Looking for info on compartment syndrome..

[pinkyrx]

Hi everybody,

I'm posting to see if any of you can help me with a "theoretical" case I'm working on:

The patient has been diagnosed with compartment syndrome. The injury is in the thigh area and was caused by a dirtbike accident. What is the best course of treatment?

The research I've done shows that fasciotomy to relieve the pressure is the main treatment for acute compartment syndrome and the quicker that it is done the less likely there is permanent damage to the leg.

Are there situations where the orthopedic surgeon should choose medications and physical therapy as an alternative? Without measuring the actual pressure of the compartment, are there alternative ways to tell how serious this particular case is? (ie, that it doesn't require surgery and that meds/PT are appropriate instead?)

If meds/PT are an appropriate alternative to surgery, what medications are typically used? Would cyclobenzaprine/naproxen be a good combination? How often should the patient be receiving PT?

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[LuckyMD2b]

Hey 3rd year med student here, I'll try and give this question a shot.

1. Compartment syndrome is an increase in pressure within a musculo-fascial compartment usu. resulting from trauma. The increased pressure is due to edema, inflammation and possibly hemorrhage.

2. Compartment syndrome is an orthopedic emergency because that increased pressure can lead to irreversible damage by occluding the vascular supply to the muscles and nerves; leaving the limb useless.

3. Fasciotomy is the primary treatment because it is the only way to alleviate that increased pressure, by opening up the compartment. The two meds you listed are primarily pain meds and will do very little, if anything at all to stop the edema and inflammation associated with compartment syndrome.

Well that's the extent of my knowledge, hopefully its not wrong if it is let me know.

 

[pinkyrx]

Thanks for the quick reply!

Everything that you've said looks correct to me according to the research I've been doing on compartment syndrome.

The problem is that in the "case" I mentioned, the patient has extreme swelling of the thigh and cannot move his leg without physically picking it up with his hands to move it. The patient was diagnosed on a Friday evening in the emergency room and they sent him home with only pain meds. The patient followed up on Monday with an orthopedic doctor and couldn't get in for an appointment until Tuesday morning. The doctor (who was in a big hurry) didn't do any sort of pressure measurement and just sent the patient home with more pain/antiinflammatory meds and an order for physical therapy the following week. I'm wondering if this was an appropriate treatment course.

 

[lattimer13]

Thanks for the quick reply!

Everything that you've said looks correct to me according to the research I've been doing on compartment syndrome.

The problem is that in the "case" I mentioned, the patient has extreme swelling of the thigh and cannot move his leg without physically picking it up with his hands to move it. The patient was diagnosed on a Friday evening in the emergency room and they sent him home with only pain meds. The patient followed up on Monday with an orthopedic doctor and couldn't get in for an appointment until Tuesday morning. The doctor (who was in a big hurry) didn't do any sort of pressure measurement and just sent the patient home with more pain/antiinflammatory meds and an order for physical therapy the following week. I'm wondering if this was an appropriate treatment course.

i'm no orthopod and i'd like to know more of the history and physical exam findings on this patient. but i'd say from the sound of it this fell short of the standard of care for compartment syndrome?

does the patient still have his leg? were there any permanent deficits w/ his leg as a result of not proceeding w/ the fasciotomy?

 

[pinkyrx]

i'm no orthopod and i'd like to know more of the history and physical exam findings on this patient. but i'd say from the sound of it this fell short of the standard of care for compartment syndrome?

does the patient still have his leg? were there any permanent deficits w/ his leg as a result of not proceeding w/ the fasciotomy?

I agree, it also seems to me that they fell short. I posted here to see if perhaps there were alternative treatments for acute compartment syndrome that I had not found in my research. I feel at the very least a pressure measurement should have been done to assess just how serious this case was.

Yes, the patient still has his leg. It is still not apparent whether or not the patient will have permanent damage to the leg as the accident just occured on 11/26.

He was seen in the ER approximately 6 hours after the accident. There was no pain in the leg until about 3 hours after the incident and it worsened until a trip to the ER was required. The leg was xrayed at the ER to confirm that it was not broken. The ER doc diagnosed him with compartment syndrome, the main symptoms being extreme swelling, pain that seemed greater than any physical findings (ie, no bruising/redness) and pain that did not begin until a few hours after the accident. No other exam was performed at the ER. He was sent home with Lortab and Naproxen and was told to follow up first thing on Monday with an orthopedic specialist.

The patient followed up on Monday 11/28 but couldn't be seen until 11/29. At that time the doctor inspected the patients leg and confirmed that there was no damage to the knee. The patient was sent home with Flexeril 5mg TID and Naproxen BID and was instructed to begin physical therapy the following week. THe patients physical therapy begins tomorrow and will be once a week for at least a month.

 

[dobonedoc]

Just reading your post, and few things come to mind.

1. If you friend had a compartment syndrome, and the ER doc diagnosed him correctly; treatment consisting of medicines would be inappropriate. A diagnosis of compartment syndrome requires EMERGENT surgical intervention.

2. Perhaps the ER doc was an idiot, your friend did not have the condition as diagnosed, and the treatment he prescribed will most likely do well. Better to be lucky than good, I guess.

3. Perhaps the ortho doc was hasty, or perhaps the ortho doc was able to determine by his physical exam that your friend did not have the condition in question. If he had any question about the possibility of a compartment syndrome, then he would be wise to do some type of objective exam to prove it, or disprove it.

4. Compartment syndrome is a simple thing: too much swelling, not enough space. It is seen in MANY conditions, trauma being the most common. It is a common condition involved in medical malpractice suits against orthopedic doctors. Diagnosing it is simple: Stryker makes a simple device that measures the pressure in a fascial compartment with a simple needle-stick and a little saline. No real physical exam skills are required. No MRI, CT, Xray, Ultrasound, etc is required, either. Just a simple knowledge of basic anatomy, and a high index of suspicion for the condition.

Good luck.

 

[pinkyrx]

Thanks for the reply! I hope that the ER doc did in fact diagnose him incorrectly and that his leg will recover fully. It has now been over a week and some of the swelling has gone away, but the thigh area is still very swollen. He can move the leg a little bit more than he could a week ago, but can still not put weight on it without severe pain.

He saw the physical therapist today and they have moved the sessions up to twice a week. Hopefully it will help.

If it was infact compartment syndrome, would the physical therapy not make a difference?

 

[moquito_17]

Thanks for the reply! I hope that the ER doc did in fact diagnose him incorrectly and that his leg will recover fully. It has now been over a week and some of the swelling has gone away, but the thigh area is still very swollen. He can move the leg a little bit more than he could a week ago, but can still not put weight on it without severe pain.

He saw the physical therapist today and they have moved the sessions up to twice a week. Hopefully it will help.

If it was infact compartment syndrome, would the physical therapy not make a difference?

I would guess that most of the research and reading that people have been doing are on compartment syndrome of the lower leg and forearm, which are usually surgical emergencies. Compartment syndrome of the thigh is quite uncommon. As you rememember from anatomy, the compartments of the thight are large and there is a lot of room for swelling, unlike in the forearm or leg where the compartments fill rather quickly.

It's a bit of a stretch (no pun intended) to say that the first orthopod was too hasty. Compartment syndrome is a CLINICAL diagnosis, NOT one made by that Stryker device. The Stryker device, in addition to being inaccurate (do a lit search on it, good article in recent JBJS) is indicated for certian patients in certian circumstances. Obtunded, intubated, etc. For most of the patients, good physical exam skills are essential.

Anyway, your buddy sounds fine so it's a moot point, but people ought to know what they are talking about before posting stuff...

Glad to hear that everything is going well.

 

[dobonedoc]

Compartment syndrome is a CLINICAL diagnosis, NOT one made by that Stryker device. The Stryker device, in addition to being inaccurate (do a lit search on it, good article in recent JBJS

Please tell me you are kidding. Everyone involved in ortho trauma knows that the physical exam can be confused by many factors. Are you telling me you are going to take every patient with a tibia fracture that has "pain out of proportion to their injury" to the OR for a 4-compartment fasciotomy? You need objective data.

I've read the article, and used the device many times. I cannot figure out where you are coming from with your recent post. Please assure us all that you are actively involved in orthopedic trauma somewhere; either as a resident or an attending orthopedic surgeon. Also, please inform us all of the current methods used in your institution to OBJECTIVELY diagnose the presence of or absence of a true compartment syndrome.

Also, please tell me that you realize that compartment syndrome can occur anywhere in the body. Though not as common in the leg or forearm, please admit that the thigh, glutes, arm, etc can all be affected by this terrible condition.

 

[moquito_17]

Please tell me you are kidding. Everyone involved in ortho trauma knows that the physical exam can be confused by many factors. Are you telling me you are going to take every patient with a tibia fracture that has "pain out of proportion to their injury" to the OR for a 4-compartment fasciotomy? You need objective data.

Also, please tell me that you realize that compartment syndrome can occur anywhere in the body. Though not as common in the leg or forearm, please admit that the thigh, glutes, arm, etc can all be affected by this terrible condition.

Yes, any compartment can have increased pressures, for many reasons. Common things are common and uncommon things are not. Gluteal, thigh, foot compartments, are less common than leg and forearm.

You said :If he had any question about the possibility of a compartment syndrome, then he would be wise to do some type of objective exam to prove it, or disprove it." And later you said that the diagnosis is made with the Stryker product.

My point is that the diagnosis is made clinically by multiple factors, not just "pain out of proportion to exam." Of course everyone with a painful tib-fib fracture doesnt get fasciotomies. But with a tight extremity, paresthesias and pain with passive strech...

The devices are good for obtunded paitents, intubated pateints or when the exam is equivocal or difficult to obtain. They are an augment to the physical exam, not a replacement for it. In the case described in this post, the patient sounded pretty reliable.

If the patient from the original post had swelling in the thigh, but soft compartments and none of the other cardnial signs of compartment syndrome 3 days after the injury, sticking him with a needle seems a bit unneccesary, wouldn't you agree? It's a little presumtuous to say that the original orthopod did something wrong.

 

[dobonedoc]

Your latest post makes you sound a bit more reasonable than I first thought. Perhaps it is because you seem to say different things in each of your posts.

Please read what I have to say very carefully. Never did I imply that the orthopod may have acted in haste. Instead, I stated: "If he [the orthopedic surgeon] had any question about the possibility of a compartment syndrome, then he would be wise to do some type of objective exam to prove it, or disprove it." In the same thought I admitted that his physical exam may have effectively ruled it out. You need to read with a greater focus on the details. A lack of attention to detail is what gets patients hurt by the hands of physicians.

Again, I stick with my statement that no real physical exam skills are required. When it comes down to it, and decisions have to be made, some type of objective, reproducible data is the key. Anyone can look at a swollen leg. We've all seen the extremity that looks like a piece of wood. I hope most of these compartment syndromes are caught long before paresthesias are present, not to mention pulselessness, and paralysis. If it takes signs such as these to make the diagnosis in your institution, you are being too slow in your assessment.

Instead, if a patient has a mechanism of injury that could produce a compartment syndrome, or if they seem to have the classic "pain out of proportion to their injury," I feel that the compartments of that extremity must be checked. Imagine an isolated deep posterior compartment syndrome in the lower extremity: the leg could look and feel quite reasonable. Miss it, and you have just screwed your patient. (These cases DO happen.)

You claim that JBJS argues that the Stryker monitor is inaccurate. Please review the article you cited (Nov 2005). Straight from the abstract of the paper it reads:

"The arterial line manometer is the most accurate device. The Stryker device is also very accurate. The Whitesides manometer apparatus lacks the precision needed for clinical use."

I do not know where you are getting your information, what level of training you have achieved, or what field of medicine you are in (perhaps you are still an undergrad trying to decide if medicine is right for you . . . ), but your arguments are off base, and your reasoning seems naive. Good luck with whatever it is you decide to do.

 

[Bull's eye]

Your latest post makes you sound a bit more reasonable than I first thought. Perhaps it is because you seem to say different things in each of your posts.

Please read what I have to say very carefully. Never did I imply that the orthopod may have acted in haste. Instead, I stated: "If he [the orthopedic surgeon] had any question about the possibility of a compartment syndrome, then he would be wise to do some type of objective exam to prove it, or disprove it." In the same thought I admitted that his physical exam may have effectively ruled it out. You need to read with a greater focus on the details. A lack of attention to detail is what gets patients hurt by the hands of physicians.

Again, I stick with my statement that no real physical exam skills are required. When it comes down to it, and decisions have to be made, some type of objective, reproducible data is the key. Anyone can look at a swollen leg. We've all seen the extremity that looks like a piece of wood. I hope most of these compartment syndromes are caught long before paresthesias are present, not to mention pulselessness, and paralysis. If it takes signs such as these to make the diagnosis in your institution, you are being too slow in your assessment.

Instead, if a patient has a mechanism of injury that could produce a compartment syndrome, or if they seem to have the classic "pain out of proportion to their injury," I feel that the compartments of that extremity must be checked. Imagine an isolated deep posterior compartment syndrome in the lower extremity: the leg could look and feel quite reasonable. Miss it, and you have just screwed your patient. (These cases DO happen.)

You claim that JBJS argues that the Stryker monitor is inaccurate. Please review the article you cited (Nov 2005). Straight from the abstract of the paper it reads:

"The arterial line manometer is the most accurate device. The Stryker device is also very accurate. The Whitesides manometer apparatus lacks the precision needed for clinical use."

I do not know where you are getting your information, what level of training you have achieved, or what field of medicine you are in (perhaps you are still an undergrad trying to decide if medicine is right for you . . . ), but your arguments are off base, and your reasoning seems naive. Good luck with whatever it is you decide to do.

I have to agree with you 100% here. Having done orthopedic trauma and used the stryker needle before (multiple times), I've been surprised at the number of times that my physical exam makes me very suspicious of Comp Syndrome and found the Delta P to be 40-50. I think we all have seen Shatzker V's without compartment syndrome and Shatzker II's with compartment syndrome. I think it is just too cliche to say it is a clinical diagnosis. We all know it is a "clinical diagnosis" but you have make the decision for surgery and justify doing the surgery. I would love to see the reactions to our chief residents and Attendings after waking them up at night for an emergent fasciotomy. Then they ask what the pressures are and you tell them "Ant/Post/Deep Post/ Sup Post all around 15 with a delta P of 55 but his pain is out of proportion to his injury" Yeah right, I would not want to be on the other end of that butt chewing.

 

[moquito_17]

I think that we are arriving to a similar place.

1) You state " that no real physical exam skills are required. " But also you state that you have to have: "a high index of suspiscion." I think that you need to do a careful and expert exam to have that high level of suspiscion.

2) I still would submit that the diagnosis is made by exam and confirmed by device, except in the patient with the aforementioned limitiations. After all, would you withhold a fasciotomy from someone who had a good history and pain with strech and parasthesias if they had a "Stryker Exam" within normal limits? It's the whole dilemma of what to do if the 'objective' data contradict the physical exam.

3) About the Stryker device, the JBJS article referenced shows the varation under ideal laboratory conditions. With straight needles there is a lot of variation. Regardless of what the authors opine, I think that the variation they show is close to being out of the acceptable range. I would argue that in the ER, things are often even more variable. Operator and equiptment error iare always possible. I am not aware of any clinical study that had tried to quantify these factors and compare them to intra-operative a-line measurements prior to fasciotomy. This would be an interesting study.

The point is that good physical exam skills ARE required and that the device should confirm or augment the physical exam.

Also, you don't need to make personal attacks to make your point. You ought to have some respect for your colleuges. I think that I am making a lucid and arguable point and to casually and rudely dismiss it is unprofessional. But like most ortho guys, I have tough skin, so no worries.

 

[dobonedoc]

Anyway, your buddy sounds fine so it's a moot point, but people ought to know what they are talking about before posting stuff...

It's all good. Glad we can all be friends. I admit its been a couple of long days on this end. I suppose I was responding to the statement you first made that is quoted above.

If you are in ortho, perhaps we can hash it out again some day at a "conference" while we ski the slopes of Colorado, or bask in the sun of Florida. Cheers.