Stryker While the Pressure is High! A Review of Compartment Syndrome

Case

25 year old male with no other medical history presented to ED for a single gunshot wound to right lower leg. Vital signs and initial labs were all within normal limits. On physical exam, the patient had a single gunshot wound on the lateral aspect of the calf with swelling and tenderness to palpation. No numbness or paresthesias were noted, and DP and PT pulses were 2+ in both legs. X-rays showed comminuted fracture of the right tibia and fibula with retained bullet fragments.

While in the ED, patient reported worsening pain despite analgesia. Upon re-exam, swelling had increased, and pulses were no longer palpable. Extreme tenderness to palpation and inability to tolerate passive toe extension or flexion were noted. Compartment pressure measured with Stryker device were:

• Lateral: 30

• Anterior: 68

• Deep posterior pressure: 70

• Superficial posterior: 50 mmHg

Diastolic blood pressure was about 75 mmHg. Patient was taken to OR for emergent fasciotomy and ORIF of his fractured tibia.

Summary of Evidence

• Acute compartment syndrome (CS) is a condition where pressures within specific compartments increase in pressure, either from edema or bleeding, to a point where the tissue is threatened from lack of perfusion. (1-2)

• This condition affects areas that have little to no room for expansion, with forearms, lower legs, hands, and feet being very susceptible. Tibial fractures make up one-third of all CS cases and CS occurs in 2-9% of tibial fractures. (3-5)

• Causes include fractures, burns, penetrating traumas, casts, constrictive dressings, and blunt trauma. Incidence is about 3.1 per 100,000, with men ten times more likely to be affected than women. (2)

• High velocity objects, such as bullets or fragments from an explosive device cause compartment syndrome due to cavitation they induce in the tissue. This cavitation causes expansion and contraction within the tissue itself, which inflicts minimal damage to elastic tissue such as skin and muscle, but can shear blood vessels and nerves that are less anatomically mobile, leading to bleeding. (6)

• Objects such as bone will absorb any energy from a high or low energy projectile, and can shatter, causing secondary cavitation pathways and further tissue damage and bleeding. 6

• Another proposed mechanism is extravasation of volume from the capillary bed leading to acidosis and hypoxia, which worsens extravasation of fluids, causing a cycle of fluid buildup in the muscle tissue; this can also be stimulated with the presence of bleeding from sheared vessels secondary to penetrating trauma. (7)

• The classic mnemonic for compartment syndrome is “pain, pallor, pulselessness, paralysis, and paresthesias,” but some of these are not seen in early compartment syndrome. Typical findings will be pain out of proportion to examination, unremitting pain despite opioids, firm tissue on palpation, paresthesias, sensory loss (e.g. indiscrimination on two-point touch), and pain on passive stretching of muscles. 2

• Pulselessness and paralysis are rare and late findings, which are found in vascular compromise or in later stages. Severe numbness is another finding that is found in later stages. 2

• Diagnosis is difficult to make due to no set standard, but can be made through physical exam findings and repeated compartment pressure measurements. Normal pressure is around 10 mmHg, while the most widely accepted pressures for intervention will be a delta pressure less than 30 mmHg. Delta pressure is diastolic pressure minus intramuscular compartment pressure. (2)

• Complications from not treating compartment syndrome include muscle necrosis, limb ischemia, amputation, renal failure, and death. One study showed that deaths were as high as 47% in thigh compartment syndrome cases. (1)

• Fasciotomy is the standard treatment for compartment syndrome, in which the skin and fascia enclosing the compartment are opened to allow for the pressure to be relieved. Fasciotomy should be done within 6 hours for best outcome (although some studies advocate for less than three); after this, the damage will become irreversible, leading to complications of compartment syndrome listed above. Monitoring patient for complications is an alternative to fasciotomy, but patient morbidity is high if delta pressure is less than 10 mmHg. (2,7)

Recommendations

• Suspect CS in the setting of severe pain associated with extremity trauma. The most common cause is tibial fractures, it is seen more often in men.

• Patient with arm or leg trauma should be checked frequently for uncontrollable pain, firm tissue at trauma, distal paresthesias, and pain on passive and active stretching of muscles in area. If suspected, surgery should be consulted and compartment pressures should be checked immediately.

• If high pressures are detected in a compartment, fasciotomy is recommended to release the pressure, and is shown to improve patient outcomes if done within 6 hours of onset.

• Patients with untreated CS are at risk for tissue necrosis, rhabdomyolysis and renal failure, amputation, and death.

References

1. Gourgiotis S, Villias C, Germanos S, Foukas A, Ridolfini MP. Acute limb compartment syndrome: a review. J Surg Educ. 2007 May-Jun;64(3):178-86. https://www.ncbi.nlm.nih.gov/pubmed/17574182

2. Donaldson J, Haddad B, Khan WS. The Pathophysiology, Diagnosis and Current Management of Acute Compartment Syndrome. Open Orthop J. 2014; 8: 185–193.

3. Mabvuure NT, Malahias M, Hindocha S, Khan W, Juma A. Acute Compartment Syndrome of the Limbs: Current Concepts and Management. Open Orthop J. 2012; 6: 535–543.

4. Raza H, Mahapatra A . Acute Compartment Syndrome in Orthopedics: Causes, Diagnosis, and Management. Adv Orthop. 2015; 2015: 543412.

5. Via AG, Oliva F, Spoliti M, Maffulli N. Acute compartment syndrome. Muscles Ligaments Tendons J. 2015 Jan-Mar; 5(1): 18–22.

6. Penn-Barwell JG, Brown KV, Fries CA. High velocity gunshot injuries to the extremities: management on and off the battlefield. Curr Rev Musculoskelet Med. 2015 Sep; 8(3): 312–317.

7. Frink M, Hildebrand F, Krettek C, Brand J, Hankemeier S. Compartment Syndrome of the Lower Leg and Foot. Clin Orthop Relat Res. 2010 Apr; 468(4): 940–950.