Published on March 3, 2014
A SPORTS MEDICINE PHYSICIAN’S PERSPECTIVE DAVID CARFAGNO, D.O., CAQSM SCOTTSDALE SPORTS MEDICINE
23 year professional football player left the game in the 2nd quarter due to lower leg pain He doesn’t recall a specific injury Upon inspection, Team Physician felt that there were no broken bones, muscle weakness, sprains or strains and declared his discomfort was due to cramping and had the player benched
Following the game, player returned home Noticed an increase in pain as the night progressed Tried to sleep, but awoke with severe lower leg pain which lead him to call the Team Physician for help
Moore was transported to the University of Colorado Hospital where he was diagnosed with lateral compartment syndrome He underwent emergency surgery to have his fascia opened to relieve increasing pressure
Q. Fractures are the cause in less than 25% of cases of compartment syndrome. A. True B. False
Acute Compartment Syndrome (ACS) is a complication following fractures, soft tissue trauma, and reperfusion injury after acute arterial obstruction. Common in participants of sports with high incidence of falls, fractures, contusions, etc. Difficult to diagnose without clinical testing Most often associated with fractures of long bones (e.g., tib-fib) Poor outcomes assoc. with delayed diagnosis
ACS is defined as a compartment pressure of >30 mmHg or within 30 mmHg of diastolic pressure. J Bone Joint Surg Br 1996;78:99–104.
1/3 of all cases involve tibial shaft fractures Young age: Patients <35 years old more likely than older patients to develop ACS following same type of injury 10x more common in males Most cases associated with fractures of long bones, although 23.2% of cases associated with soft tissue injury only No difference in incidence of ACS in open compared to closed fractures J Bone Joint Surg Br. 2000;82:200–203.
Following an injury (e.g., fracture), muscl e swelling compresses VAN in compartment Intracompartmental pressure rises Ischemia, followed by necrosis
Bleeding: after vascular injuries or from cancellous bone following fractures Edema: from increased capillary permeability & fluid extravasation due to oxygen deprivation caused by bleeding Increases perfusion barrier resulting in hypoxia + acidosis Hypoxia + acidosis further increase capillary permeability & fluid extravasation Increases intracompartmental pressure Restricted intracompartmental space: inelastic compartment cannot accommodate expansion due to finite borders defined by surrounding fascia and bone Arterial compression, ischemia, then cellular death
Delayed diagnosis often has limb- and lifethreatening consequences. Despite the relative frequency with which ACS is seen by orthopedic surgeons, the diagnosis is difficult. Clinical signs mimic other conditions Gold standard: assess intracompartmental pressure with tonometry; fasciotomy Refer to orthopedic specialist Curr Rev Musculoskelet Med. 2012 September; 5(3): 206–213.
Pain out of proportion to initial injury Pain on passive stretch of muscles within affected compartment Palpably tense compartment Weakness and paresthesia of areas supplied by nerves crossing the compartment Late signs: loss of pulses (due to arterial occlusion), paralysis High index of suspicion for compartment syndrome must be maintained, even if all diagnostic criteria are not met Clin Orthop Relat Res. 2010 April; 468(4): 940–950.
6 “P’s” 1. 2. 3. 4. 5. 6. Pain Paresthesia Paralysis/Paresis Pulselessness Pallor Pressure
Uncomplicated fracture Cellulitis Deep Venous Thrombosis Peripheral Vascular Injuries
Measure intracompartmental pressures with tonometer Doppler (rule out DVT) Serum chemistry studies (rule out rhabdomyolysis) Imaging (determine nature and severity of fractures)
Perform FASCIOTOMY when difference between compartment pressure and diastolic blood pressure is <30 mm Hg or when clinical symptoms are obvious. Fasciotomy of all compartments is required. Clin Orthop Relat Res. 2010; 468(4): 940–950.
May be significant -Skin grafts over incisions often needed -Muscle weekness in affected limb can persist Overall complication rate is 10x higher if fasciotomy is delayed 12 hours from onset - amputation rate increased to over 50% - 8% of pts (untreated) vs 68% (treated) had limb function return to normal J Bone Joint Surg Br. 2000; 82 (2):200
In patients with tibial fractures, McQueen et al. demonstrated that the time between apparent onset of compartment syndrome and surgical release influenced the outcome rather than the time between trauma and fracture stabilization. Documentation of clinical findings in ACS is important since serial examinations are necessary and the findings over time must be compared.
Infection Contracture Muscle necrosis Amputation Rhabdomyolysis Renal failure
PHASE I: Protection and Mobility (Surgery to 2-3 weeks). Protection, Rest, Ice, Compression, and Elevation. PHASE II: Light Strengthening (begin after meeting Phase I criteria, approximately 3-4 weeks following surgery). ROM, stretching. PHASE III: Progression of Strengthening (begin after meeting Phase II criteria, approximately 4-6 weeks following surgery). PHASE IV: Impact/Sport Training (Begin after meeting Phase III criteria, approximately 8-12 weeks following surgery) http://www.youtube.com/watch?v=hDHyrhbwq-M
Tibial Fracture: 12-13 weeks average healing time, followed by rehabilitation and gradual increase in exercise intensity. Fibular Fracture: 8-12 weeks Tib-fib: 6 months or more High Ankle Sprain: weeks to months Int J Sports Phys Ther. 2011 June; 6(2): 126–141.
Study: over a 23-year period, 6% of all malpractice claims against orthopedic surgeons were related to ACS and greater than 50% were ruled in favor of the patient. Linear relationship between the number of cardinal signs and the time from presentation to fasciotomy and payment size. Shadgan et al suggest that poor communication between physician, other members of the healthcare team, and the patient is associated with unfavorable outcomes. Bhattacharyya ‘04 Shadgan et al, ‘10
ACS in children most common in leg Classic signs and symptoms often present later or are completely absent Nearly 1/3 of pediatric patients present only with pain Average normal resting intracompartmental pressure is slightly higher in children (13 to 16 mmHg) than in adults (8 mmHg) J Bone Joint Surg Br. 1996;78:95–98. Curr Rev Musculoskelet Med. 2012 September; 5(3): 206–213
Compartment syndrome is a serious syndrome that needs to be diagnosed early Palpable pulses don’t exclude compartment syndrome If diagnosis and fasciotomy are done early, prognosis is good If delayed, complications will develop
David Carfagno, D.O., C.A.Q.S.M. Board Certifications: Internal Medicine, Sports Medicine (CAQ), Ringside Medicine (ABRM) Medical Director, Ironman Arizona & Rock and Roll Marathon Arizona. Team physician, USA Boxing 10133 N. 92nd Street, Suite 102 Scottsdale, AZ 85258 Office – 480.664.4615 Email – email@example.com
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