Compartment Syndrome

Laurie Kuestner MD

Iowa Heart and Vascular Institute

Acute

July 29, 2021

• Muscle groups of human limbs are divided into sections  (compartments) formed by strong unyielding fascial membranes
• Compartment syndrome occurs when increased pressure within a compartment compromises the circulation and function of the tissue within that space
• Acute compartment syndrome is a surgical emergency

Anatomy

Muscle Compartments of the Leg

• Normal capillary pressure is between 20 and 33 mm Hg
• Pressures above this shut off flow and cause ischemia
• Normal interstitial fluid pressure ~ 10 mm Hg

• long bone fracture
• acute extremity ischemia with reperfusion
• crush injury
• burn injury
• spontaneous hemorrhage/hematoma
• prolonged immobilization

Causes / Symptoms

Acute Compartment Syndrome

Causes / Symptoms

Acute Compartment Syndrome

• pain out of proportion to apparent injury                                           

• persistent deep ache or burning pain

• paresthesias                                                     

• tense compartment with a firm "wood-like" feeling
• pain with passive stretch of muscles
• diminished sensation
• muscle weakness (onset within ~2-4 hours of ACS)
• paralysis (late finding)

Acute Compartment Syndrome

Examination

Acute Compartment Syndrome

Patient's normal leg

Examination

Examination

Acute Compartment Syndrome

ACS tense swelling

with

Title Text

• history and clinical findings
• measurement of compartment pressures
• elevation in serum creatinine kinase
• myoglobinuria

Diagnosis

Acute Compartment Syndrome

Stryker

Pressure

Monitor

Diagnosis

Acute Compartment Syndrome

Management

Emergency Fasciotomy

Management

Emergency Fasciotomy

Anatomy

Compartments of the Forearm

Management

26 year old male presented with compartment syndrome after prolonged immobilization

Delayed decompression restored perfusion to ischemic muscles

Clinical and functional outcomes of acute lower extremity compartment syndrome at a major trauma hospital

Int J Crit Illn Inj Sci. 2016;6(3):133

Lollo L, Grabinsky A

• retrospective chart analysis
• 124 patients enrolled
• 104 patients assessed @ 12 months
• 81% male
• MVA caused injury in 51%
• tibia fractures in 41%
• acute kidney injury 2.4%
• mean peak serum CK 58,600 u/ml

OutComes

Clinical & Functional

Clinical and functional outcomes of acute lower extremity compartment syndrome at a major trauma hospital

Int J Crit Illn Inj Sci. 2016;6(3):133

Lollo L, Grabinsky A

OutComes

Clinical & Functional

• 12.9% required leg amputation
• foot numbness occurred in 20.5%
• foot drop in 18.2%
• @long-term f/u moderate lower extremity pain in 10.2%
• 69.2% returned to work

Clinical and functional outcomes of acute lower extremity compartment syndrome at a major trauma hospital

Int J Crit Illn Inj Sci. 2016;6(3):133

Lollo L, Grabinsky A

OutComes

Clinical & Functional

Conclusion:

Escalation in leg pain and changes in sensation are the cardinal signs for ACS rather than reliance on assessing for firm compartments and pressures

• 53 yo morbidly obese white male with HTN, hypothyroidism transferred to Mercy West Lakes from Ankeny urgent care with right calf pain and swelling

• wore 'too tight fitting socks & boots ' yesterday and performed manual snow removal for 6 hours then stood around fire for 2 hours drinking beers
• awoke 0900 with right calf pain and swelling
• denies injury to right calf

HPI

Case Presentation

Prolonged Immobilization

PE

Case Presentation

• c/o significant pain, tingling/numbness sensation in the right calf
• difficult to ambulate due to lack of sensation and motor function of right foot and ankle

• swollen right calf
• extreme tenderness to right calf
• palpable pulses
• distal RLE limited movement & sensation
• unable to dorsiflex/plantarflex right foot

Prolonged Immobilization

Labs

Case Presentation

• CK >41,000
• Covid negative
• potassium 5.7
• creatinine 1.6
• Hgb/Hct 19.4/56.3

Prolonged Immobilization

Case Presentation

Prolonged Immobilization

• no DVT right groin to popliteal fossa
• calf veins could not be visualized
• RLE could not be compressed

Imaging: Venous Duplex

Title Text

• 09:00 awoke with symptoms
• ??:?? Ankeny urgent care
• 14:26 Mercy West Lakes triage
• 15:23 CK >41,000
• 16:55 venous duplex
• 18:15 vascular called

Case Presentation

Timeline

Prolonged Immobilization

• 55 yo white male presented to MGMC with chest pain and diaphoresis, EKG with NSTEMI, in ER converted to Vtach, cardioverted , intubated, IV heparin, transferred to Mercy One
• on arrival to Mercy arrested, CPR, epi x2, ROSC after 5"
• emergently to cath lab in cardiogenic shock, 85% L main, 14Fr Impella placed L CFA, VA ECMO placed, 17 Fr R CFA, 8Fr antegrade sheath R SFA

Case Presentation

Reperfusion of Ischemic Extremity

Case Presentation

Reperfusion of Ischemic Extremity

• 6/20/21 vascular consult for diminished pulse right leg , no dopplerable pulses left leg

• 6/21/21 returns to cath lab for treatment of left main / LAD

removal of 14 Fr Impella L CFA

• return to SICU - new left thigh and calf swelling

• emergency calf and thigh fasciotomy performed in SICU procedure room

Ann Vasc Surg. 2020 Aug; 67:143-147

Legal

Considerations & Costs

Ann Vasc Surg. 2020 Aug; 67:143-147

Legal

Considerations & Costs

Ann Vasc Surg. 2020 Aug; 67:143-147

Malpractice Litigation for ACS

51.6% hospital included as defendant

Ann Vasc Surg. 2020 Aug; 67:143-147

Malpractice Litigation for ACS

32.25% of cases were found for the plaintiff or settled

award = $1,553,993.66

Summary

Acute Compartment Syndrome

Winston Churchill