Week 5 - Case 3: Compartment Syndrome Flashcards
What is the diff. diagnosis for “Shin Splints”?
Stress fractrues, Medial tibial syndrome, Compartment syndromes (anterior, deep posterior)
What is Medial Tibial Syndrome?
- Most common site is distal 1/3 of the medial boarder of the tibia
- Generally felt to be the insertion of the soleus
- Pathology is an area of tibial periostitis
- Not well understood
How to diagnose Medial Tibial Syndrome?
Physical exam, pain on palpation of the distal tibia over the length of 5 cm.
What is the treatment for Medial Tibial Syndrome?
Rest
What is compartment syndrome?
A condition in which increased pressure within a limited space compromises the circulation and function of the tissue within that space.
What is unique about Compartment Syndrome?
TRUE ORTHOPEDIC EMERGENCY
- Reduces tissue perfusion - ischemia
- results in death - necrosis
- It can affect many areas of body: hand, foot, arm, thigh, buttocks
What can cause compartment syndrome (etiology)?
- Fractures (open & closed) - 9% of all fractures
- Blunt trauma
- Cast/dressing
- Burns/electrical
- Exertional states
- Gunshot
- IV/A-lines
- Hemophiliac/coag
- Intraosseous IV (infant)
- Snake bite
- Arterial injury
What is a stress fracture?
- Overuse injury
- Occurs when muscles become fatigued and unable to absorb shock. Muscle overload shock is transferred to weight bearing bones
- Most occur in bones of lower leg and foot
What are the symptoms of a stress fracture?
Pain with activity, subsides with rest
How to diagnose and treat a stress fracture?
X-ray, MRI, bone scan
Tx: Rest
How do you tell if there is a fracture using a bone scan?
Areas with a lot of uptake = stress fracture
What is the most common cause of CS? (incidence accompanying?)
Fracture
- 9.1% CS accompanying
- Incidence directly proportional to deg. of injury to soft tissue and bone
- Occurs most often: Comminuted (fracture involving multiple splinters), grade III open injury to a pedestrian
What is the 2nd most common cause of CS?
Blunt Trauma (what our patient had during football practice!)
- About 23% of CS
- 25% of Blunt Trauma is due to a direct blow from an object or person
What is normal tissue pressure and what is normal tissue pressure with exertion?
0-4 mmHg
8-10 with exertion
What are the different numbers at which pressure should be relieved in CS?
Absolute pressure theory -30 mmHg -45 mmHg Pressure gradient theory - <20 mmHg of diastolic pressure
How long can muscle tissue survive during CS?
3-4 hrs - reversible changes
6 hrs - variable damage
8 hrs - irreversible changes
How long can nerve survive during CS?
2 hours - loose nerve conduction
4 hours - neuropraxia
8 hours - irreversible changes
How to diagnose CS?
-Pain out of proportion
-Palpably tense compartment
-Pain with passive stretch (plantarflexion)
Also - later on/more severe:
-Parethesia/hypoesthesia
-Paralysis
-Pulselessness/pallor
What is most important when evaluating a patient with possible CS?
- PAIN - most imp. Especially pain out of proportion to the injury (child becoming more and more restless/needing more analgesia)
- Most reliable signs are pain on passive stretching and pain on palpation of the involved compartment
- Other features like pallor, pulselessness, paralysis, paraesthesia (tingling, tickling) etc. appear very late and we should not wait for these things
Is it important to get a compression pressure measurement if your patient shows all physical exam signs?
NO - if a pressure measurer is not easily accessible, just go ahead and do surgical decompression ASAP!
What compartment is most common for CS?
ANTERIOR!
If patient has symptoms and PE findings of CS OR compartment is above 30 mmHg. . .
. . .you MUST do a fasciotomy - need to decompress all FOUR compartments using TWO incisions - one on each side
- One into lateral compartment
- One into Deep posterior compartment
How do you manage the wound after a fasciotomy?
- A bulky compression dressing and splint are applied
- Incision for the fasciotomy usually can be closed after three to five days
What is “Shin splits” a generic term for?
Lower leg pain with exertion
