Compartment Syndrome

Cue Scene:

  • 20yoM w/ no pmh who hurt his leg while playing basketball.  He tried to walk it off but the pain keeps getting worse.  He arrives via EMS, screaming in pain and clutching his leg.  You get an x-ray which shows a fibula fracture.
Remember your Ps:
1.  Pain out of proportion
2.  Pallor
3.  Paresthesias
4.  Paralysis- late finding!
5.  Pulseless- late finding!
Compartment syndrome is most commonly seen in legs and forearms.  Often seen in crush injuries, circumferential burns, constrictive dressings (e.g. casts that aren't bivalved), or ischemia-reperfusion injuries.  In Tibial Fractures the most common is the deep posterior compartment followed by the anterior compartment.
Here's a cool video for you to watch:
Treatment:  Fasciotomy is indicated if the difference between patient's diastolic pressure and the compartment pressure is less than 30mmHg or if the compartment pressure itself alone is over 30mmHg.  Get ortho involved ASAP if available.  Otherwise you have to perform the fasciotomy.
Now let's review with a little Board question:
  • 24M presents as a trauma code shortly after a motorcycle accident. Pt was thrown from his motorcycle when a car suddenly braked in front of him, and his leg was caught under the wheel of the vehicle. Airway is intact, he is complaining of severe leg pain, and his blood pressure is stable. He was helmeted, and his injuries appear to be isolated to the left lower extremity. When you move to the secondary survey, you note severe left lower extremity edema, and the patient screams and writhes in pain upon palpation of the distal pulses. You observe diffuse road rash but no open lacerations. His peripheral pulses are palpable and strong. Radiograph of his left lower extremity is shown in Figure A. What is the next best step in management?
  • Next best step?
    • A.  Admission for observation and pain control
    • B.  Closed reduction and splinting
    • C.  Percutaneous pinning and casting
    • D.  Multi-compartment fasciotomy
    • E.  Physical and occupational therapy
Answer:  D