CASE REPORT
An unusual presentation of compartment syndrome Cameron Martin, PA-C
ABSTRACT Compartment syndrome occurs when excessive pressure in an enclosed space in the body compromises perfusion. Without treatment, this condition can cause tissue ischemia and necrosis. Typically, acute compartment syndrome develops acutely after traumatic injury. The article describes a case of delayed compartment syndrome after a fall. Keywords: compartment syndrome, fasciotomy, negative pressure wound therapy, orthopedic trauma, paresthesia, edema
CASE A 39-year-old woman presented at the ED complaining of heaviness and describing paresthesias radiating into her right foot from her lower leg. She said that a week ago, she slipped while going down a short course of steps and fell onto her right knee. She went to a local ED, and radiographs taken there were interpreted to show no fracture (Figure 1). She was placed in a knee immobilizer and discharged with an analgesic for pain control. The patient subsequently had increased pain in her knee and was seen by her primary care provider 4 days after her discharge from the local ED. The primary care provider ordered an MRI of the patient’s knee, which was interpreted to show a nondisplaced proximal fibular head fracture (Figure 2). The MRI also showed some edema in the lateral tibial plateau. No change was made to the treatment plan. A week after her fall, the patient began to experience increased swelling and pain in her lower right leg over a period of several days, prompting the current ED visit. She had no history of repeat trauma or blood clot. An appointment with a local orthopedist was pending. The patient’s medical history includes obesity, hypertension, asthma, seizure disorder, fibromyalgia, celiac disease, irritable bowel syndrome, interstitial cystitis, and ovarian cancer status post resection and oral medical therapy. Her At the time this article was written, Cameron Martin practiced in the Department of Orthopedics, Orthopedic Trauma Team, at Eastern Maine Medical Center in Bangor, Maine. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000460920.82885.67 Copyright © 2015 American Academy of Physician Assistants
36
FIGURE 1. Plain radiograph showing a subtle cortex disruption
that was missed at the first ED
surgical history consists of four cesarean sections and a hysterectomy with bilateral oophorectomy. She denied use of tobacco, alcohol, or illicit drugs. She takes 600 mg of oral gabapentin daily, 10 mg of oral montelukast daily, and albuterol by inhaler as needed. She reports allergies to amoxicillin, penicillin, erythromycin, prochlorperazine, lidocaine, latex, contrast dye, pentosan polysulfate sodium, and clindamycin. A review of systems was unremarkable save for what was reflected in the chief complaint. In the current ED, the patient had increased pain with passive range of motion that was difficult to control with repeated 2-mg doses of IV morphine. The ED physician ordered a venous Doppler study; results were negative for deep vein thrombosis. An orthopedic trauma consult was requested due to the pain out of proportion with the injury and the on-call orthopedic traumatologist evaluated the patient in the ED. Relevant physical examination findings included pulse, 97, and BP, 134/88 mm Hg. The patient was intermittently crying throughout her stay. A focused examination of the
www.JAAPA.com
Volume 28 • Number 5 • May 2015
Copyright © 2015 American Academy of Physician Assistants
An unusual presentation of compartment syndrome
Key points Compartment syndrome occurs when the pressure in a body compartment compromises the capillary perfusion pressure, resulting in tissue ischemia and necrosis. No universally accepted guidelines exist for diagnosing compartment syndrome. Most of the pertinent clinical findings have low positive predictive value and appear after irreversible damage has occurred. Clinical findings and a high level of suspicion based upon mechanism of injury may point to compartment syndrome; measuring compartment pressures directly can confirm a diagnosis. Urgent fasciotomy to open the affected compartments is the recommended treatment.
lower extremities was difficult because of copious adipose tissue throughout the patient’s calves and thighs bilaterally. Her feet were warm bilaterally with 2+ dorsalis pedis pulses. She reported some paresthesias in the lateral plantar distribution of her right foot. She could wiggle her toes, but right ankle dorsiflexion and plantar flexion were painful for her. Extension and flexion of her right knee also were painful. Available imaging was reviewed and a proximal fibula fracture was identified on plain radiograph and MRI. The MRI also indicated some mild bruising at the lateral tibial plateau. An intracompartmental pressure monitor was used to measure the compartment pressures in her right leg. Although other compartment pressures were essentially normal, a measurement of 115 mm Hg was obtained near the fibular head in the lateral compartment. The diagnosis of compartment syndrome was firmly established because the compartment pressure was 27 mm Hg above the diastolic BP. The patient was taken to the OR urgently and a right leg four-compartment fasciotomy was performed through a single longitudinal lateral incision. The superficial posterior compartment contained edematous, contused muscle. However, the muscle was not debrided because it demonstrated contractility to stimulation and was not necrotic. Muscle in all other compartments appeared normal. A negative pressure wound therapy closure dressing set at 125 mm Hg continuous therapy was applied. The leg was returned to the knee immobilizer. Postoperatively, the patient was placed on IV hydromorphone via patient-controlled analgesia (PCA) pump. She was administered subcutaneous enoxaparin daily for deep vein thrombosis prophylaxis throughout her hospital stay. The patient returned to the OR on the following day and hematoma evacuation with delayed primary closure was performed successfully. She had persistent paresthesia in the lateral plantar distribution of the affected foot after closure, expected given the location of the edematous
FIGURE 2. MRI ordered by the patient’s primary care provider,
which more clearly showed the fracture of the fibular head
muscle discovered intraoperatively. Dorsiflexion and plantar flexion strength were 5/5. By hospital day 3, her pain had improved and she was transitioned off the PCA pump to oral combination oxycodone and acetaminophen taken every 4 hours. Passive range of motion of the toes was no longer painful. She was bearing weight on the limb. She was discharged on hospital day 3 in a knee immobilizer with a prescription for combination oxycodone and acetaminophen and is progressing well through follow-up. She will follow up 2 weeks postdischarge in the clinic to ensure that her fasciotomy wound has healed and her symptoms are continuing to improve. Follow-up after that will be as needed. DISCUSSION Compartment syndrome was first described by Volkmann in 1881.1 In this syndrome, pressure within an enclosed body space (in this case the lateral compartment of the leg) rises to the point of causing tissue ischemia and necrosis if not treated. Volkmann contracture describes the resulting condition, in which the limb is severely contracted and nonfunctional. Compartment syndrome in an otherwise healthy patient with an isolated tibia fracture can increase length of hospital stay by a factor of three and double the costs associated with treatment.2 Most recent research on the syndrome has focused on the potential role of inflammatory markers in aiding the diagnosis of compartment syndrome.3 Potential causes of the increased pressure in an anatomical compartment include fracture, exercise, edema, anabolic steroids, burns, blood clots, overly tight bandaging or casting, or prolonged external crushing forces. Compartment syndrome can occur in any body compartment. The most common orthopedic injury associated with compartment syndrome
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2015 American Academy of Physician Assistants
www.JAAPA.com
37
An unusual presentation of compartment syndrome
is fracture of the tibial diaphysis.4 The risk of compartment syndrome as a result of orthopedic trauma in men is tenfold that of women.4 The diagnosis of compartment syndrome requires a combination of clinical findings, objective data, and clinical suspicion based on clinician experience and mechanism of injury. Compartment syndrome is challenging to diagnose in patients who are obtunded, unconscious, intubated, or have altered pain sensation, all of which may be common in trauma patients. Clinical findings for diagnosis include: • pain out of proportion to the injury that typically begins within the first 48 hours after injury • pain on passive stretch of the muscles in the affected compartment • paresthesia (late sign) • paresis (late sign).4 Additionally, myoglobin and creatinine phosphokinase may be elevated when significant muscle damage has occurred.5 The presence or absence of a pulse is controversial as part of the diagnostic criteria because arterial compromise occurs late in the disease process.4 Evaluation of swelling, while subjective, is also a pertinent finding and can increase the clinician’s suspicion. Research has established that the presence of these clinical findings has a much greater negative than positive predictive value. The absence of these findings is useful in excluding the diagnosis while the presence of three or more findings helps to maximize positive predictive value.6 Given the potential for permanent damage due to a missed diagnosis, compartment pressure testing should be performed when compartment syndrome is suspected. Compartment pressures are measured relative to the diastolic BP. In general, normal tissue perfusion may occur if difference between the diastolic BP and the measured tissue compartment pressure is greater than 30 mm Hg. Compartment pressures that rise to within 20 to 30 mm Hg of the patient’s diastolic BP indicate compartment syndrome. Repeat measurements may be used to evaluate trends and assist in the diagnosis. The diagnosis may also be made intraoperatively during fracture fixation by direct observation of tissues surrounding the fracture site. Compromised muscle will be discolored, will not bleed, and will not contract with stimulation.7 Once the diagnosis of compartment syndrome is made, the compartments must be released urgently. For compartment syndrome resulting from a tibia fracture, this involves opening all four compartments in the lower leg by performing fasciotomies. The compartments must be opened to the atmosphere to release the pressure and allow normal perfusion to return. In the leg, the approach may be made either through a single lateral incision or through medial and lateral incisions. Both involve equal risk of subsequent infection and nonunion while achieving the desired goal, which is the normalization of compartment pressures to allow tissue perfusion.8
A negative pressure wound therapy dressing is typically applied to the fasciotomy wounds in lieu of primary closure. This has been shown to have several positive effects, including decreasing edema formation, removing bacteria, and potentially reducing time to primary closure.9 Repeated surgeries every 24 to 48 hours to irrigate and debride devitalized tissue continue for a period of several days until the negative pressure dressing can be removed and the wound closed by primary closure or a split-thickness skin graft. Treatment can be complex in patients with high-energy open fractures with contamination, bone loss, and/or tissue loss. These complications require more involved multispecialty treatments including long-term IV antibiotics, extensive debridement that may result in muscle and function loss, the need for vascular repair, and tissue flaps to repair soft tissue defects. CONCLUSION This case was unique in that the patient developed compartment syndrome several days after her original injury. In addition, her injury was not one that typically results in compartment syndrome, so the on-call physician/PA orthopedic trauma team initially had a very low index of suspicion for compartment syndrome. However, the presence of three pertinent clinical findings (edema, paresthesias, pain with passive stretch of the affected muscles) increased the likelihood of compartment syndrome in this patient. This prompted a measurement of compartment pressures, which firmly established the diagnosis. Practitioners must include compartment syndrome in the differential diagnosis whenever a patient presents for treatment following trauma to a limb. Rapid identification and treatment of compartment syndrome may prevent permanent loss of limb function. JAAPA REFERENCES 1. Von Volkmann R. Die ischämischen Muskellahmungen und Kontrakturen. Centrabl f Chir. 1881:51-801. 2. Schmidt AH. The impact of compartment syndrome on hospital length of stay and charges among adult patients admitted with a fracture of the tibia. J Orthop Trauma. 2011;25(6):355-357. 3. Harvey EJ, Sanders DW, Shuler MS, et al. What’s new in acute compartment syndrome? J Orthop Trauma. 2012;26(12):699-702. 4. Rockwood CA, Bucholz RW, Court-Brown CM, et al. Acute compartment syndrome. In: Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P, eds. Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2010. 5. Smith JS. Compartment syndrome. JAAPA. 2013;26(9):48-49. 6. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma. 2002;16(8):572-577. 7. McQueen MM, Duckworth AD, Aitken SA, Court-Brown CM. The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome. J Bone Joint Surg Am. 2013;95(8):673-677. 8. Bible JE, McClure DJ, Mir HR. Analysis of single-incision versus dual-incision fasciotomy for tibial fractures with acute compartment syndrome. J Orthop Trauma. 2013;27(11):607-611. 9. Pollak AN. Use of negative pressure wound therapy with reticulated open cell foam for lower extremity trauma. J Orthop Trauma. 2008;22(10 suppl):S142–S145.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2015 American Academy of Physician Assistants
www.JAAPA.com
39
An unusual presentation of compartment syndrome Cameron Martin, PA-C
ABSTRACT Compartment syndrome occurs when excessive pressure in an enclosed space in the body compromises perfusion. Without treatment, this condition can cause tissue ischemia and necrosis. Typically, acute compartment syndrome develops acutely after traumatic injury. The article describes a case of delayed compartment syndrome after a fall. Keywords: compartment syndrome, fasciotomy, negative pressure wound therapy, orthopedic trauma, paresthesia, edema
CASE A 39-year-old woman presented at the ED complaining of heaviness and describing paresthesias radiating into her right foot from her lower leg. She said that a week ago, she slipped while going down a short course of steps and fell onto her right knee. She went to a local ED, and radiographs taken there were interpreted to show no fracture (Figure 1). She was placed in a knee immobilizer and discharged with an analgesic for pain control. The patient subsequently had increased pain in her knee and was seen by her primary care provider 4 days after her discharge from the local ED. The primary care provider ordered an MRI of the patient’s knee, which was interpreted to show a nondisplaced proximal fibular head fracture (Figure 2). The MRI also showed some edema in the lateral tibial plateau. No change was made to the treatment plan. A week after her fall, the patient began to experience increased swelling and pain in her lower right leg over a period of several days, prompting the current ED visit. She had no history of repeat trauma or blood clot. An appointment with a local orthopedist was pending. The patient’s medical history includes obesity, hypertension, asthma, seizure disorder, fibromyalgia, celiac disease, irritable bowel syndrome, interstitial cystitis, and ovarian cancer status post resection and oral medical therapy. Her At the time this article was written, Cameron Martin practiced in the Department of Orthopedics, Orthopedic Trauma Team, at Eastern Maine Medical Center in Bangor, Maine. The author has disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000460920.82885.67 Copyright © 2015 American Academy of Physician Assistants
36
FIGURE 1. Plain radiograph showing a subtle cortex disruption
that was missed at the first ED
surgical history consists of four cesarean sections and a hysterectomy with bilateral oophorectomy. She denied use of tobacco, alcohol, or illicit drugs. She takes 600 mg of oral gabapentin daily, 10 mg of oral montelukast daily, and albuterol by inhaler as needed. She reports allergies to amoxicillin, penicillin, erythromycin, prochlorperazine, lidocaine, latex, contrast dye, pentosan polysulfate sodium, and clindamycin. A review of systems was unremarkable save for what was reflected in the chief complaint. In the current ED, the patient had increased pain with passive range of motion that was difficult to control with repeated 2-mg doses of IV morphine. The ED physician ordered a venous Doppler study; results were negative for deep vein thrombosis. An orthopedic trauma consult was requested due to the pain out of proportion with the injury and the on-call orthopedic traumatologist evaluated the patient in the ED. Relevant physical examination findings included pulse, 97, and BP, 134/88 mm Hg. The patient was intermittently crying throughout her stay. A focused examination of the
www.JAAPA.com
Volume 28 • Number 5 • May 2015
Copyright © 2015 American Academy of Physician Assistants
An unusual presentation of compartment syndrome
Key points Compartment syndrome occurs when the pressure in a body compartment compromises the capillary perfusion pressure, resulting in tissue ischemia and necrosis. No universally accepted guidelines exist for diagnosing compartment syndrome. Most of the pertinent clinical findings have low positive predictive value and appear after irreversible damage has occurred. Clinical findings and a high level of suspicion based upon mechanism of injury may point to compartment syndrome; measuring compartment pressures directly can confirm a diagnosis. Urgent fasciotomy to open the affected compartments is the recommended treatment.
lower extremities was difficult because of copious adipose tissue throughout the patient’s calves and thighs bilaterally. Her feet were warm bilaterally with 2+ dorsalis pedis pulses. She reported some paresthesias in the lateral plantar distribution of her right foot. She could wiggle her toes, but right ankle dorsiflexion and plantar flexion were painful for her. Extension and flexion of her right knee also were painful. Available imaging was reviewed and a proximal fibula fracture was identified on plain radiograph and MRI. The MRI also indicated some mild bruising at the lateral tibial plateau. An intracompartmental pressure monitor was used to measure the compartment pressures in her right leg. Although other compartment pressures were essentially normal, a measurement of 115 mm Hg was obtained near the fibular head in the lateral compartment. The diagnosis of compartment syndrome was firmly established because the compartment pressure was 27 mm Hg above the diastolic BP. The patient was taken to the OR urgently and a right leg four-compartment fasciotomy was performed through a single longitudinal lateral incision. The superficial posterior compartment contained edematous, contused muscle. However, the muscle was not debrided because it demonstrated contractility to stimulation and was not necrotic. Muscle in all other compartments appeared normal. A negative pressure wound therapy closure dressing set at 125 mm Hg continuous therapy was applied. The leg was returned to the knee immobilizer. Postoperatively, the patient was placed on IV hydromorphone via patient-controlled analgesia (PCA) pump. She was administered subcutaneous enoxaparin daily for deep vein thrombosis prophylaxis throughout her hospital stay. The patient returned to the OR on the following day and hematoma evacuation with delayed primary closure was performed successfully. She had persistent paresthesia in the lateral plantar distribution of the affected foot after closure, expected given the location of the edematous
FIGURE 2. MRI ordered by the patient’s primary care provider,
which more clearly showed the fracture of the fibular head
muscle discovered intraoperatively. Dorsiflexion and plantar flexion strength were 5/5. By hospital day 3, her pain had improved and she was transitioned off the PCA pump to oral combination oxycodone and acetaminophen taken every 4 hours. Passive range of motion of the toes was no longer painful. She was bearing weight on the limb. She was discharged on hospital day 3 in a knee immobilizer with a prescription for combination oxycodone and acetaminophen and is progressing well through follow-up. She will follow up 2 weeks postdischarge in the clinic to ensure that her fasciotomy wound has healed and her symptoms are continuing to improve. Follow-up after that will be as needed. DISCUSSION Compartment syndrome was first described by Volkmann in 1881.1 In this syndrome, pressure within an enclosed body space (in this case the lateral compartment of the leg) rises to the point of causing tissue ischemia and necrosis if not treated. Volkmann contracture describes the resulting condition, in which the limb is severely contracted and nonfunctional. Compartment syndrome in an otherwise healthy patient with an isolated tibia fracture can increase length of hospital stay by a factor of three and double the costs associated with treatment.2 Most recent research on the syndrome has focused on the potential role of inflammatory markers in aiding the diagnosis of compartment syndrome.3 Potential causes of the increased pressure in an anatomical compartment include fracture, exercise, edema, anabolic steroids, burns, blood clots, overly tight bandaging or casting, or prolonged external crushing forces. Compartment syndrome can occur in any body compartment. The most common orthopedic injury associated with compartment syndrome
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2015 American Academy of Physician Assistants
www.JAAPA.com
37
An unusual presentation of compartment syndrome
is fracture of the tibial diaphysis.4 The risk of compartment syndrome as a result of orthopedic trauma in men is tenfold that of women.4 The diagnosis of compartment syndrome requires a combination of clinical findings, objective data, and clinical suspicion based on clinician experience and mechanism of injury. Compartment syndrome is challenging to diagnose in patients who are obtunded, unconscious, intubated, or have altered pain sensation, all of which may be common in trauma patients. Clinical findings for diagnosis include: • pain out of proportion to the injury that typically begins within the first 48 hours after injury • pain on passive stretch of the muscles in the affected compartment • paresthesia (late sign) • paresis (late sign).4 Additionally, myoglobin and creatinine phosphokinase may be elevated when significant muscle damage has occurred.5 The presence or absence of a pulse is controversial as part of the diagnostic criteria because arterial compromise occurs late in the disease process.4 Evaluation of swelling, while subjective, is also a pertinent finding and can increase the clinician’s suspicion. Research has established that the presence of these clinical findings has a much greater negative than positive predictive value. The absence of these findings is useful in excluding the diagnosis while the presence of three or more findings helps to maximize positive predictive value.6 Given the potential for permanent damage due to a missed diagnosis, compartment pressure testing should be performed when compartment syndrome is suspected. Compartment pressures are measured relative to the diastolic BP. In general, normal tissue perfusion may occur if difference between the diastolic BP and the measured tissue compartment pressure is greater than 30 mm Hg. Compartment pressures that rise to within 20 to 30 mm Hg of the patient’s diastolic BP indicate compartment syndrome. Repeat measurements may be used to evaluate trends and assist in the diagnosis. The diagnosis may also be made intraoperatively during fracture fixation by direct observation of tissues surrounding the fracture site. Compromised muscle will be discolored, will not bleed, and will not contract with stimulation.7 Once the diagnosis of compartment syndrome is made, the compartments must be released urgently. For compartment syndrome resulting from a tibia fracture, this involves opening all four compartments in the lower leg by performing fasciotomies. The compartments must be opened to the atmosphere to release the pressure and allow normal perfusion to return. In the leg, the approach may be made either through a single lateral incision or through medial and lateral incisions. Both involve equal risk of subsequent infection and nonunion while achieving the desired goal, which is the normalization of compartment pressures to allow tissue perfusion.8
A negative pressure wound therapy dressing is typically applied to the fasciotomy wounds in lieu of primary closure. This has been shown to have several positive effects, including decreasing edema formation, removing bacteria, and potentially reducing time to primary closure.9 Repeated surgeries every 24 to 48 hours to irrigate and debride devitalized tissue continue for a period of several days until the negative pressure dressing can be removed and the wound closed by primary closure or a split-thickness skin graft. Treatment can be complex in patients with high-energy open fractures with contamination, bone loss, and/or tissue loss. These complications require more involved multispecialty treatments including long-term IV antibiotics, extensive debridement that may result in muscle and function loss, the need for vascular repair, and tissue flaps to repair soft tissue defects. CONCLUSION This case was unique in that the patient developed compartment syndrome several days after her original injury. In addition, her injury was not one that typically results in compartment syndrome, so the on-call physician/PA orthopedic trauma team initially had a very low index of suspicion for compartment syndrome. However, the presence of three pertinent clinical findings (edema, paresthesias, pain with passive stretch of the affected muscles) increased the likelihood of compartment syndrome in this patient. This prompted a measurement of compartment pressures, which firmly established the diagnosis. Practitioners must include compartment syndrome in the differential diagnosis whenever a patient presents for treatment following trauma to a limb. Rapid identification and treatment of compartment syndrome may prevent permanent loss of limb function. JAAPA REFERENCES 1. Von Volkmann R. Die ischämischen Muskellahmungen und Kontrakturen. Centrabl f Chir. 1881:51-801. 2. Schmidt AH. The impact of compartment syndrome on hospital length of stay and charges among adult patients admitted with a fracture of the tibia. J Orthop Trauma. 2011;25(6):355-357. 3. Harvey EJ, Sanders DW, Shuler MS, et al. What’s new in acute compartment syndrome? J Orthop Trauma. 2012;26(12):699-702. 4. Rockwood CA, Bucholz RW, Court-Brown CM, et al. Acute compartment syndrome. In: Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P, eds. Rockwood and Green’s Fractures in Adults. 7th ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2010. 5. Smith JS. Compartment syndrome. JAAPA. 2013;26(9):48-49. 6. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma. 2002;16(8):572-577. 7. McQueen MM, Duckworth AD, Aitken SA, Court-Brown CM. The estimated sensitivity and specificity of compartment pressure monitoring for acute compartment syndrome. J Bone Joint Surg Am. 2013;95(8):673-677. 8. Bible JE, McClure DJ, Mir HR. Analysis of single-incision versus dual-incision fasciotomy for tibial fractures with acute compartment syndrome. J Orthop Trauma. 2013;27(11):607-611. 9. Pollak AN. Use of negative pressure wound therapy with reticulated open cell foam for lower extremity trauma. J Orthop Trauma. 2008;22(10 suppl):S142–S145.
JAAPA Journal of the American Academy of Physician Assistants
Copyright © 2015 American Academy of Physician Assistants
www.JAAPA.com
39
