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We report two cases of compartment syndrome following isolated ankle fractures. Both required decompression of all the compartments following early clinical diagnosis and measurements of the intra-compartmental pressures.
The compartment syndrome, a well known complication in traumatized patients, is not taken enough notice of in the literature of vascular surgery despite it's obviously important pathophysiological context. Considering arterial occlusive disease the ischemia as well as the reperfusion can increase the compartmental volume respectively the tissue pressure. The subfascial pressure measurement should not lead to a false certainty, since no critical pressure values exist that can serve as a general criterion for diagnosis and treatment. The "thought about it" may be the first step to a clinical diagnosis and subsequent therapy. Decompression of all four compartments at the lower leg by the technique of Matsen represents the therapy of choice for the compartment syndrome of the lower leg.
OBJECTIVES: To study the effects of secondary wound closure on intramuscular pressure (IMP) in patients treated by fasciotomy for acute compartment syndrome. STUDY DESIGN: Prospective experimental study with an unbiased observer. METHODS: Twelve patients (mean age, thirty years) were treated for acute compartment syndrome by fasciotomy, early postoperative edema reduction, and secondary wound closure on the third or fourth day. The syndrome was confirmed by measurements of IMP in seven legs, three thighs, and two arms. The IMP was recorded in appropriate compartments with a noninfusion technique before, during, and after secondary wound closure by wire sutures. The IMP was not allowed to exceed thirty millimeters of mercury (four kilopascals) in the underlying compartment during wound closure. Patients were followed up at thirty-six months after surgery. RESULTS: By using an IMP limit of thirty millimeters of mercury, local perfusion pressure remained above fifty millimeters of mercury in all patients. With this protocol, the wound was closed on the third or fourth day in five patients. Seven patients needed repeated secondary wound closure. The distance between skin edges did not exceed 0.5 centimeter in any of the patients by the eleventh day. No patient needed skin transplantation. None had signs of ischemic contracture at follow-up. CONCLUSION: Secondary wound closure or wound adaptation starting on the third day after fasciotomy seems to be a safe method of treatment in normotensive patients if IMP during wound closure is not allowed to exceed thirty millimeters of mercury.
BACKGROUND: The aim of this study was to determine the success of fasciotomy of lower limb compartments with elevated intra-compartment pressure. METHODS: The present report is a retrospective cohort study at No. 3 Combat Support Hospital involving a survey and case note review of patients who had undergone fasciotomy for compartment syndrome at least 6 months earlier (December 1997-December 2000). RESULTS: Fourteen patients met the inclusion criteria. Eleven reported success with complete resolution of symptoms and return to military fitness levels. Two reported no change and significant residual symptoms. One reported worse symptoms and one required re-operation with a successful result. CONCLUSION: Surgical decompression is the accepted treatment of compartment syndrome as proven by pressure manometry, after failure of conservative treatment.
INTRODUCTION: The chronic exertional compartment syndrome of the musculus tibialis anterior is thought to be responsible for a major part of complaints of the lower leg among active sportsmen. There is an important role of tissue pressure measurement in diagnosing chronic anterior compartment syndrome during muscular activity. However, there is a controversial debate about the relevant parameters. METHODS: Metaanalysis of all the 21 studies (1979-1998) measuring intracompartmental pressures during muscular activity. Parameters of analysis: type of exercise, catheter technique, recommendations of diagnostic criteria. RESULTS: Analysis of literature shows that there has been no standardisation concerning the type of muscular exertion (isometrics for 5-10 min, exercise on the treadmill between 3.2 and 12 km/h). In 8 of the 21 studies the results have been attained through the unsuitable Wick-catheter-technique. In the overall view none of the suggested criterions for diagnosis is taken up by other teams. There are considerable variations up to 500% regarding the recommended parameters. CONCLUSIONS: From all studies no uniform recommendation for parameters of diagnostic relevance can be derived. On this background it should be demanded that future research is conducted by a uniform regimen for examination and modern technique of measuring with a high temporal resolution. Under these standardised conditions the investigated parameters of the intracompartmental pressure curve should be reconsidered once more regarding diagnostic predictability by calculations of specifity and sensitivity.
This paper reviews the etiology, clinical picture, treatment and follow-up in 25 patients treated for a forearm compartment syndrome at the medical school in Hanover. A volar-ulnar and, when indicated, a straight dorsal incision gave adequate decompression in all operatively treated patients. Follow-up examination revealed no damage or deficit that could be related to fasciotomy. Therefore, these results support the concept that operative treatment is widely indicated for forearm compartment syndrome.
Compartment syndrome in the well leg as a complication of prolonged positioning in a hemilithotomy position is a serious complication that is rarely reported in the orthopaedic literature. A similar entity has been well described in urologic, gynecologic, and general surgery literature but, to the authors' knowledge, has been reported in only seven patients in the orthopaedic literature. The authors report two cases of unilateral compartment syndrome in a well leg during femoral nailing of the contralateral leg. Risk factors, theories of pathogenesis, and preventive measures are identified and discussed.
For over a century, raised intra-abdominal compartment syndrome (ACS) has been known. The physiology and clinical results of this syndrome produce significant morbidity and quite high mortality rates. Increased intra-abdominal pressure causes progressive hypoperfusion and ischemia of the intestines as well as other peritoneal and retroperitoneal structures, including the pulmonary, cardiovascular, renal, splanchnic, and central nervous systems. The most effective prevention of ACS is early recognition and preemptive interventions, as well the choice of appropriate abdominal closures with constant care and surveillance in intensive care units.
The clinical presentation and diagnostic evaluation of a septic neonate with sclerema neonatorum and impending tissue loss secondary to compartment syndromes is presented. Vascular disease leading to tissue loss is uncommon in children. To our knowledge, this is the only reported case of a compartment syndrome leading to tissue loss in a neonate.
Western diamondback rattlesnake envenomation is usually managed by administration of neutralizing antivenom. The development of compartment syndrome is a rare complication that has sparked considerable debate regarding medical vs. surgical management. We report a case of compartment syndrome resulting from a rattlesnake envenomation, which responded to large doses of neutralizing antivenom given concomitantly with mannitol and hyperbaric oxygen. This regimen obviated the need for surgical fasciotomy and its associated morbidity.
Compartment syndrome has been observed in five burn patients. In all five patients the diagnosis was delayed and muscle necrosis occurred. Three limbs in two patients required amputation because of complete muscle necrosis, and the function of limbs in the three other patients was affected to different degrees. It is suggested that early limb escharotomies or fasciotomies in patients with full-thickness burns is necessary. Dressing should not be very tightly wound in limbs that have been grafted and the sensory and motor function of fingers or toes must be monitored carefully as well as distal circulation in limbs after operation.
The Abdominal Compartment Syndrome (ACS) is a clinical entity, which can be defined as the adverse physiologic consequences that occur as a result of a severe increase in intra-abdominal pressure (IAP), and is characterized by cardiovascular, pulmonary, renal, splanchnic, and intra-cranial disturbances regardless of the cause. The level of IAP at which ACS occurs is not known in children, therefore we suggest that the clinical signs of tensely distended abdomen, inability to palpate the femoral pulses, cyanosis of the lower extremities, progressive oliguria and hypoxia due to increasing airway pressures are sufficient to justify abdominal decompression. We report three cases of ACS and review the management of this condition.
BACKGROUND/PURPOSE: Abdominal compartment syndrome (ACS) is defined as cardiopulmonary or renal dysfunction caused by an acute increase in intraabdominal pressure. Although the condition is well described in adults, particularly trauma patients, little is known about ACS in children. METHODS: Three girls, ages 4, 5, and 5 years, were treated for ACS by silo decompression. Each child presented in profound shock, required massive fluid resuscitation, and had tremendous abdominal distension. The first child sustained a thoracoabdominal crush injury, underwent immediate celiotomy for splenic avulsion and a liver laceration, and required decompression 5 hours postoperatively. The second underwent ligation of her bluntly transected inferior vena cava; because of massive edema, her abdominal wall could not be closed, and prophylactic decompression had to be performed. The third presented with shock of unknown etiology, and ACS developed acutely with a bladder pressure of 26 mm Hg. RESULTS: Respiratory, renal, and hemodynamic function improved immediately in all 3 patients after decompression. Subsequently, each child underwent abdominal wall reconstruction and recovered uneventfully. CONCLUSIONS: ACS is a potentially lethal complication of severe trauma and shock in children. To prevent the development of renal or cardiopulmonary failure in these patients, decompression should be considered for acute, tense abdominal distension.
UNLABELLED: Chronic exertional compartment syndrome (CECS) is a well-documented cause of lower leg pain in active individuals. The pathophysiology is unclear, although it is generally believed to be associated with increased intramuscular pressure, but there is very little information about muscle function in relation to the onset of pain. PURPOSE: To investigate strength, fatigue, and recovery of the anterior tibial muscles in CECS patients and healthy subjects during an isometric exercise protocol. METHODS: Twenty patients and 22 control subjects (mean age 27.6 yr and 33.0 yr, respectively) performed a 20-min isometric exercise protocol consisting of intermittent maximal voluntary contractions (MVC). Central fatigue was evaluated by comparing changes in electrically stimulated (2 s at 50 Hz) and voluntary contraction force before and during the exercise, and then throughout 10 min of recovery. Muscle size was measured by ultrasonography. Pain and cardiovascular parameters were also examined. RESULTS: The absolute MVC forces were similar, but MVC:body mass of the patients was lower (P < 0.05) as was the ratio of MVC to muscle cross-sectional area (P < 0.01). The extent of central and peripheral fatigue was similar in the two groups. The patients reported significantly higher levels of pain during exercise (P < 0.05 at 4 min) and after the first minute of recovery (P < 0.001). An 8% increase in muscle size after exercise was observed for both groups. There were no differences in the cardiovascular responses of the two groups. CONCLUSIONS: CECS patients were somewhat weaker than normal but fatigued at a similar rate during isometric exercise. Patients reported higher pain than controls despite comparable changes in muscle size, suggesting that abnormally tight fascia are not the main cause of CECS symptoms.
BACKGROUND: The abdominal compartment syndrome (ACS) has been implicated in the pathogenesis of postinjury multiple organ failure. The ACS is defined as intra-abdominal hypertension causing adverse physiologic response. This study was designed to determine the effects of IAH on the production of interleukin-1b (IL-1beta), interleukin-6 (IL-6), tumor necrosis factor (TNF-alpha), and the effects on remote organ injury. METHODS: IAH was induced in Sprague-Dawley rats which were divided into 5 groups, 10 animals each. Intra-abdominal pressure (IAP) was increased to 20 mm Hg for 60 and 90 minutes in two different groups. In a third group following IAP of 20 mm Hg the abdomen was decompressed for 30 minutes before samples were collected. The other animals were used as controls. Hemodynamic response was monitored throughout the procedure. Cytokine levels were assessed in the plasma. Remote organ injury was assessed by histopathology and myeloperoxidase activity. RESULTS: IAH caused a significant decrease in MAP. After abdominal decompression MAP returned to baseline levels. A significant decrease in arterial pH was also noted. Increase in the levels of TNF-alpha and IL-6 was noted 30 minutes after abdominal decompression. Plasma concentration of IL-1b was elevated after 60 minutes of IAH. Abdominal decompression, however, did not cause a significant increase in the levels of this cytokine. Lung neutrophil accumulation was significantly elevated only after abdominal decompression. Histopathological findings showed intense pulmonary inflammatory infiltration including atelectasis and alveolar edema. CONCLUSIONS: IAH provokes the release of pro-inflammatory cytokines which may serve as a second insult for the induction of MOF.
The abdominal compartment syndrome (ACS) is a clinical entity that develops after sustained and uncontrolled intra-abdominal hypertension. ACS has been demonstrated to affect multiple organ systems including the cardiovascular, respiratory, gastrointestinal, genitourinary, and neurologic systems. To date most descriptions of ACS are found in the trauma literature, but the development of ACS in the general surgical population is being increasingly observed. In this study the development of ACS in a nontrauma surgical population is described and examined. The records of 18 surgical intensive care unit patients with documented ACS were reviewed retrospectively. Data acquired included demographics, urine output in mL/hour, cardiac index in L/m2/min: systemic vascular resistance index in mm Hg/L/m2/min: and pulmonary artery occlusion pressure, peak inspiratory pressure, partial pressure of oxygen in arterial blood, pH, partial pressure of carbon dioxide, and intra-abdominal pressure (all in mm Hg). When they were available values were obtained before and after decompression. Data are presented as mean +/- standard deviation and are analyzed by Student's t-test; significance was accepted to correspond to a P value <0.05. Nineteen episodes of ACS were identified in 18 patients. The average age was 69.2 years, and the observed mortality of the group was 61.1 per cent (11 of 18). Diagnoses included abdominal aortic aneurysm (eight), postoperative laparotomy (six), pancreatitis (three), and cerebral aneurysm (one). Of the parameters examined urine output, peak inspiratory pressure, and cardiac index demonstrated a significant change before and after decompression. The average intra-abdominal pressure was 43.4 mm Hg. Five of 18 patients (two with abdominal aortic aneurysm, two with postoperative laparotomy, and one with pancreatitis) were found to have necrotic bowel on decompressive laparotomy. The development of ACS is described in a surgical intensive care unit. ACS is the end result of uncontrolled intra-abdominal hypertension and results in systemic derangements. Surgical decompression of ACS significantly reduces peak inspiratory pressure while increasing urine output and cardiac index. The observed association between ACS and ischemic bowel may result from decreased mucosal perfusion as a direct result of abdominal hypertension. In our patient population ACS resulted in a 61.1 per cent mortality.
Open reduction and internal fixation with anterior compartment fasciotomy for fractures of both tibial plateaus in a 36-year-old woman was complicated by deep-vein thrombosis three days after surgery. After establishing anticoagulation, continuous passive motion (CPM) was instituted. Twenty-four hours after the commencement of CPM, an anterior compartment syndrome developed. A second operation revealed a large hematoma within the anterior compartment musculature, the development of which appeared to be the result of the combination of continuous passive motion and anticoagulation therapy in a seriously injured limb. In this clinical condition, especially close observation for the development of signs of elevated intracompartmental pressure is mandatory.
We present a case of a patient with Type 1 diabetes mellitus (DM) who spontaneously developed severe bilateral anterior tibial compartment syndromes which required extensive surgical treatment. While infarction of skeletal muscle in Type 1 DM remains rare and usually affects the larger compartments of the thigh, this diagnosis must be entertained in any patient presenting with acute leg pain. If a patient displays any features of acute compartment syndrome, prompt fasciotomy must be undertaken.