Updated: 3/29/2018

Compartment Syndrome

Topic
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Snapshot
  • A 21-year-old man presents for evaluation of a painful right leg. He had previously had a tibial fracture and had a tightly bound cast in place. He reports excruciating pain when the cast is released and when the muscles underneath are palpated. A catheter is introduced into the limb and the intracompartmental pressures is 40 mmHg. A surgical consult is immediately called.
Introduction
  • Clinical definition
    • a painful emergency condition that occurs when the tissue pressure inside an anatomical compartment, bound by fascia, exceeds the perfusion pressure, resulting in ischemia and necrosis
  • Epidemiology
    • location
      • lower extremity > upper extremity
      • leg
      • forearm
      • hand
      • foot
      • thigh
    • risk factors
      • trauma
      • anticoagulation therapy
      • bleeding disorders
  • Etiology 
    • most common cause is a fracture 
      • tibia fracture
    • soft tissue injury
    • circumferential burns 
    • crush injuries 
    • constrictive dressing (e.g., splints, casts, or poor surgical positioning)
    • penetrating wounds
  • Pathogenesis
    • blood flow is blocked when the tissue pressure exceeds the perfusion pressure within a fixed-volume compartment
    • this results in a lack of oxygen and the accumulation of waste products, causing pain and decreased peripheral sensation
      • irreversible tissue damage occurs between 6-8 hours after onset
  • Prognosis
    • higher chance of regaining function of the affected limb if a fasciotomy is performed within 12 hours
Presentation
  • Symptoms
    • burning pain out of proportion to injury
      • the most specific and important symptom
    • pain with active contraction of the compartment
    • may have paresthesia or numbness
  • Physical exam
    • firm, swollen, and wooden feeling of the muscles on palpation
    • may have skin findings such as bullae
    • ↓ vibration sensation
    • ↓ 2-point discrimination
    • 6 P’s only manifest in the late stages of the syndrome 
      • Pallor
      • Pain out of proportion
        • worse with passive stretch
      • Paresthesia
        • “pins and needles” sensation
      • Pulselessness
      • Poikilothermia
      • Paralysis
Imaging
  • Radiography
    • indication
      • typically not needed for diagnosing compartment syndrome, but useful for characterizing any trauma such as fractures
Studies
  • Compartment pressure measurement
    • indication
      • to confirm diagnosis if clinicians are unable to elicit the symptoms or history
    • modality
      • a transducer is connected to a catheter and is used to measure the intracompartmental pressure (ICP)
  • Making the diagnosis
    • most cases are clinically diagnosed or guided by pressure measurement
      • absolute ICP  > 30 mm Hg
      • Δ pressure (diastolic blood pressure - ICP) < 30 mmHg
        • normal ICP = 0 mm Hg
Differential
  • Cellulitis
    • distinguishing factor
      • normal neurovascular exam
  • Rhabdomyolysis
    • distinguishing factors
      • abnormal laboratory evaluation, including creatine phosphokinase, renal function studies, urine myoglobin, and potassium
Treatment
  • Management approach
    • management is focused on early decompression
    • observation and conservative management is appropriate only if ICPs are not high
  • Conservative
    • place limb at the level of the heart without elevation
      • indication
        • for all patients while awaiting the diagnosis or decompression
    • immediate removal of any wraps, splints, or casts
      • indication
        • for all patients
    • immobilization
      • indication
        • for all patients
  • Operative
    • fasciotomy
      • indications
        • ICP  > 30 mmHg (with lower threshold for compartment syndrome of the hand)
        • prolonged duration of compartment syndrome > 8 hours
Complications
  • Volkmann contracture
    • permanent nerve and muscle damage
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

(M1.MK.66) A 17-year-old male presents to the emergency department after a knife fight. He initially refused to come to the hospital, but one of his wounds overlying the right antecubital fossa would not stop bleeding. Vitals include: BP 90/65, HR 115, and RR 24. He reports that he is light-headed and having visual changes. You hold direct pressure over the wound on his right arm while the rest of the team resuscitates him with crystalloid and pRBCs. After his vitals signs normalize, you note that his right arm is cool and you are unable to palpate a radial pulse. The vascular surgery team explores his right arm, finding and repairing a lacerated brachial artery. Two hours post-operatively he is complaining of 10/10 pain in his right forearm and screams out loud when you passively move his fingers. What is the most appropriate next step in management? Review Topic

QID: 104608
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Watchful waiting

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(0/16)

2

Increase his dose of hydromorphone

6%

(1/16)

3

Compressive bandage

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4

Measure forearm compartment pressures

62%

(10/16)

5

Nerve block

31%

(5/16)

M1

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