• Virtual Rounds Session 11: Compartment Syndrome (Premed Shadowing)

Virtual Rounds Session 11: Compartment Syndrome (Premed Shadowing)

Throughout each premed virtual shadowing session, you will actively participate by answering and asking questions about the week’s proposed case. Like an in-person shadowing experience, we strive to stimulate students intellectually and ultimately reaffirm their interest in medicine.

 

Introduction – Acute Compartment Syndrome

Compartment syndrome is a dangerous condition which results in increasing inflammation within the affected compartment (typically muscle) and leads to increasing pressures and eventual irreversible ischemic damage to the muscle, nerves, and vasculature. Musculature compartments are defined by their separation via fascial layers (a connective tissue). Fascia is not flexible, so when swelling occurs, the affected compartment gets tighter but is not able to expand to compensate for the increasing pressures. It is considered a surgical emergency and requires a procedure called a fasciotomy in order to save the affected limb. It commonly occurs in the lower extremities, but is also possible in other areas of the body, such as the abdomen. It is generally caused by trauma, casts for broken bones which are set too tightly, and burns resulting in circumferential eschars (scabs).

Medical Jargon (revisit this section as you go through the case and physical exam so you understand the terminology).

  • HEENT: Head, ears, eyes, nose, throat
  • EOM: Extraocular movements/eye movements
  • Erythema: Redness
  • Edema: Swelling
  • Capillary refill: Circulation test-Squeeze a patient’s finger and watch blood refill it. Normal takes </=2 seconds
  • PERRL: Pupils equal round and reactive to light  
  • Normocephalic: Head is of normal size and shape
  • Abrasion: Superficial scratches (like a ‘rug burn’) 
  • Poikilothermia: Inability to regulate temperature, leads to ischemic tissues (due to a lack of blood flow and oxygen)
  • Reflexes: Tests function of motor and sensory neurons (like your patella reflex, L2-4 spinal nerve roots). Graded 0-4 (2 is normal)
  • Delta Pressure: (Diastolic-compartment)/(tissue pressure) (normal </= 30 mmHg)

Case Highlights

A 28-year-old female presents to the emergency department with a chief complaint of right lower leg pain. Patient states that about 2 hours ago she was in her yard cutting down trees when a large branch suddenly fell onto her right lower leg, briefly pinning her to the ground. After the branch was removed, she noted immediate sharp pain, redness of the skin, and tenderness to touch. Since the incident, she has developed worsening sharp pain and decreased sensation to touch. She is not able to bear weight on the leg and has minimal ability to move her right toes and ankle. She has tried icing and ibuprofen for the pain, but says nothing is making the pain better. She says her leg is feeling “tight” and the pain has become unbearable. She is worried that she broke a bone and would like to get imaging…

Physical Exam

  1. Vitals: HR 100 RR 19 BP 160/80 T 98.5 F SpO2: 100%
  2. General: Appears uncomfortable and in moderate distress.
  3. HEENT: Head atraumatic, normocephalic. No tenderness to palpation of neck. Normal ROM of neck. PERRL & EOM intact b/l.
    Lungs: CTAB, no increased work of breathing.
    Cardiovascular: Tachycardic. Radial pulses intact b/l. Capillary refill <2 seconds in b/l UE. Pedal pulses difficult to palpate in RLE. 
  4. Neurological: CN II-XII intact. Sensation to light touch diminished RLE distal to knee. Achilles reflex 1/4 in RLE.
  5. Musculoskeletal: skin overlying RLE appears edematous and tense with diffuse superficial abrasions. Severe and diffuse tenderness to palpation. Pain worse with passive and active flexion and extension of R ankle.

Pathology 

In order to best treat your future patients, you must think carefully about your assessment (differential diagnosis) and be able to rule out the other conditions that may develop in a similar fashion. For our patient, we want to consider the following:

  • Acute Compartment Syndrome
    1. This condition is defined by an abrupt increase in the pressure within a muscle compartment (which houses nerves, blood vessels, and muscle). Each compartment is surrounded by fascia, which does not expand and leads to compression of the internal structures.Caused by trauma (crush injuries), circumferential eschars (scabs), casts placed for broken bones that are too tight. Be suspicious if you find or see…Pain out of proportion to the exam, tight-looking skin, difficulties with range of motion or sensation.The best initial test (and confirmatory test) is to use a manometer to measure the pressure within the muscle compartment (to calculate the delta pressure). Normal ∆ pressure is ≤ 30 mmHg.
  • Deep Venous Thrombosis
    1. This condition presents similarly to acute compartment syndrome. Patients often present with unilateral leg swelling, pain, increased diameter of the affected leg, overlying erythema of the skin and tenderness to touch. It is diagnosed with an ultrasound, which is often able to identify the perpetrating clot as well as labs to assess the patient’s coagulation (clotting) factors. Patients who are immobile (ex. Due to a recent surgery), take certain medications (oral contraceptive pills), or have certain conditions (such as pregnancy) are at an increased risk for the development of a venous thrombosis. It is important to treat patients with medications, such as blood thinners, to prevent the development of complications, such as a pulmonary embolism (this occurs when a piece of the clot breaks off and travels to the lung).
  • Rhabdomyolysis
    1. This is a condition which is often caused by excessive exercise leading to muscle damage and the release of intracellular contents (such as myoglobin and electrolytes) into the bloodstream. Without treatment, patients can develop cardiac arrhythmias (from the excess electrolytes) and severe kidney damage. Treatment is primarily through rest and rehydration to filter the kidneys. Although rhabdomyolysis is often associated with excessive exercise, it can also occur as a result of trauma or other conditions which lead to muscle breakdown.

 Take home points

    1. Acute compartment syndrome is a condition which occurs due to excessive swelling within a fascial compartment (often of the musculature) and subsequent ischemic damage to the vasculature, nerves and muscle itself. 
    2. If left untreated, patients could develop severe complications such as loss of the affected limb, or necrosis of the musculature.
    3. To treat the patient, you must consult surgery (this is a surgical emergency!), collect the delta pressure readings with a manometer to confirm the diagnosis, and prepare the patient for surgery with fluid administration, analgesics, and methods for decreasing swelling (cold packs). 
    4. Finally, make sure you consider emergency medicine as a potential specialty! You’ll have the most exciting career and be trained to handle any situation-you just never know what you’ll see next!

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