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Severe Polytrauma with Acute Compartment Syndrome

Case Introduction

A 23 year old male presents via ambulance status post a motor vehicle crash. On arrival, he is tachycardic at 150 beats per minute, blood pressure 100/79, GCS 15. Primary survey notes severe trauma to bilateral lower extremities which includes open fracture-dislocation of both ankles. He is intubated immediately upon presentation. E-FAST is negative. Compartment pressures in the right lower extremity are measured and elevated at 44 and 45 mm Hg in the anterior and posterior superficial compartments respectively. The patient was taken to the operating room (OR) for emergent fasciotomy. Additional associated injuries include a right radius fracture, right tibial plateau fracture and L3 chance fracture.

Discussion

Acute compartment syndrome (ACS) occurs when pressure inside a given compartment exceeds arterial perfusion pressure into the compartment, most commonly due to trauma. The incidence is estimated to be between 1 and 7.3 per 100,000 people.1McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82:200–203 Trauma is the most common cause with fractures representing about 75% of cases.2Mauser N, Gissel H, Henderson C, Hao J, Hak D, Mauffrey C. Acute Lower-leg Compartment Syndrome. Orthopedics. 2013;36:619–624. Most commonly this occurs due to tibial shaft fractures and ACS is seen in between 2 and 9% of these fractures. It is more commonly seen in men than women.
Ankle Xray AP Right ankle radiograph demonstrating complex fracture dislocation
Ankle Xray AP Right ankle radiograph demonstrating complex fracture dislocation s/p reduction and splinting.

The most commonly cited cause is the arteriovenous pressure gradient theory (APG).3Murdock M, Murdoch MM. Compartment syndrome: a review of the literature. Clin Podiatr Med Surg. 2012;29:301–310. viii. Tissue ischemia of the affected compartment(s) occurs when blood flow does not meet the metabolic demands. Subsequently, a cascade of events occurs include increased inflammation, arterial spasm, disrupted capillary flow, increased osmotic pressure, proteinaceous exudate, muscle fiber swelling, and edema. Without surgical intervention, the cycle self propagates and contributes to further increased intracompartmental pressure (ICP). As ICP increases tissue and venous pressure compromises capillary function with muscle and nerve ischemia occurring. Without surgical decompression, irreversible pressure-induced ischemia results in tissue and cellular death.

Common etiologies include orthopedic (tibial shaft fractures are #1, blunt or penetrating trauma, total knee arthroplasty), vascular (reperfusion therapy, arterial puncture or injury, hemorrhage, deep vein thrombosis), soft tissue (crush injury, contusion, burn or snake bite), and iatrogenic (drugs especially anticoagulants, bleeding disorders including sickle cell disease, casts or splints, constrictive dressings, extravasatio
Cross sectional anatomy of the lower leg
Cross sectional anatomy of the lower leg1Pechar, Joanne, and M. Melanie Lyons. "Acute compartment syndrome of the lower leg: a review." The Journal for Nurse Practitioners 12.4 (2016): 265-270.
It is worth reviewing the anatomy of the lower leg, where most cases of ACS occur. The Anterior Compartment of the Leg contains Tibialis Anterior, Extensor Hallucis Longus, Extensor Digitorum Longus, Peroneus Tertius, the anterior tibial artery and deep peroneal nerve. The Lateral Compartment of the Leg contains Fibularis Longus, Fibularis Brevis branches of the posterior tibial and fibular artery and the superficial peroneal nerve. The Superficial Posterior Compartment of the Leg contains Gastrocnemius, Soleus, Plantaris, Tibial Artery and Tibial Nerve. The Deep Posterior Compartment of the Leg contains Tibialis Posterior, Flexor Hallucis Longus, Flexor Digitorum Longus, Popliteus, branches of the tibial artery and tibial nerve.
Anatomy of the lower leg with symptoms associated with ACS in the right column
Anatomy of the lower leg with symptoms associated with ACS in the right column2Pechar, Joanne, and M. Melanie Lyons. "Acute compartment syndrome of the lower leg: a review." The Journal for Nurse Practitioners 12.4 (2016): 265-270.
Clinical appearance of a patient with a right fractured tibia and suspected compartment syndrome.
Clinical appearance of a patient with a right fractured tibia and suspected compartment syndrome.3Image courtesy of https://www.orthopaedia.com/, "Acute Compartment Syndrome"
The diagnosis is primarily a clinical one. The defining feature is pain out of proportion to the exam. The patient should have tender, swollen compartments but that may not always be true and can be delayed up to 48 hours after the inciting event. In the setting of polytrauma, ACS may be missed on the initial survey due to distracting injuries. Thus, early recognition is critical and requires a high index of suspicion.
The “5 or 6 Ps” of compartment syndrome are often taught and tested and worth reviewing here. Although not universally present in each patient, they serve as crucial indicators when present. Pain, often the initial symptom, manifests as severe and disproportionate to physical findings, exacerbated by passive movement due to increased pressure from muscle extension. Paresthesia, occurring in the sensory distribution of the affected nerve, accompanies the pain. Pallor may ensue, followed by paralysis, a late finding typically emerging around 30 minutes after onset, indicated by limb weakness subsequent to the loss of light touch. Pulselessness, another late indicator, bears a poor prognosis, with arterial insufficiency not initially present, and brisk capillary refill early on. Additionally, poikilothermia, marked by temperature changes or limb coolness, highlights further complications
stryker compartment pressure measurement
Picture of stryker compartment measurement device4Pechar, Joanne, and M. Melanie Lyons. "Acute compartment syndrome of the lower leg: a review." The Journal for Nurse Practitioners 12.4 (2016): 265-270.
Evaluation begins with radiographs to identify the fracture. When measuring compartment pressures, all 4 compartments of each leg should be tested for reference. Normal is generally considered < 20 mm Hg. There is no clear diagnostic criteria for pathologic pressures, although > 30 mm Hg is generally considered elevated. Thus, 20 to 30 mm Hg could represent normal or ACS depending on the clinical picture and context must always be considered. Higher pressures tend to accelerate the damage to compartment pressure structures. Delta pressure may be more accurate which is characterized by subtracting compartment pressure from diastolic pressure. If the delta pressure drops dramatically, < 30 mm Hg for example, this suggests ACS is likely present. All that being said, ACS is primarily a clinical diagnosis and more often than not, the decision to operate is made clinically without compartment pressures. Certain labs are useful when ACS is present including evaluating for rhabdomyolysis (CK, urinalysis) and metabolic panel (kidney function, potassium).
Management almost universally requires a fasciotomy. Time to fasciotomy matters as more than 8 hours of ischemia is associated with permanent injury. The decision not to operate should be made by the surgical team. Any casts, splints, and/or compression dressings should be removed which can reduce ICP by up to 65%.4Garfin SR, Mubarak SJ, Evans KL, Hargens AR, Akeson WH. Quantification of intracompartmental pressure and volume under plaster casts. J Bone Joint Surg Am. 1981;63:449–453. In these patients, serial examination should be performed. Acute complications of ACS include rhabdomyolysis, hyperkalemia, sepsis, multi-organ failure, loss of limb and even death. More chronically, foot drop, contractures, paralysis and delayed amputation can also occur.

Case Conclusion

After the fasciotomy, the patient was admitted to the surgical ICU. He underwent multiple surgeries in the subsequent days and weeks. For his right leg, he required a fasciotomy, external fixation, multiple debridement and irrigation procedures and eventually a right below the knee (BKA) amputation. The decision to undergo a right BKA was based on the following considerations: need for subsequent reconstructive surgeries, risk for infection and likelihood of long-term chronic pain. On his left leg, he underwent external fixation, multiple debridement and irrigation procedures and finally a tibiotalocalcaneal arthrodesis. His right radial fracture required an open reduction and internal fixation. For the lumbar fracture, the patient underwent a L1-L5 spinal fusion with neurosurgery. Five months following presentation to the emergency department, the patient is now ambulatory with a prosthetic limb and crutches.

3 Key Points

  1. Acute compartment syndrome (ACS) occurs when pressure inside a given compartment exceeds arterial perfusion pressure into the compartment, most commonly due to trauma
  2. The diagnosis is primarily clinical, with pain out of proportion to examine being the best indicator of elevated compartments
  3. ACS is a surgical emergency treated with fasciotomy and shorter time to intervention correlates with better outcomes.

– Read More @ Wiki Sports Medicinehttps://wikism.org/Acute_Compartment_Syndrome

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