EM@3AM – Compartment Syndrome

Author: Erica Simon, DO, MHA (@E_M_Simon, EMS Fellow, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 33-year-old male presents to the emergency department by EMS (patient transfer) following an injury to his right upper extremity. Per paramedics, approximately three hours prior to arrival the man’s right hand and proximal forearm were crushed in an industrial metal press. Unable to provide orthopedic services for the patient’s injury, the sending facility identified the right upper extremity as neurovascularly intact, applied a splint, and administered cefazolin, a tetanus vaccination, and pain control.

When questioned regarding the incident, the patient reports his pain as worsening since the time of initial injury (despite two appropriate, weight-based doses of IV dilaudid). He notes the development of right hand paresthesias during transport.

Triage VS: BP 138/91, HR 110, T 99.1 Oral, RR 12, SpO2 99% on room air.

Pertinent physical examination findings:

Right upper extremity:
Shoulder: atraumatic; full, painless ROM; brachial pulse palpable and bounding.
Elbow: atraumatic; full, painless ROM.
Forearm: severe edema and ecchymosis, obvious deformity of the mid-forearm with open radial fracture; tense anterior forearm compartment.
Wrist: severe crush injury: pain limits ROM.
Hand: severe crush injury; numerous palpable metacarpal fractures; pain limiting ROM, limited two-point discrimination median and radial nerve distributions; cool to the touch.

What’s the next step in your evaluation and treatment?

Answer: Compartment Syndrome^1-6

• Pathophysiology: Compartment syndrome occurs secondary to ischemic injury from increased pressure within a confined tissue space. Etiologies include (list not all encompassing): burns, crush injuries, electrocution, trauma (fracture/hematoma), IV infiltration, reperfusion injury, prolonged malposition, physical activity (exertional compartment syndrome), and snake envenomation.
• Epidemiology: Occurs ten times more often in men than in women.² High energy tibial fractures => most common association with compartment syndrome (occurring in up to 24% of polytrauma patients).³ Also frequently occurs with fractures of the forearm.
• Presentation: Syndrome classically characterized by pain with passive motion (pain out of proportion), paresthesias, poikilothermia, paralysis, pallor, and pulselessness.
  • Poikilothermia, paralysis, pallor, and pulselessness = late findings indicative of complete ischemia and poor prognosis.⁴
• Evaluation:
  • Assess ABCs and obtain VS.
  • Perform a thorough H&P: Question specifically regarding blood dyscrasias/anticoagulation (increased risk for compartment syndrome), recent trauma, and attempts at pain control.
  • Compartment syndrome is a clinical diagnosis: numerous techniques/tools available for measuring compartment pressures: needle manometer, arterial line catheter, Stryker Stic catheter system, microporous catheter => none reliable for the diagnosis of compartment syndrome.¹
  • Utilize the H&P to direct laboratory/imaging evaluation (e.g. crush injury: BMP, CK, etc.)
    • Previous studies have demonstrated a CK > 4,000 U/L, a chloride > 104 mg/dL, and a BUN < 10 mg/dL as correlated to the development of compartment syndrome, however, these values are of limited clinical utility in the polytrauma patient (numerous musculoskeletal injuries).⁵

• Treatment:
  • Remove all circumferential dressings as applicable.
  • Consult ortho for evaluation => examination + measurement of compartmental pressures +/- Δp determination:
    • Unequivocally positive findings on examination => fasciotomy
    • Exam limited by patient mental status/condition, polytrauma, or exam inconclusive: Δp determination
      • Δp = diastolic blood pressure – measured compartmental pressure
        • Δp < 30 mmHg = fasciotomy
        • Δp > 30 mmHg = continuous compartmental monitoring and serial examination
•  Pearls:
  • Palpate all extremity compartments and pulses in the polytrauma patient: distracting injury, obtundation, or sedation may result in delayed diagnoses and increased morbidity.¹
  • In a patient reporting atraumatic extremity pain that is out of proportion to examination findings: question regarding drug/alcohol abuse: incapacitation => prolonged maintenance of position => crush injury.
  • Open fractures do not exclude the possibility of compartment syndrome (occurs in 6-9% of open tibial fractures).⁶

 References:

1. Shuler M, Roskosky M, Freedman B. Compartment Syndromes. In Skeletal Trauma: Basic Science, Management, and Reconstruction. 5^th ed. Philadelphia, Elsevier Saunders. 2015; 16:437-463.e3.
2. McQueen M, Gaston P, Court-Brown C. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000; 82: 200-203.
3. O’Toole R, Whitney A, Merchant N, et al. Variation in diagnosis of compartment syndrome by surgeons treating tibial shaft fractures. J Trauma. 2009; 67:735-741.
4.  Thomas E, Michael M. The pathophysiology of compartment syndrome. Tech Orthop. 2012; 27.
5. Valdez C, Schroeder E, Amdur R, et al. Serum creatine kinase level with extremity compartment syndrome. J Trauma Acute Care Surg. 2013; 74:441.
6. Blick S, Brumback R, Poka A, et al. Compartment syndrome in open tibial fractures. J Bone Joint Surg Am. 1986; 68: 1348-1353.

For Additional Reading:

Core EM: Compartment Syndrome

CORE EM: Compartment Syndrome