Orthopedic Trauma and Compartment Syndrome

Question 1

What percentage of patients experience chronic postsurgical pain syndrome?

Answer 1

10 - 50% after common procedures including orthopedic procedures with 2 - 10% of these patients developing severe chronic pain.

Question 2

What percentage of patients with chronic postsurgical pain syndrome develop severe chronic pain?

Answer 2

2 - 10%

Question 3

What is the current understanding of safety of short-term perioperative use of NSAIDs?

Answer 3

Animal studies indicate negative effects of NSAIDs on fracture healing only with long-term use. Human data are contradictory on this point. Short-term use is presumably not harmful for fracture healing.

Question 4

What are the eight primary advantages of regional anesthesia in orthopedic trauma?

Answer 4

1) Improved postoperative pain management
2) Decreased incidence of DVT
3) Ability to evaluate mental status changes
4) Facilitation of early mobilization
5) Decreased blood loss
6) Improved vascular flow
7) Shorter hospital stay
8) Reduced morbidity

Question 5

What is the incidence of clinically relevant infections with perineural catheters?

Answer 5

Less than 1%.

Question 6

What is compartment syndrome?

Answer 6

A condition in which swelling and increased pressure within a closed muscle compartment compromises circulation and results in ischemia and muscle necrosis.

Question 7

Describe the pain of compartment syndrome.

Answer 7

The ischemic pain of compartment syndrome is in addition to the pain associated with the initial injury and is of a different nature, possibly due to the significant acidosis as well as other factors in the area of ischemia..

Question 8

What is the annual incidence of compartment syndrome in the US?

Answer 8

Annually more than 200,000 people.

Question 9

What are common causes of acute compartment syndrome?

Answer 9

Prolonged limb compression, such as by a cast.
Fractures
Crush injuries
Soft tissue trauma
Intramedullary nailing
Reperfusion injuries

Question 10

What are the risk factors for the development of compartment syndrome?

Answer 10

Male gender
History of drug use
Type of injury
Use of cast
Intramedullary nailing
Prolonged elevated positioning

Question 11

What types of injuries account for the majority of acute compartment syndrome?

Answer 11

Tibial shaft fractures (40%)
Soft tissue tibial traumas (23%)
Forearm fractures (18%)

Question 12

What is incidence of acute compartment syndrome for tibial shaft fractures?

Answer 12

4.3%

Question 13

What is incidence of acute compartment syndrome for diaphyseal forearm fractures?

Answer 13

3.1%

Question 14

What is incidence of acute compartment syndrome for distal radius fractures?

Answer 14

0.25%

Question 15

Within how many hours can untreated compartment syndrome result in permanent nerve damage?

Answer 15

Eight hours

Question 16

Can regional anesthesia mask developing compartment syndrome?

Answer 16

This is controversial. Mar et al did a comprehensive review of all cases of acute compartment syndrome associated with regional anesthesia and found that in most cases the symptoms suggestive of compartment syndrome had been present for many hours but had been ignored and assumed to be related to the regional anesthesia technique.

Question 17

What is the common theme in published case reports of compartment syndrome in the setting or regional analgesia?

Answer 17

A patient with stable therapeutic analgesia who suddenly experiences a significant increase in pain.

Question 18

What have recent military experiences shown regarding the use of regional techniques in trauma patients?

Answer 18

They’ve shown success provided:

1) a high index of suspicion
2) ongoing patient assessment
3) diligent nursing care
4) compartment pressure measurements are utilized

Question 19

Is compartment syndrome always identified in the absence of a regional block?

Answer 19

No. Missed compartment syndrome occurs in patient on PCA. Four cases of tibia nailing had delayed diagnosis with PCA. Having a non-sedated patient who can communicate and has an analgesic but not anesthetic block may actually help identify developing compartment syndrome.

Question 20

What prospective, randomized studies have evaluated the safety of regional anesthesia in ortho trauma patients who develop compartment syndrome?

Answer 20

Incidence is so low that it is nearly impossible to evaluate this way. However the number of case reports suggesting safety is increasing.

Question 21

How might regional analgesia be helpful in identifying patients with developing compartment syndrome?

Answer 21

Having a non-sedated patient who can communicate who has an analgesic but NOT anesthestic block can help identify developing compartment syndrome. Patients on PCAs have had missed compartment syndrome.

Question 22

What is the key to early diagnosis of compartment syndrome?

Answer 22

Diligent care and close observation. Protocols for perioperative monitoring of the patients and data reviewed q2hrs. Consider inter-compartment pressure monitoring.