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Question

31yo male was involved in a pedestrian vs car accident and presents as a trauma transfer to your facility 3 hours after the injury. On initial presentation, the patient is in extreme distress and pain. Physical examination shows decreased dorsalis pedis and posterior tibial pulses, significant swelling, decreased sensation in the lower leg, and increased pain with passive dorsiflexion. Radiograph reveals a minimally displaced proximal tibia and fibula fracture.

1. What is your main concern at this point?
2. How do you test for it?
3. What do you do about it?

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Answer

• The main concern given the mechanism of injury and physical examination findings is compartment syndrome. This is a limb-threatening condition and needs to be acted upon immediately.
  • The hallmark findings of compartment syndrome are:
    • Pain
      • Out of proportion
      • With passive stretching of muscles
    • Paralysis
    • Pulselessness
    • Paresthesias
    • Pallor
    • Poikilothermia
• Testing for compartment syndrome involves directly measuring the pressure within the compartment. Commercial devices (such as Stryker) are common, but simple 18g needles attached to arterial line pressure monitors can also be used.
  • Normal pressure of tissue compartments should be < 10 mmHg.
  • Delta pressure = DBP – measured compartment pressure
    • Delta pressure < 30 indicates need for fasciotomy
  • Measuring of pressures SHOULD NOT delay transfer or consultation

• Management of compartment syndrome is to perform a 4-compartment fasciotomy
  • Double-incision technique is most common to release all four compartments
    • Lateral incision – between fibular shaft and crest of tibia
    • Medial incision – 2cm medial to tibial margin

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References

1. Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. The Journal of the American Academy of Orthopaedic Surgeons. 2005; 13(7):436-44. [pubmed]
2. Shadgan B, Menon M, O’Brien PJ, Reid WD. Diagnostic techniques in acute compartment syndrome of the leg. Journal of orthopaedic trauma. 2008; 22(8):581-7. [pubmed]Olson SA, Glasgow RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. The Journal of the American Academy of Orthopaedic Surgeons. 2005; 13(7):436-44. [pubmed]
3. Hammerberg EM, Whitesides TE, Seiler JG. The reliability of measurement of tissue pressure in compartment syndrome. Journal of orthopaedic trauma. 2012; 26(1):24-31; discussion 32. [pubmed]
4. Nelson JA. Compartment pressure measurements have poor specificity for compartment syndrome in the traumatized limb. The Journal of emergency medicine. 2013; 44(5):1039-44. [pubmed]
5. Fasciotomy. Wheeless’ Textbook of Orthopaedics. http://www.wheelessonline.com/ortho/12806