M M McQueen, C M Court-Brown
Compartment monitoring in tibial fractures. The pressure threshold for decompression.
J Bone Joint Surg Br. 1996 Jan;78(1):99-104.
Abstract/Text
We made a prospective study of 116 patients with tibial diaphyseal fractures who had continuous monitoring of anterior compartment pressure for 24 hours. Three patients had acute compartment syndrome (2.6%). In the first 12 hours of monitoring, 53 patients had absolute pressures over 30 mmHg and 30 had pressures over 40 mmHg, with four higher than 50 mmHg. Only one patient had a differential pressure (diastolic minus compartment pressure) of less than 30 mmHg; he had a fasciotomy. In the second 12-hour period 28 patients had absolute pressures over 30 mmHg and seven over 40 mmHg. Only two had differential pressures of less than 30 mmHg; they had fasciotomies. None of our 116 patients had any sequelae of the compartment syndrome at their latest review at least six months after injury. A threshold for decompression of 30 mmHg would have indicated that 50 patients (43%) would have required fasciotomy, and at a 40 mmHg threshold 27 (23%) would have been considered for an unnecessary fasciotomy. In our series, the use of a differential pressure of 30 mmHg as a threshold for fasciotomy led to no missed cases of acute compartment syndrome. We recommended that decompression should be performed if the differential pressure level drops to under 30 mmHg.
M M McQueen, P Gaston, C M Court-Brown
Acute compartment syndrome. Who is at risk?
J Bone Joint Surg Br. 2000 Mar;82(2):200-3.
Abstract/Text
We have analysed associated factors in 164 patients with acute compartment syndrome whom we treated over an eight-year period. In 69% there was an associated fracture, about half of which were of the tibial shaft. Most patients were men, usually under 35 years of age. Acute compartment syndrome of the forearm, with associated fracture of the distal end of the radius, was again seen most commonly in young men. Injury to soft tissues, without fracture, was the second most common cause of the syndrome and one-tenth of the patients had a bleeding disorder or were taking anticoagulant drugs. We found that young patients, especially men, were at risk of acute compartment syndrome after injury. When treating such injured patients, the diagnosis should be made early, utilising measurements of tissue pressure.
M M McQueen, J Christie, C M Court-Brown
Acute compartment syndrome in tibial diaphyseal fractures.
J Bone Joint Surg Br. 1996 Jan;78(1):95-8.
Abstract/Text
We reviewed 25 patients with tibial diaphyseal fractures which had been complicated by an acute compartment syndrome. Thirteen had undergone continuous monitoring of the compartment pressure and the other 12 had not. The average delay from injury to fasciotomy in the monitored group was 16 hours and in the non-monitored group 32 hours (p < 0.05). Of the 12 surviving patients in the monitored group, none had any sequelae of acute compartment syndrome at final review at an average of 10.5 months. Of the 11 surviving patients in the non-monitored group, ten had definite sequelae with muscle weakness and contractures (p < 0.01). There was also a significant delay in tibial union in the non-monitored group (p < 0.05). We recommend that, when equipment is available, all patients with tibial fractures should have continuous compartment monitoring to minimise the incidence of acute compartment syndrome.
B Gulli, D Templeman
Compartment syndrome of the lower extremity.
Orthop Clin North Am. 1994 Oct;25(4):677-84.
Abstract/Text
Compartment syndrome is a devastating consequence of extremity trauma that is preventable with early recognition and treatment. A high index of suspicion and careful clinical evaluation will detect most impending or established compartment syndromes. Compartmental pressure measurements can be a useful adjunctive evaluation. Once the diagnosis of compartment syndrome is confirmed, or highly suspect, fasciotomy should be performed without delay. The functional and cosmetic results of fasciotomy are always acceptable if done early. The results of inadequate treatment of compartment syndrome are never satisfactory.
George C Velmahos, Konstantinos G Toutouzas
Vascular trauma and compartment syndromes.
Surg Clin North Am. 2002 Feb;82(1):125-41, xxi. doi: 10.1016/S0039-6109(03)00145-2.
Abstract/Text
Vascular injuries produce ischemia, and their repair produces reperfusion. Ischemia and reperfusion produce compartment syndrome. Although a local event, a compartment syndrome risks not only the affected extremity, but also the life of the patient. A high index of suspicion coupled with adequate knowledge of subtle clinical symptoms (and confirmed by intracompartmental pressure measurement) improve management of compartment syndrome, and this article discusses common pitfalls in its diagnosis and treatment.
TE Whitesides, MM Heckman
Acute Compartment Syndrome: Update on Diagnosis and Treatment.
J Am Acad Orthop Surg. 1996 Jul;4(4):209-218.
Abstract/Text
Acute compartment syndrome can have disastrous consequences. Because unusual pain may be the only symptom of an impending problem, a high index of suspicion, accurate evaluation, and prophylactic treatment will allow the physician to intervene in a timely manner and prevent irreversible damage. Muscles tolerate 4 hours of ischemia well, but by 6 hours the result is uncertain; after 8 hours, the damage is irreversible. Ischemic injury begins when tissue pressure is 10 to 20 mm Hg below diastolic pressure. Therefore, fasciotomy generally should be done when tissue pressure rises past 20 mm Hg below diastolic pressure.
M M Heckman, T E Whitesides, S R Grewe, R L Judd, M Miller, J H Lawrence
Histologic determination of the ischemic threshold of muscle in the canine compartment syndrome model.
J Orthop Trauma. 1993;7(3):199-210.
Abstract/Text
Our objective was to define the critical tissue pressure at which irreversible muscle damage occurs and to compare our results to those thresholds advocated in the orthopaedic literature. A standard plasma infusion compartment syndrome model was created in a canine model. Four dogs were in each of four experimental groups with compartment pressure maintained as follows: (a) 30 mm Hg with support of diastolic blood pressure to a level > 50 mm Hg; (b) 20 mm Hg less than diastolic pressure; (c) 10 mm Hg less than diastolic blood pressure; (d) a level equal to the animal's diastolic blood pressure. All animals were sacrificed 14 days after the procedure. Histology revealed the following: (a) tissues pressurized to 30 mm Hg in a normotensive dog demonstrated no significant abnormalities; (b) tissues pressurized to 20 mm Hg less than diastolic revealed occasional cells undergoing regeneration but no evidence of infarction or fibrosis; (c) tissues pressurized to 10 mm Hg less than diastolic showed scattered small areas of infarction and fibrosis; and (d) tissues pressurized to diastolic blood pressure demonstrated more widespread infarction and scarring. The ischemic threshold of muscle, beyond which irreversible tissue damage occurs, is directly related to the difference in compartment and perfusion pressure. Our findings document this pressure to be 10 mm Hg less than diastolic blood pressure or within 30 mm Hg of mean arterial pressure. This data refutes the use of absolute tissue pressure values as a guide to the necessity of fasciotomy. To abort an impending compartment syndrome and avoid irreversible tissue injury and their sequelae, fasciotomy should be done if tissue pressure reaches within 10-20 mm Hg of diastolic pressure.
M J Matava, T E Whitesides, J G Seiler, K Hewan-Lowe, W C Hutton
Determination of the compartment pressure threshold of muscle ischemia in a canine model.
J Trauma. 1994 Jul;37(1):50-8.
Abstract/Text
A canine model was used to test the hypothesis that critical intracompartmental pressure leading to ischemic muscle necrosis is linked to diastolic blood pressure. Twenty adult dogs were subjected to an infusion of autologous plasma into the anterolateral muscle compartment of the left hindlimb to create an elevation in compartment pressure. There were four experimental groups of five dogs each. In group I, the compartment pressure (CP) was maintained at the animals' diastolic blood pressure (DBP); in group II, at 10 mm Hg less than the DBP; in group III, at 20 mm Hg less than the DBP; and in group IV, at 30 mm Hg. The pressure was measured continuously in the proximal, central, and distal segments of the compartment during an 8-hour period. Immediately postoperatively, and, on the first, fourth, seventh, and fourteenth days one animal from each group was killed. The tibialis cranialis muscle was then removed and analyzed using light and electron microscopy. The critical pressure threshold for ischemic muscle necrosis was found to be 20 mm Hg less than the diastolic blood pressure.
E A Ouellette
Compartment syndromes in obtunded patients.
Hand Clin. 1998 Aug;14(3):431-50.
Abstract/Text
A high index of suspicion for a compartment syndrome in the upper extremity should be maintained in all obtunded patients who are at risk for the condition. Obtunded patients are those with a dulled or altered physical or mental status secondary to injury, illness, or anesthesia; those with diminished or absent sensation in the upper extremity because of nerve injury or anesthesia; and those whose ability to communicate is impeded, such as infants and young children and the mentally ill or disabled. These patients represent a vulnerable group whose inability to demonstrate the hallmark symptoms and signs of the syndrome puts them in jeopardy of a late diagnosis of a compartment syndrome and its potentially devastating sequelae. The most likely causes of a compartment syndrome in this population are skeletal or soft-tissue trauma, prolonged limb compression, thrombolytic therapy after myocardial infarction, arterial or intravenous fluid administration, and upper extremity Surgery. Whenever a compartment syndrome of the hand, forearm, or upper arm is suspected, the obtunded patient should be examined closely and frequently, and any changes over time should be documented carefully. Intracompartmental pressure measurement provides a useful adjunct to the physical examination and history in these patients and may be diagnostic if other symptoms and signs are obscured. Once the compartment syndrome is diagnosed, emergent fasciotomy is indicated. To avoid a loss of function in the obtunded patient, special care must be taken postoperatively to assure that early motion exercises are carried out.
T E Whitesides, T C Haney, K Morimoto, H Harada
Tissue pressure measurements as a determinant for the need of fasciotomy.
Clin Orthop Relat Res. 1975 Nov-Dec;(113):43-51.
Abstract/Text
An experimental and clinical tehcnique of measuring tissue pressures within closed compartments demonstrates a normal tissue pressure is approximately zero mmHg, and increased markedly in compartmental syndromes. There is inadequate perfusion and relative ischemia when the tissue pressure within a closed compartment rises to within 10-30 mm Hg of the patient's diastolic blood pressure. Fasciotomy is usually indicated, therefore, when the tissue pressure rises to 40-45 mm Hg in a patient with a diastolic blood pressure of 70 mm Hg and any of the signs or symptoms of a compartmental syndrome. There is no effective tissue perfusion within a closed compartment when the tissue pressure equals or exceeds the patient's diastolic blood pressure. A fasciotomy is definitely indicated in this circumstance, although distal pulses may be present. The measurement of tissue pressure aids in the early diagnosis and appropriate treatment of compartmental syndromes.
Matsen FA: Compartmental Syndromes. New York, NY, Grune and Stratton, 1980.
B R Moed, P K Thorderson
Measurement of intracompartmental pressure: a comparison of the slit catheter, side-ported needle, and simple needle.
J Bone Joint Surg Am. 1993 Feb;75(2):231-5.
Abstract/Text
An experimental model of acute compartment syndrome involving the anterolateral compartment of the hindlimb in dogs was used to compare three methods of measurement of intracompartmental pressure: the simple-needle technique, use of the slit catheter, and use of the side-ported needle. No statistical difference was found between the values obtained with the slit catheter and those obtained with the side-ported needle; the mean difference was 1.4 millimeters of mercury throughout the range of compartment pressures that were measured. The side-ported needle appeared to be as accurate as the slit catheter for the measurement of compartment pressures (p = 0.355, 1-beta = 0.9). The values obtained with use of the simple needle were consistently higher than those obtained with the other two methods (p < 0.001): an average of 18.3 millimeters of mercury higher than the values measured with the slit catheter and 19.3 millimeters of mercury higher than those measured with the side-ported needle. Clinically, the side-ported needle or the slit catheter can be used to obtain accurate measurements of compartment pressure. Use of the simple 18-gauge needle is not recommended for this purpose.
Antony R Boody, Montri D Wongworawat
Accuracy in the measurement of compartment pressures: a comparison of three commonly used devices.
J Bone Joint Surg Am. 2005 Nov;87(11):2415-22. doi: 10.2106/JBJS.D.02826.
Abstract/Text
BACKGROUND: In situations in which accurate physical diagnosis is inconclusive, an objective method for measuring compartment pressure can aid in the diagnosis of compartment syndrome. Previous studies have compared measurement devices with each other but not with an accurately determined gold standard. The purpose of the present study was to devise a reproducible in vitro model of compartment pressure and to compare commonly used measurement devices in order to determine their accuracy.
METHODS: With a graduated cylinder being used to generate a known pressure, freshly harvested ovine muscle was placed into a chamber for testing. The cylinder was incrementally filled with saline solution (in fifty-five steps), and measurements of tissue pressure were obtained with use of the Stryker Intracompartmental Pressure Monitor System, an arterial line manometer, and the Whitesides apparatus. Each device was tested with a straight needle, a side-port needle, and a slit catheter, for a total of nine setups in all. Five trials were done with each setup. Control pressures were calculated on the basis of the height of the saline solution column (test range, 0.13 to 10.80 kPa). Multiple regression analysis was used to compare measured tissue pressures with calculated control pressures.
RESULTS: Most methods demonstrated excellent correlation (R2> 0.95) between calculated and measured pressures. The arterial line manometer with the slit catheter showed the best correlation (R2= 0.9978), and the Whitesides apparatus with the side-port needle showed the worst (R2= 0.9115). Furthermore, the Stryker system with the side-port needle demonstrated the least constant bias (+0.06 kPa). Straight needles tended to overestimate pressure. Two of the three needle configurations involving the Whitesides apparatus overestimated pressure. The data for the Whitesides methods had the highest standard errors, showing clinically unacceptable scatter.
CONCLUSION: Side-port needles and slit catheters are more accurate than straight needles are. The arterial line manometer is the most accurate device. The Stryker device is also very accurate. The Whitesides manometer apparatus lacks the precision needed for clinical use.
S J Mubarak, A R Hargens, C A Owen, L P Garetto, W H Akeson
The wick catheter technique for measurement of intramuscular pressure. A new research and clinical tool.
J Bone Joint Surg Am. 1976 Oct;58(7):1016-20.
Abstract/Text
The wick catheter technique was developed in 1968 for measurement of subcutaneous pressure and has been modified for easy intramuscular insertion and continuous recording of interstitial fluid pressure in animals and humans. Studies in dogs of the anterolateral compartment of the leg in simulation of the compartment syndrome showed the technique to be accurate and reproducible. The wick catheter technique is capable of important clinical applications in the diagnosis and treatment of acute and chronic compartment syndromes.
D S Bae, R K Kadiyala, P M Waters
Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome.
J Pediatr Orthop. 2001 Sep-Oct;21(5):680-8.
Abstract/Text
Compartment syndrome can be difficult to diagnose in a child, with delays in diagnosis leading to disastrous outcomes. Thirty-six cases of compartment syndrome in 33 pediatric patients were treated at the authors' institution from January 1, 1992, to December 31, 1997. There were 27 boys and 6 girls, with nearly equal upper and lower extremity involvement. Approximately 75% of these patients developed compartment syndrome in the setting of fracture. Pain, pallor, paresthesia, paralysis, and pulselessness were relatively unreliable signs and symptoms of compartment syndrome in these children. An increasing analgesia requirement in combination with other clinical signs, however, was a more sensitive indicator of compartment syndrome: all 10 patients with access to patient-controlled or nurse-administered analgesia during their initial evaluation demonstrated an increasing requirement for pain medication. With early diagnosis and expeditious treatment, >90% of the patients studied achieved full restoration of function.
Philip S Yuan, Maya E Pring, Tracey P Gaynor, Scott J Mubarak, Peter O Newton
Compartment syndrome following intramedullary fixation of pediatric forearm fractures.
J Pediatr Orthop. 2004 Jul-Aug;24(4):370-5.
Abstract/Text
This study was designed to evaluate the incidence of compartment syndrome (CS) resulting from the treatment of both-bone forearm fractures in children. A retrospective analysis of 285 consecutive children who presented with both-bone forearm fractures was performed. Of 235 closed injuries, 205 were treated with closed reduction and casting; none of these patients developed CS. Thirty of the closed injuries were treated with closed reduction and intramedullary fixation; three of these patients (10%) developed CS. Fifty patients sustained open fractures and were treated with debridement and open reduction with intramedullary pinning; CS developed in three of these patients (6%). The eighty patients treated with intramedullary fixation had an increased incidence of CS compared with the 205 patients treated with closed reduction and casting (P < 0.001). Within the group of patients who had surgery, patients with longer operative times and more use of intraoperative fluoroscopy were at higher risk of developing CS.
Copyright 2004 Lippincott Williams and Wilkins
F A Matsen
Compartmental syndromes.
N Engl J Med. 1979 May 24;300(21):1210-1. doi: 10.1056/NEJM197905243002108.
Abstract/Text
M J Allen, A J Stirling, C V Crawshaw, M R Barnes
Intracompartmental pressure monitoring of leg injuries. An aid to management.
J Bone Joint Surg Br. 1985 Jan;67(1):53-7.
Abstract/Text
Acute compartment syndromes often develop insidiously and are often recognised too late to prevent permanent disability. Management is difficult as the compartment involved is seldom clinically apparent. By continuously monitoring the intracompartmental pressure these problems can be avoided: transient compartment syndromes can be differentiated from established ones and the correct compartment can be surgically decompressed. Pressure monitoring techniques were used in 28 patients; three developed a compartment syndrome requiring surgical intervention, seven had a temporary increase of pressure and in 18 the pressure remained unaltered. Of the three with compartment syndromes, one was unusual in that it affected the thigh and another, unique in our experience, affected both the thigh and the calf. Intracompartmental pressure monitoring significantly altered the management of two cases giving successful results with minimal intervention.
G W Sheridan, F A Matsen
Fasciotomy in the treatment of the acute compartment syndrome.
J Bone Joint Surg Am. 1976 Jan;58(1):112-5.
Abstract/Text
Sixty-six cases of acute compartment syndrome were treated by fasciotomy in forty-six extremities of forty-four patients. Fasciotomy performed early, that is, less than twelve hours after the onset of the compartment syndrome, resulted in normal function in 68 per cent of the extremities. Only 8 per cent of those having late fasciotomy had normal function. The complication rates for the early and late fasciotomized extremities were 4.5 per cent and 54 per cent, respectively. No significant differences in residual function or complication rate were noted with "open" or "closed" fasciotomy.
J A Finkelstein, G A Hunter, R W Hu
Lower limb compartment syndrome: course after delayed fasciotomy.
J Trauma. 1996 Mar;40(3):342-4.
Abstract/Text
OBJECTIVE: To determine the end result of patients who underwent delayed fasciotomy, i.e., more than 35 hours for an established lower limb compartment syndrome.
DESIGN: A retrospective review of patients undergoing delayed treatment for a closed injury of the lower extremity, where fasciotomy should ideally have been performed earlier.
MATERIALS AND METHODS: Nine fasciotomies in five patients were identified where there was a delay of more than 35 hours after the injury. The average ischemic time was 56 hours (range 35-96 hours).
RESULTS: One patient died of multiorgan failure and septicemia. The remaining four patients required lower limb amputation, because of local infection and septicemia. The one late amputation was performed 6 months after the injury, because the patient was left with a functionless insensate foot. Where recognition of an established compartment syndrome is delayed for more than 8 to 10 hours, we propose that the traditional inevitable fasciotomy be reassessed.
A M Fitzgerald, P Gaston, Y Wilson, A Quaba, M M McQueen
Long-term sequelae of fasciotomy wounds.
Br J Plast Surg. 2000 Dec;53(8):690-3. doi: 10.1054/bjps.2000.3444.
Abstract/Text
A retrospective study of patients admitted to an Orthopaedic Trauma Unit over an 8-year period requiring fasciotomies, of either upper or lower limb, to reduce the risk of compartment syndrome was performed. Sixty patients were studied, of which 49 had an underlying fracture. The long-term morbidity of the wounds was studied. Ongoing symptoms such as pain related to the wound occurred in six patients (10%) and altered sensation within the margins of the wound occurred in 46 patients (77%). Examination revealed 24 patients (40%) with dry scaly skin, 20 patients (33%) with pruritus, 18 patients (30%) with discoloured wounds, 15 patients (25%) with swollen limbs, 16 patients (26%) with tethered scars, eight patients (13%) with recurrent ulceration, eight patients (13%) with muscle herniation and four patients (7%) with tethered tendons. The appearance of the scars affected patients such that 14 (23%) kept the wound covered, 17 (28%) changed hobbies and seven (12%) changed occupation. This study reveals a significant morbidity associated with fasciotomy wounds. In light of these findings, further consideration should be given to techniques that reduce both the symptoms and examination findings mentioned above and the aesthetic insult to the affected limb.
Copyright 2000 The British Association of Plastic Surgeons.
N D Reis, M Michaelson
Crush injury to the lower limbs. Treatment of the local injury.
J Bone Joint Surg Am. 1986 Mar;68(3):414-8.
Abstract/Text
We treated fifteen patients who had been trapped under the masonry of collapsed buildings for various periods of time. In one group of patients who had been buried for twelve hours, treatment commenced only twenty-four hours after the injury, and the other group was treated more promptly. In the second group, the success of forced diuresis and alkalinization of the urine in preventing the renal complications of the crush syndrome was evident. A reassessment of the treatment of the local lesion was made and a scheme of treatment is proposed. The injury is essentially closed, and incomplete excision of the necrotic muscle is fraught with risk. Local rigor in the affected muscles is important.
