Signs, Symptoms, and Science
What are the 6 P’s in the presentation of compartment syndrome?
Pain (out of proportion), paresthesia (numbness, tingling, burning sensation), pallor (pale or mottled skin), paralysis, pulselessness, poikilothermia (loss of thermoregulation)
What parts of the body are most impacted by CS?
Usually: leg, forearm
*but can happen in the thigh, foot, gluteal region, and hand as well
What are the steps of fasciotomy and the associated wound management?
-2 Longitudinal incisions for 4 compartments (lateral and medial)
-left open initially due to swelling, covered with a temporary dressing, surgeons look again around 48-72 hours for any necrotic tissue, then close or use a skin graft around 7-10 days
Compare upper motor neuron vs. lower motor neuron lesions
Upper: spasticity, hypertonicity, hyperreflexia, disuse atrophy, Babinski toes point up
Lower: flaccid, hypotonicity, hyporeflexia, denervation atrophy, babinski toes point down
A 30-year-old patient comes to the ER after a tibial fracture. He reports unrelenting pain that worsens when you dorsiflex his foot, and his leg feels tense when palpated. What are the early vs. late signs of compartment syndrome that you should consider when examining the patient?
Early: Pain (severe w/ passive stretch), paresthesia, tense wood-like palpation of the compartment, pallor (sometimes can be very slight)
Late: paralysis, pulselessness, poikilothermia, loss of sensation, muscle breakdown
What structure creates the compartments in the leg, and how does it relate to compartment syndrome?
Fascia (+ intermuscular septa are extensions that separate the muscle groups; they do not expand in times of swelling or bleeding, so as volume increases in the compartment, the pressure increases
Explain the importance of timing for compartment syndrome and related consequences
- Its a surgical emergency, leads to irreversible muscle and nerve damage
- If surgery performed within 4-6 hours than patient has greater change of full limb function
-After 6 hours: nerve damage
-After 8 hours: muscle and nerve damage
-After 12 hours:
-Beyond that increases chances of amputation, necrosis, infection, and neurological injury
*other consequences: volkmann contracture, kidney failure, sepsis, multiorgan failure
SMA is classified by what, and what are the types?
-Classified by age of onset, max motor function, and number of SMN gene copies
-Types: 0 (prenatal onset), 1 (infantile onset, don't sit independently), 2 (onset 6-18 months, sit but can't walk), 3 (onset >18 months), 4 (adulthood onset)
You’re the ER physician. Two trauma patients arrive simultaneously: one with an open femur fracture, the other with closed tibia fracture and suspected CS (pain on stretch, tense leg). Who should go to the OR first and why?
Closed Tibia fracture, since there is a higher pressure, while other pt's pressure is relieved since it is open
Fill in the following blanks about compartment syndrome:
Progresses ______, ______ venous outflow/drainage, causing arterial ______, _______ lymphatics, _______ tissue perfusion, causing anoxia/rhabdomyolysis, which then leads to_______
Progresses rapidly, decreasing venous outflow/drainage, causing arterial collapse/inflow, decreased lymphatics, decreased tissue perfusion, causing anoxia/rhabdomyolysis, which then leads to necrosis
What is diagnostic testing, and what do lab findings show?
- Pain with passive stretch
-Needle manometer monitors pressure (>30 mmHg)
Lab values:
CK = High (muscle breakdown)
Myoglobin= rhabdomyolysis
K+= hyperkalemia
Ca2+= hypocalcemia
Phosphate= hyperphosphatemia
If the injury were to occur in the forearm, what arteries and nerves would you see impacted and what motor and sensory structures would be impacted their respective issues?
Arteries: ulnar, anterior interosseous artery, posterior interosseous artery
Nerves: Median, anterior interosseous, ulnar, posterior interosseous, radial, radial
-median and anterior interosseous nerves: finger and wrist flexion, pronation
-ulnar nerve: wrist and finger flexion, innervates intrinsic hand muscles
-posterior interosseous nerve: finger and wrist extension, and supination
-Sensory: lateral cutaneous, medial cutaneous, posterior cutaneous
A patient with a crush injury arrives 10 hours post-injury. What complications are you most concerned about and why?
Rhabdomyolysis (muscle breakdown), ischemia (that impacts nerves), muscle/tissue necrosis
Compare Acute vs. Chronic compartment syndrome?
Acute: By trauma, usually in leg or forearm, but also seen in foot, thigh, abdomen, and gluteal region
Chronic (usually athletes): exercise → increase muscle size → incr intracompartmental pressure → fluid exudation into interstitial space → compromised blood flow, symptoms occur during physical activity but subside when activity stops
What does Long Term management for the patient look like?
Rehabilitation/ Physical Therapy, Occupational therapy, splint/bracing (maintain joint position or prevent contracture), post-fasciotomy care, scar care, chronic pain, mental health support
Explain the treatment medication options for organophosphate toxicity
- Atropine: muscarinic ACh receptor antagonist, competitive binding, can cross the blood-brain barrier
-Pralidoxime: reacts with inhibited AChE by binding OP at the active site and removing it, needs to be administered early before "aging"
Compare and Contrast Blunt Force Trauma and Crush injury
Blunt force:
Primarily causes local hemorrhage and edema, leading to increased pressure. The body's initial compensatory response is to maintain perfusion by local vasodilatation, but the rigid fascia prevents expansion.
Crush injury:
crushing accidents causing muscle necrosis (rhabdomyolysis and myoglobinuria), conditions (metabolic issues, local muscle damage, organ dysfunction), causes (drug overdose so trunk compression of forearm and leg, surgical knee chest position compression ant leg compartment, and crushing industrial accidents), muscles dying like this become fibrotic and shortened causing non functional and deformed
crushing injury/limb compression → soft tissue injury → ischemia → muscle necrosis or compartment syndrome
Which of the following scenarios is the least likely to cause compartment syndrome?
A. A patient with a closed, displaced tibial fracture.
B. A patient on anticoagulation therapy who experiences significant blunt trauma.
C. A person who lies on their arm for several hours due to drug intoxication (prolonged compression).
D. A competitive swimmer experiencing muscle soreness after an intense training session.
E. A patient whose leg bandage and cast are applied too tightly after surgery.
D. A competitive swimmer experiencing muscle soreness after an intense training session.
You are counseling a patient with permanent foot drop post-CS about returning to work. What interdisciplinary plan would you propose to the patient and how?
-Work with orthopedic and PM&R physicians to assess functional readiness
-Documentation for workers' compensation
-Disability accommodations, adapative modifications
-Physical Therapy, occupational therapy, social support
Explain the relationship between action potentials and the presentation of compartment syndrome
As ischemia continues to progress, cellular ion pumps (ex: Na/K+ ATPase pump) lack ATP so fail, so lose membrane potential (so less excitable), causing an inability to generate AP
-causing paralysis, loss of sensation, and damage