Week 5 - Case 3: Compartment Syndrome

Question 1

What is the diff. diagnosis for “Shin Splints”?

Answer 1

Stress fractrues, Medial tibial syndrome, Compartment syndromes (anterior, deep posterior)

Question 2

What is Medial Tibial Syndrome?

Answer 2

• Most common site is distal 1/3 of the medial boarder of the tibia
• Generally felt to be the insertion of the soleus
• Pathology is an area of tibial periostitis
• Not well understood

Question 3

How to diagnose Medial Tibial Syndrome?

Answer 3

Physical exam, pain on palpation of the distal tibia over the length of 5 cm.

Question 4

What is the treatment for Medial Tibial Syndrome?

Answer 4

Rest

Question 5

What is compartment syndrome?

Answer 5

A condition in which increased pressure within a limited space compromises the circulation and function of the tissue within that space.

Question 6

What is unique about Compartment Syndrome?

Answer 6

TRUE ORTHOPEDIC EMERGENCY

• Reduces tissue perfusion - ischemia
• results in death - necrosis
• It can affect many areas of body: hand, foot, arm, thigh, buttocks

Question 7

What can cause compartment syndrome (etiology)?

Answer 7

• Fractures (open & closed) - 9% of all fractures
• Blunt trauma
• Cast/dressing
• Burns/electrical
• Exertional states
• Gunshot
• IV/A-lines
• Hemophiliac/coag
• Intraosseous IV (infant)
• Snake bite
• Arterial injury

Question 8

What is a stress fracture?

Answer 8

• Overuse injury
• Occurs when muscles become fatigued and unable to absorb shock. Muscle overload shock is transferred to weight bearing bones
• Most occur in bones of lower leg and foot

Question 9

What are the symptoms of a stress fracture?

Answer 9

Pain with activity, subsides with rest

Question 10

How to diagnose and treat a stress fracture?

Answer 10

X-ray, MRI, bone scan

Tx: Rest

Question 11

How do you tell if there is a fracture using a bone scan?

Answer 11

Areas with a lot of uptake = stress fracture

Question 12

What is the most common cause of CS? (incidence accompanying?)

Answer 12

Fracture

• 9.1% CS accompanying
• Incidence directly proportional to deg. of injury to soft tissue and bone
• Occurs most often: Comminuted (fracture involving multiple splinters), grade III open injury to a pedestrian

Question 13

What is the 2nd most common cause of CS?

Answer 13

Blunt Trauma (what our patient had during football practice!)

• About 23% of CS
• 25% of Blunt Trauma is due to a direct blow from an object or person

Question 14

What is normal tissue pressure and what is normal tissue pressure with exertion?

Answer 14

0-4 mmHg

8-10 with exertion

Question 15

What are the different numbers at which pressure should be relieved in CS?

Answer 15

Absolute pressure theory
-30 mmHg
-45 mmHg
Pressure gradient theory
- <20 mmHg of diastolic pressure

Question 16

How long can muscle tissue survive during CS?

Answer 16

3-4 hrs - reversible changes
6 hrs - variable damage
8 hrs - irreversible changes

Question 17

How long can nerve survive during CS?

Answer 17

2 hours - loose nerve conduction
4 hours - neuropraxia
8 hours - irreversible changes

Question 18

How to diagnose CS?

Answer 18

-Pain out of proportion
-Palpably tense compartment
-Pain with passive stretch (plantarflexion)
Also - later on/more severe:
-Parethesia/hypoesthesia
-Paralysis
-Pulselessness/pallor

Question 19

What is most important when evaluating a patient with possible CS?

Answer 19

• PAIN - most imp. Especially pain out of proportion to the injury (child becoming more and more restless/needing more analgesia)
• Most reliable signs are pain on passive stretching and pain on palpation of the involved compartment
• Other features like pallor, pulselessness, paralysis, paraesthesia (tingling, tickling) etc. appear very late and we should not wait for these things

Question 20

Is it important to get a compression pressure measurement if your patient shows all physical exam signs?

Answer 20

NO - if a pressure measurer is not easily accessible, just go ahead and do surgical decompression ASAP!

Question 21

What compartment is most common for CS?

Answer 21

ANTERIOR!

Question 22

If patient has symptoms and PE findings of CS OR compartment is above 30 mmHg. . .

Answer 22

. . .you MUST do a fasciotomy - need to decompress all FOUR compartments using TWO incisions - one on each side

• One into lateral compartment
• One into Deep posterior compartment

Question 23

How do you manage the wound after a fasciotomy?

Answer 23

• A bulky compression dressing and splint are applied

- Incision for the fasciotomy usually can be closed after three to five days

Question 24

What is “Shin splits” a generic term for?

Answer 24

Lower leg pain with exertion

Question 25

What is the differential for lower leg pain?

Answer 25

Stress fracture, medial tibial stress syndrome, compartment syndromes

Question 26

What is an example of a surgical emergency?

Answer 26

Acute anterior compartment syndrome

Question 27

-19 yr old male
-4 day history of left leg pain
-can’t sleep due to pain
-can dorsiflex or evert the foot
-Swelling over anterior and lateral area, very tender to palpation
What is the likely diagnosis?

Answer 27

Compartment Syndrome!

Question 28

What is diff. diagnosis for CS?

Answer 28

• Torn muscle
• Fracture
• Myositis
• Sickle Cell Anemia
• DVT (deep vein thrombosis)

Question 29

What does increased Creatine Kinase indicate?

Answer 29

MUSCLE DAMAGE