Evidence Of Compartment Syndrome Research Articles

Delayed Presentation of Popliteal Artery Injury after Salter-Harris III Proximal Tibia Fracture

Introduction. Proximal tibia physeal fractures in children are not very common but can be dangerous because they can harm popliteal fossa structures, especially the popliteal artery. Popliteal artery injuries (PAI) are most commonly the result of trauma to the lower extremity, including blunt force, hyperextension injuries, complex fractures, and knee dislocations that can compromise popliteal neurovascular structures. Case Presentation. A 14-year-old boy presents to the emergency department after being transferred from an outside hospital 24 hours after a left lower extremity hyperextension injury. Radiographs demonstrated a Salter-Harris III proximal tibia fracture with posterior displacement. ABIs were deferred due to palpable distal pulses and no evidence of compartment syndrome. Closed reduction and percutaneous pinning were planned to correct the fracture. Intraoperatively, it was discovered that knee extension decreased lower extremity perfusion while knee flexion returned perfusion. An angiography revealed a popliteal artery occlusion with no distal flow. Based on this, an above-knee to below-knee popliteal bypass using the contralateral great saphenous vein was performed followed by closed reduction and percutaneous pinning of the proximal tibia. Conclusion. Proximal tibia physeal injuries, especially the Salter-Harris III and IV injuries, warrant a high index of suspicion of popliteal artery injuries. Palpable pulses and delayed presentation in the distal lower extremity do not rule out a PAI because collateral flow to the anterior and posterior tibial arteries may mask signs of an avascular limb, highlighting the need for a thorough history and physical exam. The authors present this case to reaffirm the importance of an ankle-brachial index when evaluating hyperextension injuries with proximal tibial epiphyseal fractures.

Concomitant Dislocation of Proximal and Distal Interphalangeal Joints of Small Finger: A Case Report

A 24 old man sustained an injury to his right hand when playing soccer as goalkeeper, most probably from a direct strike for the ball or offender foot. On physical examination the injury was limited to the right middle finger, which was swollen, tender an essentially no active motion could be observed in none of the interphalangeal joints. The injury was a close one and no wound or nerve injury was present. No evidence of compartment syndrome was observed. The neurovascular examination was normal. Radiograms were taken immediately which revealed double dislocation of both interphalangeal joints in the right fifth finger. Closed reduction under general anaesthesia was performed and early active and passive range of motion was began as soon as possible. In follow up full range of motion of the joints was retained. The case emphasizes the necessity of whole finger radiologic examination in distal interphalangeal dislocations in the hand.

Rare cause of bleeding in a young footballer

A 12-year-old male soccer player had a 1-week history of injury to the left lower leg. He was playing football and was involved in a collision with another player. He was wearing shin guards. He was referred to the fracture clinic with a large haematoma on the anterior surface of his left tibia, which measured 12×10 cm; skin was intact and distal pulses were intact. Plain X-rays were normal. Ultrasound indentified a well-defined non-homogenous haematoma. There was no clinical evidence of compartment syndrome. With these results, it seemed that this was an excessive response to an injury; as such, further investigation was undertaken. A full blood count and blood film identified thrombocytopenia (platelet count 22×10/L). Additional investigations undertaken included coagulation screening; renal and liver profiles; vitamin B12, folate and iron studies; coeliac screening; and thyroid function tests. These were normal. He had no petechiae or other constitutional symptoms. There was no evidence of recent viral infection (EBVor parvovirus) to suggest post-viral bone marrow suppression. He had a history of a similar previous injury 2 months prior to this presentation. His mother felt that he bruised easily. He experienced frequent epistaxes (one to two per month). These were not particularly heavy and were relieved by pressure alone. He had no past gum bleeds and no prior surgery. His past medical history included hay fever and G6P deficiency. No relevant family history was described. He had not required medical attention prior to this presentation and was not on anymedication or herbal remedies. He remained well whilst an inpatient under observation. Subsequent repeat full blood counts demonstrated a fluctuating thrombocytopenia. A diagnosis of chronic immune thrombocytopenia was made. Conservative management was sufficient in this case. A 4-day course of prednisone was used to increase and stabilise his platelet count before being discharged. Swelling resolved over 2 weeks with physiotherapy. Recovery was uneventful. Both the patient and his family were advised that any future surgery, dental procedure or serious trauma would require consultation with a haematologist. Patient remained well at follow-up 1 year later and has returned to sport.

Contracture of Extensor Hallucis Longus Tendon Occurring after Intramedullary Nailing for a Tibial Fracture

Toe deformities occurring after tibial shaft fracture can result from compartment syndrome or adhesion of muscle to tendon. Claw toes or checkrein deformity caused by injury of posterior compartment muscles has been reported relatively often. But, a deformity due to injury of the anterior compartment muscles is very rare. We observed the two cases of an extension deformity at the metatarsophalangeal joint of the hallux following intramedullary nailing of a tibial shaft fracture. There was no evidence of compartment syndrome. Extension deformity of the hallux was decreased with dorsiflexion of the ankle and increased with plantar flexion. Contracture of the extensor hallucis longus tendon was diagnosed, and Z-lengthening of that tendon was performed. Satisfactory results were obtained without a recurrence of deformity. We report these rare cases of toe deformities occurring after a tibial shaft fracture, with a brief review of the literature.

Risk Factors for Compartment Syndrome in Traumatic Brachial Artery Injuries: An Institutional Experience in 139 Patients

The brachial artery is the most common vascular injury encountered in upper extremity trauma. If not treated promptly, it can result in compartment syndrome (CS) and long-term disability. Here, we report an institutional experience of traumatic brachial artery injuries and establish risk factors for the development of upper extremity CS in this setting. A retrospective review of 139 patients with traumatic brachial artery injury from 1985 to 2001 at a single institution. Patients were divided into two cohorts, those with evidence of CS and those without CS (NCS), for comparison. One hundred thirty-nine patients presented with traumatic brachial artery injuries (mean age, 28.4 years). Twenty-nine patients (20.9%) were diagnosed with upper extremity CS, and 28 of these patients underwent fasciotomy on recognition of their CS. Seven patients (6.4%) in the NCS cohort underwent fasciotomy as a result of absent distal pulses on initial examination. Mean follow-up was 51.6 days. Two patients required revision of their arterial repair, and one patient underwent amputation. The risk of CS was increased in the presence of combined arterial injuries (p = 0.03), combined nerve injuries (p = 0.04), motor deficits (p < 0.0001), fractures, and increased intraoperative blood loss (p = 0.001). Multivariate logistic regression performed on these variables revealed that elevated intraoperative blood loss, combined arterial injury, and open fracture were independent risk factors for the development of CS (OR 1.12, 5.79, and 2.68, respectively). Prompt evaluation and management of traumatic brachial artery injuries is important to prevent CS, which can lead to functional deficits. In the setting of combined arterial injury, open fracture, and significant intraoperative blood loss, prophylactic fasciotomy should be considered.

Complications of heroin abuse

A 21-year-old man presented to the emergency department in St James's Hospital by ambulance. He was found collapsed at home by his uncle. He was complaining of severe pain and swelling to his left lower limb, with reduced sensation to his left foot. He was hepatitis C positive from intravenous drug use, and had most recently used both heroin and cocaine 5 days previously on his release from prison. Musculoskeletal exam showed extensive swelling of his left lower limb, with tense calf compartments. Initial laboratory results showed a raised creatine kinase of more than 155,000 IU/l. Urine toxicology was positive for methadone, heroin and benzodiazepines, whereas urinary dipstick was positive for blood, which was confirmed to be myoglobin by subsequent laboratory analysis. Atraumatic rhabdomyolysis is a syndrome characterized by injury to skeletal muscle with subsequent release of intracellular contents, that is myoglobin and creatine kinase. Drugs have direct toxic effects, but may also cause coma-induced rhabdomyolysis, owing to unrelieved pressure on gravity-dependent body parts. Diagnosis is made with history (i.e. recent heroin or cocaine use), elevated serum CK, plus the possible presence of myoglobinuria. Aggressive i.v. rehydration remains the mainstay of treatment. If there is any evidence of compartment syndrome, urgent fasciotomy is required. Electrolyte imbalances should be corrected, unless very mildly abnormal. We have learned from our experience with this case that a high index of suspicion and thereby early recognition is crucial to prevent complications in intravenous drug users presenting with unusual symptoms and signs.

Anabolic steroid-induced rhabdomyolysis

A 25-year-old male with no prior medical history presented with bilateral thigh and calf pain. He was a professional dancer, who had not been dancing for a year following an appendicectomy and was now getting back into training. Two days before presentation he had increased the intensity and duration of his workout to maximum 45 minutes on a cross-trainer. The next day he noticed pain in his legs which intensified with muscle cramps and 24 hours later he presented to accident and emergency. He was sent home on diclofenac tablets,with a diagnosis of musculo-skeletal pain. He re-presented 2 days later with difficulty walking. He admitted taking two preparations of anabolic steroids recently. On examination, his legs were diffusely tender in the region of the quadriceps and the inferior portion of gastrocnemius, but they were soft, with no warmth or swelling. He had reduced power at the hip flexors and occasional muscle spasms but no focal neurology. Creatinine kinase (CK) was 17 171 iu/litre (normal range for men &lt;250 iu/litre), with normal renal function and no myoglobinuria. Orthopaedic review found no evidence of compartment syndrome and he was treated with intravenous fluids, diazepam and paracetamol. His CK initially decreased but then increased to peak at 22 226 iu/litre on day three, with evidence of myoglobinuria. Management continued with hydration and urinary alkalinization. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels were normal and human immunodeficiency virus (HIV) test was negative. Magnetic resonance imaging (MRI) of his legs showed areas of high signal in several muscle groups with no focal areas of necrosis (Figure 1). Following a muscle biopsy, he was started on oral prednisolone and then a course of methylprednisolone, during which CK levels decreased rapidly. His muscle biopsy and electromyography (EMG), were reported as normal and an autoantibody screen was negative, hence the steroids were rapidly tapered off. At discharge, his CK had continued to decrease (1100 iu/litre) and his mobility slowly improved. A diagnosis of anabolic steroid-induced rhabdomyolysis was made. He had been taking two steroid preparations; WinstrolTM (stanazolol) and PrimabolanTM (metenolon). He had used WinstrolTM several times in the past and on this occasion he had used four ampoules each a week apart. However, he used only one ampoule of PrimabolanTM a few days before presentation. He usually injected into his thighs.

Acute Median Nerve Compression Neuropathy From a Foreign Body in the Forearm

Acute compression of the median nerve in the forearm usually occurs from compartment syndrome. A case of acute compression neuropathy of the median nerve from a foreign body, where there was no evidence of compartment syndrome, is reported. The diagnosis was made from the patient's symptoms and radiographs. Early recognition and decompression of the forearm with removal of the foreign body led to full recovery.

Utility of near-infrared spectroscopy in the diagnosis of lower extremity compartment syndrome.

To determine the utility of near-infrared spectroscopy in the diagnosis of lower extremity compartment syndrome (CS). Nine patients with CS confirmed by physical examination and elevated compartment pressures (64 +/- 17 mm Hg) were evaluated before and after fasciotomy. Control readings were also performed on 33 surgical patients who had no evidence of CS. The deltoid muscle was used as a reference value. The deltoid muscle oxygen saturation (StO2) readings revealed a mean = 84 +/- 17% prefasciotomy and mean = 83 +/- 12% postfasciotomy in the CS group. The control group had a mean StO2 of 83 +/- 11%. In the CS group, the leg compartment with the highest pressure had a StO2 mean = 56 +/- 27% before fasciotomy. This value was statistically significantly lower (p < 0.05) than either the postfasciotomy mean StO2 in that compartment (82 +/- 16%) or the values found in matched control patients with no evidence of CS (87 +/- 7%). Near-infrared spectroscopy-derived StO2 values in the lower extremities of trauma patients with CS were diminished relative to the control patients and usually normalized after fasciotomy. Near-infrared spectroscopy evaluation may offer a rapid, noninvasive method of assessing extremities at risk for CS.

Histology and Intramuscular Pressure in Spastic Muscle

A prospective study was performed to delineate the pathologic processes occurring in the degradation of muscle function with the onset of spasticity. Sixteen adult patients with spasticity secondary to traumatic brain injury (TBI) were evaluated clinically and histologically. Short-term patients showed even distribution of mild, moderate, and severe spasticity, while moderate spasticity predominated in the chronic group. Motor control was predominately selective with pattern overlay in both groups. Muscles with spasticity of less than 6 months duration showed nonspecific histologic changes. Muscles with spasticity of duration longer than 1 year demonstrated neurogenic atrophy, some also showed signs of denervation followed by reinnervation. No evidence of compartment syndrome was found in the spastic muscles studied. Transient high elevation of intramuscular pressure was noted in some patients during muscle stretch or activity. Muscles that become spastic following TBI demonstrate neurogenic degeneration, generally apparent greater than 1 year after the injury. Prior to this, spastic muscles demonstrate nonspecific atrophic changes.

Predictors of amputation for popliteal artery injuries

Background: Popliteal artery injuries continue to result in limb loss. This study identifies risk factors that predict amputation. Methods: Over a 5-year period, a retrospective chart review was conducted of 80 consecutive patients with 81 popliteal artery injuries. Results: The overall amputation rate was 16.5%. Blunt trauma carried a higher rate of amputation (47%) than penetrating injuries (6.2%); P <0.0001). Associated fractures had a higher amputation rate, regardless of mechanism (odds ratio +2.7, 95% confidence limits 1.2 to 6.2). Fasciotomy at the time of operation was associated with reduced amputation rate. Conclusions: Blunt injuries and associated fractures carry an increased risk for amputation. Compartmental pressures should be appropriately monitored postoperatively. Fasciotomy at the time of vascular repair may be considered even without evidence of compartment syndrome.

The use of the unreamed nail in tibial fractures with concomitant preoperative or intraoperative elevated compartment pressure or compartment syndrome.

Twelve patients with tibial shaft fractures and evidence of compartment syndrome or with documented elevated compartment pressures were treated with an unreamed locked intramedullary nail and a single-incision lateral four-compartment fasciotomy. There were six closed fractures and three grade I and three grade II open fractures. Ten fractures have achieved a solid union without shortening or significant angulation at an average follow-up of 8.1 months (range 4-26). Two patients were lost to follow-up. There were two delayed unions and one nonunion, all of which healed after additional treatment. Average time to tibial union was 5.8 months (range 2-24), with six fractures healing in < or = 4 months. One patient whose treatment was delayed > 12 h after his injury has a persistent neurologic deficit with a claw toe deformity. There were no superficial or deep infections. All patients obtained an excellent range of motion of the knee and ankle. Unreamed nailing of diaphyseal tibial fractures with an associated compartment syndrome provides optimal internal fixation while allowing excellent access for soft tissue care. We believe that the unreamed tibial nail, when combined with a single-incision, lateral, four-compartment fasciotomy, offers substantial advantage in the treatment of this injury, permitting optimal treatment of a difficult fracture and soft tissue injury.