standard. However, clinicians should be cognizant that compartment pressure monitoring lacks diagnostic specificity, and could lead to unnecessary fasciotomy when used as the sole criterion for diagnosis. Therefore, pressure monitoring is ideally used in situations where clinical suspicion is raised.
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14
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Rao SS, Mawn JG, Lobaton GO, Puvanesarajah V, Amin RM, Humbyrd CJ, Sterling RS. Opioid-related compartment syndrome and associated morbidity. Injury 2019; 50:1429-1432. [PMID: 31279477 DOI: 10.1016/j.injury.2019.06.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/13/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Opioid-related compartment syndrome (ORCS) is an understudied complication related to opioid overdose. We hypothesized that ORCS would be associated with worse clinical outcomes, including higher amputation rates, need for multiple surgical procedures, and rhabdomyolysis on admission, compared with nonopioid-related compartment syndrome (NORCS). METHODS We used Current Procedural Terminology codes for fasciotomy as a proxy marker for cases of compartment syndrome treated at 1 health system from January 1, 2016, to December 21, 2018. We excluded patients younger than 18 years, those treated for exertional compartment syndrome, and those who underwent elective fasciotomies. Seventy-four patients met our inclusion criteria. Data reviewed included patient characteristics, cause of compartment syndrome, time until evaluation for compartment syndrome, peak creatinine kinase levels, number of surgical procedures required, duration of hospital stay, and postoperative inpatient morbidity and death. Patients were categorized as having ORCS (n = 8) or NORCS (n = 66). Alpha = .05. RESULTS All cases of ORCS occurred in men. Opioid use was the third most common cause of compartment syndrome. Two patients underwent amputation, both in the ORCS group (p < 0.01). The median number of debridements was significantly higher for the ORCS group (median, 4; interquartile range [IQR]: 3-6) than for the NORCS group (median, 3; IQR 2-4) (p = 0.03). Duration of hospital stay was longer for the ORCS group (median, 27 days; IQR 16-38) compared with the NORCS group (median, 9 days; IQR: 5-13) (p < 0.001). Mean (± standard deviation) peak creatinine kinase level was significantly higher in the ORCS group (224,000 ± 225,052 U/L) compared with the NORCS group (7550 ± 32,500) (p < 0.001). The proportion of patients who underwent hemodialysis was higher in the ORCS group (88%) than in the NORCS group (35%) (p < 0.001). All ORCS patients presented >8 h after immobilization in a dependent position. CONCLUSION Patients in the ORCS group had delayed presentations and significantly more morbidity compared with patients in the NORCS group.
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Affiliation(s)
- Sandesh S Rao
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - J Gregory Mawn
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Gilberto O Lobaton
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Raj M Amin
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Casey Jo Humbyrd
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Robert S Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Baltimore, MD 21287, USA.
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15
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Ko JU, Seo H, Lee GJ, Park D. Bilateral sciatic neuropathy with severe rhabdomyolysis following venlafaxine overdose: A case report. Medicine (Baltimore) 2018; 97:e12220. [PMID: 30212953 PMCID: PMC6155956 DOI: 10.1097/md.0000000000012220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Venlafaxine is an antidepressant and anxiolytic agent that functions by inhibiting central serotonin and norepinephrine reuptake, and it is a relatively recently introduced drug. In particular, overdose of venlafaxine has been reported to cause severe cardiac toxicity including ventricular tachycardia, prolongation of QT interval, and seizure or severe muscular injury. However, reports describing venlafaxine-induced rhabdomyolysis with neuropathy remain scarce. Accordingly, we report such a case involving a 49-year-old woman with bilateral sciatic neuropathy combined with rhabdomyolysis following venlafaxine overdose. PATIENT CONCERNS The patient complained of severe pain and tenderness in both thighs, weakness in both ankle flexor and extensor muscles, and a tingling sensation in the toes of both feet. DIAGNOSES Bilateral sciatic neuropathy combined with rhabdomyolysis following venlafaxine overdose. INTERVENTION Needle electromyography revealed fibrillation potentials and positive sharp waves, with absent recruitment in all the major muscles innervating the sciatic nerve bilaterally. Pelvic magnetic resonance imaging was performed after electromyography and revealed multifocal enhancement of signal intensity, suggesting muscle necrosis in the gluteus and thigh muscles, and swelling of both sciatic nerves on short tau inversion recovery (STIR) imaging sequences. OUTCOMES Two months later, the patient's ankle dorsiflexion strength, measured with manual muscle test, was grade 0/0, and ankle plantar flexion was grade 0/0. The patient reported little sensation at the lateral and posterior aspects of her lower leg, and dorsum and sole of the foot. A follow-up electromyography study revealed improvement in the long head of the right biceps femoris; polyphasic motor unit action potentials with diminished recruitment were observed, but otherwise unchanged. LESSONS When encountering patients who have overdosed on venlafaxine, it is very important to detect and treat severe complications such as cardiac toxicity, seizure, and rhabdomyolysis, among others. However, if rhabdomyolysis has already materialized, it should not be forgotten that the secondary damage caused by it. Physicians should rapidly detect and be minimized to mitigate future complications.
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Affiliation(s)
- Jae Ung Ko
- Department of Rehabilitation Medicine, Chungbuk National University Hospital, Cheongju
| | - Hyeunsuk Seo
- Department of Rehabilitation Medicine, Chungbuk National University Hospital, Cheongju
| | - Goo Joo Lee
- Department of Rehabilitation Medicine, Chungbuk National University Hospital, Cheongju
| | - Donghwi Park
- Department of Rehabilitation Medicine, Daegu Fatima Hospital, Daegu, Republic of Korea
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16
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Abstract
A 39-year-old woman with a history of chronic back pain due to spinal haemangiomas, multiple malignancies and depression was brought by Emergency medical servicesS to the emergency centre (EC) after being found unresponsive on the bathroom floor. The patient had an exacerbation of her back pain the previous day for which she admitted to taking double her usual dose of oxycodone, in addition to alprazolam, lorazepam, diphenhydramine and a glass of wine. She reported that she lost consciousness and was down for over 8 hours. In the EC, she complained of right forearm pain which was accompanied by mild diffuse soft-tissue swelling and decreased sensation in the right hand. Radial pulse was intact. Creatine kinase was found to be at 4663 U/L. The patient was found to have acute compartment syndrome and underwent emergent forearm fasciotomy. She eventually regained full function of the right arm.
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Affiliation(s)
- Ahmad Said
- Internal Medicine, Beaumont Health System, Royal Oak, Michigan, USA
| | - Alexandra Halalau
- Internal Medicine, Beaumont Health System, Royal Oak, Michigan, USA
- Internal Medicine, Oakland University, Rochester, Michigan, USA
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17
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Rocos B, Ward A. Gluteal compartment syndrome with sciatic nerve palsy caused by traumatic rupture of the inferior gluteal artery: a successful surgical treatment. BMJ Case Rep 2017; 2017:bcr-2016-216709. [PMID: 28122800 DOI: 10.1136/bcr-2016-216709] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Gluteal compartment syndrome is a rare entity, usually caused by direct trauma. This occurrence with sciatic nerve palsy caused by inferior gluteal artery laceration and compressive haematoma has not been reported in the literature. We describe such a case treated successfully by urgent surgical decompression and resolution of the sciatic nerve palsy. A man aged 41 years sustained blunt trauma to the right gluteal region causing a rupture of the inferior gluteal artery, gluteal compartment syndrome and rapidly progressive sciatic nerve palsy. The condition was treated urgently with interventional radiology, open surgical decompression and debridement. Recovery was complicated by recurrent haematoma formation, treated successfully with subsequent complete resolution of the sciatic nerve palsy. A review of the literature of traumatic gluteal compartment syndrome is presented with discussion of the clinical diagnosis, multidisciplinary treatment and recommendations for treatment of this injury.
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Affiliation(s)
- Brett Rocos
- Department of Trauma and Orthopaedics, North Bristol NHS Trust, Bristol, UK
| | - Anthony Ward
- Department of Orthopaedics, North Bristol NHS Trust, Bristol, UK
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18
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Delayed Presentation of Gluteal Compartment Syndrome: The Argument for Fasciotomy. Case Rep Orthop 2016; 2016:9127070. [PMID: 27073707 PMCID: PMC4814676 DOI: 10.1155/2016/9127070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 03/01/2016] [Indexed: 11/27/2022] Open
Abstract
A male patient in his fifties presented to his local hospital with numbness and weakness of the right leg which left him unable to mobilise. He reported injecting heroin the previous morning. Following an initial diagnosis of acute limb ischaemia the patient was transferred to a tertiary centre where Computed Tomography Angiography was reported as normal. Detailed neurological examination revealed weakness in hip flexion and extension (1/5 on the Medical Research Council scale) with complete paralysis of muscle groups distal to this. Sensation to pinprick and light touch was globally reduced. Blood tests revealed acute kidney injury with raised creatinine kinase and the patient was treated for rhabdomyolysis. Orthopaedic referral was made the following day and a diagnosis of gluteal compartment syndrome (GCS) was made. Emergency fasciotomy was performed 56 hours after the onset of symptoms. There was immediate neurological improvement following decompression and the patient was rehabilitated with complete nerve recovery and function at eight-week follow-up. This is the first documented case of full functional recovery following a delayed presentation of GCS with sciatic nerve palsy. We discuss the arguments for and against fasciotomy in cases of compartment syndrome with significant delay in presentation or diagnosis.
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19
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Lederman A, Turk D, Howard A, Reddy S, Stern M. Case study: Gluteal compartment syndrome as a cause of lumbosacral radiculoplexopathy and complex regional pain syndrome. ACTA ACUST UNITED AC 2016; 53:483-6. [DOI: 10.1682/jrrd.2015.01.0007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 07/21/2015] [Indexed: 11/05/2022]
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