Recognizing and managing upper extremity compartment syndrome.

Compartment syndrome is an acute limb-threatening condition typically treated with emergency fasciotomy. Although limbs often are saved, ischemia can cause irreversible neurologic damage to the extremity. Patients with upper extremity compartment syndrome may lose fine motor function, which can result in long-term impairment of perceived quality of life. This article reviews the anatomy, physiology, presentation, diagnosis, and treatment of upper extremity compartment syndrome, including rehabilitation, which can reduce complications that occur even in patients who were promptly and properly treated.

Compartment Syndrome of the Hand after Laparoscopic Gynecologic Surgery.

Acute compartment syndrome of the hand is a potentially devastating and infrequent condition observed after trauma, arterial injury, or prolonged compression of the upper limb. We present the case of a patient diagnosed with compartment syndrome of the hand after laparoscopic surgery for epithelial ovarian cancer. The patient is a 42-year-old woman with incidental finding of high-grade ovarian serous carcinoma after an emergency surgery. On imaging evaluation, the patient was found to have evidence of residual retroperitoneal adenopathy and was taken to the operating room for a staging procedure by laparoscopy. In the immediate postoperative period, she developed compartment syndrome of the right hand that required multiple fasciotomies and multidisciplinary management by plastic surgery, orthopedics, and rehabilitation medicine. The patient was discharged from the hospital 7 days after laparoscopic surgery to undergo rehabilitation. Three months after surgery, she is continuing to recover, with near complete recovery of hand function. The patient has completed a total of 3 cycles of chemotherapy with carboplatin/paclitaxel. Compartment syndrome of the hand is an uncommon event, but it can generate major functional deficits and even death if it is not diagnosed and treated in a timely manner. Strict criteria for patient positioning in laparoscopy surgery may avoid or reduce this complication. To date, this is the first case reporting such complications associated with laparoscopic gynecologic surgery.

Is surgery effective for deep posterior compartment syndrome of the leg? A systematic review.

BACKGROUND: Results of surgery for lower leg deep posterior chronic exertional compartment syndrome (dp-CECS) are inferior compared to other types of CECS. Factors influencing suboptimal surgical results are unknown. The purpose of this systematic review was to provide a critical analysis of the existing literature on the surgical management of dp-CECS aimed at identifying parameters determining surgical results. METHODS: A literature search was performed using Pubmed, EMBASE, MEDLINE and CINAHL (EBSCO). Studies including surgical results for dp-CECS were systematically reviewed. RESULTS: 7 studies of level III evidence reporting on a total of 131 patients met inclusion criteria (>5 patients, reporting intracompartmental pressures (ICP), clearly stating postoperative outcome). Only four studies strictly adhered to predefined ICP criteria. Cutoff ICP levels varied widely among the 7 studies. Surgical procedures ranged from a superficial crural fasciotomy to multiple fasciotomies of various deep posterior compartments. No single surgical procedure proved superior. Prolonged high ICP levels following provocation were associated with postoperative success. Success rates after fasciotomy were modest ranging from 30% to 65%. Risk factors for failure of surgery were not identified. CONCLUSIONS: The quality of studies reporting on surgery for dp-CECS is poor. Prospective, controlled or randomised studies are lacking. Diagnostic criteria and surgical techniques are diverse. As functional results of current management regimes are disappointing, future studies of dp-CECS should focus on optimising diagnostic criteria and standardisation of treatment modalities.

Effect of whole body vibration on intracompartmental pressure in the lower leg.

BACKGROUND: Whole body vibration has important effects on neuromuscular functions. It seems to be a promising tool in the conservative treatment and rehabilitation of compartment syndrome. In the present study we investigated the effect of whole body vibration on intracompartmental pressure in the lower leg during a strenuous static exercise program. METHODS: We conducted a cross-over pilot study in which fifteen healthy male subjects participated. They twice performed a 20.5-min static exercise program on the Fitvibe Medical whole body vibration device, once with 27 Hz vibrations and once without. The intracompartmental pressure was measured by two examiners at the superficial posterior compartment of the left and right lower leg, at rest and during the exercise programs. RESULTS: A general linear model for repeated measures showed a significant difference between the exercise program with vibrations and that without (P = 0.001) and a significant difference in intracompartmental pressure for the factor time of measurement (P < 0.001). Mean intracompartmental pressure was at any point in time lower in the vibrating than in the non-vibrating exercise conditions, though not always significant. In the program with vibrations the exercise pressures showed a non-significant trend to decrease (from 23.5 mmHg to 21.3 mmHg) as the program advanced, while in the non-vibration program, there was a trend to increase (from 24.1 to 27.9 mmHg). CONCLUSIONS: The mean intracompartmental pressure was lower when whole body vibration at 27 Hz was superimposed. Therefore, whole body vibration seems to be a possible tool to lower intracompartmental pressure. Further research is needed to confirm whether these findings are also applicable in patients, athletes, and in dynamic exercises.

Management of a case of human bite complicated by myonecrosis and compartment syndrome.

Case reports concerning rare complications of human bite injuries are uncommon in the literature. Further, rehabilitation of the resultant dysfunction is also hardly reported. A 41-year-old housewife who had had a human bite during an altercation 6 months ago was referred to the rehabilitation department with a nonfunctioning right hand. Twelve days after the injury she developed a compartment syndrome with complicating myonecrosis, which required fasciotomy and resulted in amputation of the fifth digit on the 17th day. Soft-tissue defects were reconstructed with skin grafts. Unfortunately, the patient did not attend followup visits, and 6 months after the initial injury she had to be admitted to the rehabilitation department with a nonfunctional hand. She had marked limitations of range of motion of the wrist and almost all finger joints. A rehabilitation program was initiated to improve the functional limitations of her hand. After the rehabilitation program, she was able to use her right hand in her daily routine activities. Rehabilitation can still be useful in order to avoid permanent disability even in late and complicated cases of bite injuries.

Compartment syndrome following ankle sprain.

Injury to the perforating branch of the peroneal artery has not been reported previously as a cause of acute compartment syndrome following soft-tissue injury to the ankle. We describe the case of a 23-year-old male who sustained such an injury resulting in an acute compartment syndrome. In a review of the literature, we could find only five previous cases, all of which gave rise to a false aneurysm which was detected after the acute event.

Outcomes of children with abdominal compartment syndrome.

INTRODUCTION: Abdominal compartment syndrome (ACS) is a problem across all critical care scenarios and is associated with a high mortality. It has not been well described in pediatric populations. OBJECTIVE: To describe the occurrence of ACS in a subset of critically ill pediatric patients and determine its effects on mortality and length of pediatric intensive care stay (PICU LOS). We also aimed to find predictors of mortality and development of ACS. SETTING: 25 bed tertiary pediatric intensive care unit. PATIENTS: Patients less than 50 kg on mechanical ventilation and a urethral catheter. MEASUREMENTS: Intra-abdominal pressures (IAP) were monitored using the intra-vesical technique. ACS was defined as IAP of >12mmHg associated with new organ dysfunction or failure. Demographics, physiologic measures of organ dysfunction, PICU LOS and mortality were monitored. MAIN RESULTS: 14 (4.7%) of 294 eligible patients had ACS. Mortality was 50% among those with ACS versus 8.2% without (p<.001). PICU LOS stay did not differ between groups. No difference in mortality or PICU LOS was seen in primary versus secondaryACS or in patients who underwent abdominal decompression compared to those without decompression. IAP and ACS were independent predictors of mortality (odds ratio 1.53, 95% CI, 1.17- 1.99 and 9.09, 95% CI, 1.07 - 76.84) respectively. IAP and a PRISM score of >17 were predictive of developing ACS. CONCLUSIONS: ACS is a clinical problem that increases the risk of mortality in critically ill children. IAP and PRISM scores may help identify children likely to develop ACS.

Opening wedge high tibial osteotomy: an operative technique and rehabilitation program to decrease complications and promote early union and function.

BACKGROUND: High tibial osteotomy has been associated with significant complications, including delayed union or nonunion, loss of correction, arthrofibrosis, and patella infera. HYPOTHESES: A technique for opening wedge osteotomy that incorporates an autogenous iliac crest bone graft will prevent delayed union or nonunion, allow early rehabilitation and weightbearing, and prevent knee arthrofibrosis and patella infera. Secondly, the authors' methods for calculating the desired correction of valgus alignment prevent undesired alterations in tibial slope. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 55 consecutive patients who underwent high tibial osteotomy were observed at a mean of 20 months postoperatively. Preoperative and postoperative measurements of radiographs were conducted by independent examiners for bony union, tibial slope, and patellar height. The osteotomy opening size ranged from 5 to 17.5 mm; 35 knees (64%) had openings < or =10 mm, and 20 knees (36%) had openings >11 mm. RESULTS: The osteotomy united in all patients. Three patients had a delay in union, which resolved by 6 to 8 months postoperatively. A loss of fixation occurred in 1 patient, who admitted to full weightbearing immediately after surgery; the osteotomy required revision. The iliac crest graft site healed without complications, and there were no infections, loss of knee motion, nerve or arterial injuries, alterations in tibial slope, or cases of patellar infera postoperatively. Full weightbearing was achieved at a mean of 8 weeks (range, 4-11 weeks) postoperatively. CONCLUSIONS: The operative technique including use of an autologous iliac crest bone graft in addition to a progressive rehabilitation program successfully prevented nonunion, change in tibial slope, and knee arthrofibrosis in this study.

[Analysis of some related factors of effect on gluteus muscle contraction].

OBJECTIVE: To study some related factors of effect on gluteus muscle contraction and provide the therapeutic basis. METHODS: The curative effect was assessed in 154 patients who were classified by age, patient's condition, orthopedic degree in operation and rehabilitation with an average follow-up period of 25 months(ranging from 5 to 36 months). RESULTS: The excellent rate of 18-24 years old (25/30) was lower than that of 5-17 years old(120/124) (P < 0.05); the excellent rate of slight patients was higher (107/109) than that of serious patients (38/45) (P < 0.01); the excellent rate from higher orthopedic degree was higher (111/113) than that from lower orthopedic degree (34/41) (P < 0.01); and the excellent rate of rehabilitation was much higher (107/110) than that of general treatment (38/44) (P < 0.05). CONCLUSION: Age, patient's condition, orthopedic degree in operation and rehabilitation are important factors to affect the curative effect on gluteu muscle contraction.

[Nonoperative treatment of ischemic contractures of forearm and hand]. / Die nichtoperative Behandlung der ischämischen Muskelkontraktur an Unterarm und Hand.

The acute compartment syndrome of the forearm and hand leads to severe muscle necrosis and nerve damage if the diagnosis is not recognized. The resulting ischemic contractures and paralyses require a distinctive regime of therapy. Therefore,physiotherapy and occupational therapy are of main importance. In mild cases exclusively nonoperative treatment is possible. The goal is to exercise the function of the remaining muscles, mobilize the joints, and stretch muscle scars. Severe forms need surgery. To reach the best starting point for the operation, extensive preoperative active and passive exercises as well as splint therapy are required. Postoperatively, this regime has to be continued to retain a favorable outcome. The treatment approach is demonstrated with a case report.

The impact of lower leg compartment syndrome on health related quality of life.

Although the aetiology, pathophysiology and treatment of acute compartment syndrome have been well described in the literature, there is limited information on the long-term impact of compartment syndrome on quality of life. We reviewed the medical records and radiographs of all the patients treated with surgical decompression of compartment syndrome. Between 1993 and 1998, 42 cases were identified. There were 30 cases of tibial compartment syndrome and 12 cases involving other limbs. These 30 patients were recalled for a follow-up assessment during which they were asked to complete an EQ-5D (EuroQol), a standardised measure of health related quality of life based on five dimensions (self-care, pain/discomfort, mobility, usual activities and anxiety/depression). Patients were compared with EQ-5D age/sex norms derived from a randomly selected group of patients that had sustained isolated closed tibial shaft fractures. The minimum follow-up time was 12 months. Patients who stated that the appearance of the surgical site was a problem, reported significantly poorer health related quality of life than did patients who had no problem with the appearance. Patients with skin graft reported more problems with pain and discomfort than patients without skin graft. Patients with faster closure times of the wound showed significantly better self-rated health status than patients in whom the wound closure time was longer. Although the patients in this study reported significantly more problems on the dimensions of EQ-5D than were reported in the control group, their overall self-rated health was not statistically different. This study has demonstrated that compartment syndrome may be associated with long-term impact on health related quality of life.

Fasciotomy for chronic compartment syndrome in the lower limb.

BACKGROUND: The aim of this study was to determine the success of fasciotomy of lower limb compartments with elevated intra-compartment pressure. METHODS: The present report is a retrospective cohort study at No. 3 Combat Support Hospital involving a survey and case note review of patients who had undergone fasciotomy for compartment syndrome at least 6 months earlier (December 1997-December 2000). RESULTS: Fourteen patients met the inclusion criteria. Eleven reported success with complete resolution of symptoms and return to military fitness levels. Two reported no change and significant residual symptoms. One reported worse symptoms and one required re-operation with a successful result. CONCLUSION: Surgical decompression is the accepted treatment of compartment syndrome as proven by pressure manometry, after failure of conservative treatment.

A case of acute renal failure and compartment syndrome after an alcoholic binge.

A 25 year old man presented with anuria and bilateral leg pain two days after an alcoholic binge. He subsequently developed rhabdomyolysis causing acute renal failure, with compartment syndrome of both lower legs. This required urgent dialysis and fasciotomy respectively within six hours of admission. He remained dialysis dependent for three weeks and only after four months was he able to weight bear on both legs. Alcohol is a leading cause of rhabdomyolysis. Early recognition and prompt treatment is essential to prevent serious complications.

Multidisciplinary conservative management in classical Volkmann's contracture: a case report.

This clinical note describes the case of a nine-year-old girl with classical Volkmann's contracture of the left forearm. The report demonstrates the results and follow-up of conservative orthotic management used as a mode of treatment by a multidisciplinary team. When using an orthosis it is essential to check regularly to attain the desired result.

Reinnervated free gracilis muscle transplantation in the treatment of Volkmann's syndrome of the forearm.

Between 1989 and 1994 free gracilis muscle reinnervation was used to treat three patients severely affected with Volkmann's syndrome of the forearm. All three patients were males and they had supracondyloid fracture of the humerus, treated nonsurgically an average of 7.6 years previously. Mean age at the time of surgery was 19.3 years. The flap was transplanted in flexor function of the fingers in two of the patients, in extensor function of the wrist in one. Electromyography and successive clinical monitoring revealed an increase in contractile strength up to one year after surgery. In the first two cases final hold strength exceeded by more than 50% that of the contralateral limb, in the third case excursion of the wrist which could not be quantified, but which was useful for elementary activities was recovered. When myotendinous units for transplantation are not available, free gracilis muscle reinnervation constitutes a valid surgical solution in cases of severe Volkmann's syndrome of the forearm.

Common compartment syndromes in athletes. Treatment and rehabilitation.

Compartment syndromes in athletes are rare, but they can also be limb-threatening events. Chronic exertional compartment syndrome (CECS) is a less emergent form where symptoms recur with repetitive loading or exertional activities. CECS is the most common form of compartment syndrome seen in athletes. Acute compartment syndromes may also occur in athletes secondary to direct trauma or may develop from pre-existing CECS. The leg is by far the most common site of compartment syndrome in athletes. The thigh, forearm, and foot are the next most common sites, although any fascially limited compartment can be affected. Awareness of the clinical presentation and pathophysiology of compartment syndromes can help the examiner make a prompt and accurate diagnosis. The treatment of acute compartment syndrome is emergent while the treatment of CECS is not. Conservative treatment and rehabilitation can be successful in treating CECS. Acute compartment syndromes must be treated immediately with surgical decompression. With CECS, if conservative treatment fails, surgical decompression is also indicated. Some authors have suggested that the results of surgical fasciotomy and rate of return to sport for athletes with CECS has not been uniform. If the diagnosis is accurate and carefully documented, a high degree of success with athletes returning to sport can be expected.

A dentist's experience with change of hand dominance.

Ten years ago as a young dentist, the author found himself completely unable to engage in his practice as a result of a serious nerve injury permanently affecting his dominant right hand and forearm. Some unique opportunities and chance encounters have enabled him to overcome the permanence of the injury and to advance into a dental specialty field considered very demanding bimanually. Chronicled below are the process by which this occurred and, in particular, the author's assessment of what led to the necessary change of hand dominance. Also described is an interesting process that was required by the admissions committee of the postgraduate specialty training program as part of their assessment of the author's ability to adequately perform clinical procedures prior to his admission into the program. Descriptions of certain office design changes as well as changes in instrumentarium and techniques and the inventions to support those changes are described.

The effect of exercise on patellar tracking in lateral patellar compression syndrome.

The influence of a physical therapy program on pain and patellar tracking was investigated clinically and radiologically with tangential views in 51 knees with lateral patellar compression syndrome. A pretest-posttest design was used to evaluate physical measurements of patellar alignment in subjects who had had patellofemoral pain for a minimum of 6 weeks. Eighty-four percent of the subjects were pain-free after an average of 8 weeks of rehabilitation or 11 physical therapy visits, with a mean quadriceps strength to total body weight ratio of 61% in women and 86% in men. The pretest-posttest difference in Merchant's congruence angle was significant at a probability of 0.0066 in the patients who were pain-free after exercise, demonstrating less lateral patellar tracking. The pretest-posttest difference in iliotibial band flexibility was significant at a probability of 0.0017, with the patients who were pain-free after exercise becoming more flexible. No significant differences were observed from before to after exercise in the patellofemoral index, Q angle, hamstring flexibility, thigh measurement, sclerotic subchondral bone, or sulcus angle. We were unable to predict which subjects would become pain-free with exercise by patellar position because the group that improved began more laterally tilted. The results of this study indicate that patellar tracking is improved with vastus medialis oblique strengthening, iliotibial band stretching, and joint mobility exercise in the majority of subjects with lateral patellar compression syndrome.

[Functional rehabilitation of the upper extremity after compartment syndrome]. / Funktionswiederherstellung an der oberen Extremität nach Kompartmentsyndrom.

In established compartment syndrome discrimination between the different forms of flexion contracture, i.e., manifest Volkmann's contracture and intrinsic contracture is necessary. A combination of both is also possible. Classification is essential for determination of whether reconstruction is indicated and what procedure should be selected. Shortening osteotomies of the ulna and radius are now of historical interest only, as is carpalectomy. Lengthening of the flexor tendons is indicated only in mild and localized limited contracture of only some of the long fingers, but there is a danger of possible further adhesions limiting the range of motion. Thus, cases of stage I and II according to Tsuge with persisting partial flexor motor function are treated mainly by muscle sliding operation (Scaglietti) combined with microsurgery for internal neurolysis of the median and ulnar nerves. The latter is anteriorly transposed. In cases of solitary intrinsic contracture we prefer the Littler release procedure. The most useful repair in advanced compartment syndrome, however, consists in free microsurgical tissue transfer. The non-contractile, degenerated scarred flexor muscle remnants are excised and substituted orthotopic by transfer of free, neurovascular muscle, with salvage of flexor motor function in the forearm.