Compartment Syndrome

Question 1

You are asked to review a 30yoM on the ward who had surgery for a fractured right tibia & fibula last night. What are the signs/symptoms of compartment syndrome? What is the management?

Answer 1

Compartment syndrome: is increased interstitial pressure within fascial compartments. Can lead to microvascular compromise and subsequent tissue ischaemia. Is a serious complication of fracture, Hb or other soft-tissue injuries, requiring rapid decompression with Fasciotomy. Would want to have a high index of suspicion in this post-op case.

DDX/complications to consider/ rule out:

• Rhabdomyolysis
• DVT / PE
• Acute lower-limb ischaemia
• Haematoma
• Muscle tear

Goals of management:

• Identify signs of compartment syndrome
• Prevent complications (surgical emergency)
• Initiate appropriate patient management

Question 2

Compartment syndrome - History

Answer 2

History:
- Pain out of proportion (with passive stretch), persistent deep ache or burning, pressure, parasthaesia, pulselessness, pallor, paralysis (less common)
o NB: pulses present doesn’t exclude compartment syndrome
- Utilise modified Wells Criteria to assess pre-test probability of DVT
- Other factors
o Recent injury
o Tight cast/compression applied
o Recent surgery
o Bleeding risk (medications, deficiency’s)

Question 3

Compartment syndrome - Examination

Answer 3

Exam:

• Vital signs - can also get septic compartment so assess for temperature
• Lower limb assessment for the 6 p’s
• signs: swelling, oedema, distal pallor, wood-like, hard and tense, muscular weakness/paralysis, paraesthesia’s

Question 4

Compartment syndrome - Investigations

Answer 4

Investigations:
This is a surgical emergency, largely clinical assessment and need to initiate timely management (<6 hours since onset of compartment syndrome)

• Bedside: compartment pressure measurement
• Bloods: D-Dimer, pre-op bloods, serial Creatinine-kinase, UEC, LDH
• Imaging: Duplex ultrasound (for DVT)

Question 5

Compartment syndrome - Management

Answer 5

Management:
- Mainstay of management is peripheral fasciotomy to relive interstitial osteofascial pressure and prevent muscle necrosis
o Time-critical procedure, needs to occur within 6 hrs of onset of compartment syndrome to limit rates of amputation and other morbidity
- left open and packed with saline-soaked gauze
- Would be urgently contacting ortho reg to inform of patient and ask for immediate review with intention to take to theatres for fasciotomy
- remove any casts present/restrictive clothing
- position at the level of the heart, not above or below

Pre-op:

• NBM
• pre-op bloods
• analgesia
• supplemental oxygen

Other supportive:

• Fluids
• Analgesia
• Regular review of patient
• ?sodium bicarb in instance of urinary alkalisation

Ongoing

• Wound care, appropriate dressings
• Infection control