Neurologic Conditions Associated with Cavus Foot Deformity.

The cavus foot deformity is an often less understood deformity within the spectrum of foot and ankle conditions. The hallmark concern is the possibility of an underlying neurologic or neuromuscular disorder. Although a proportion of these deformities are idiopathic, a significant majority do correlate with an underlying disorder. The appropriate evaluation of this deformity, in coordination within the multidisciplinary scope of health care, allows for a timely diagnosis and understanding of the patient's condition. We provide an abbreviated survey of possible underlying etiologies for the patient with the cavus foot deformity as a reference to the foot and ankle surgeon.

Comparison of Three Devices to Measure Pressure for Acute Compartment Syndrome.

INTRODUCTION: Acute compartment syndrome (ACS) is a well-recognized and common emergency. Undiagnosed ACS leads to muscle necrosis, limb contracture, intractable pain, and may even result in amputation. METHODS: Three devices (Synthes, Stryker, and MY01) were compared in a pre-clinical rat abdominal compartment syndrome simulation. Simultaneous measurements of intracompartmental pressures allowed concurrent comparison among all devices. RESULTS: Large variations from the reference values are seen with the Synthes and Stryker devices. Variances are large in these two devices even under ideal conditions. The MY01 device was the truest indicator of reference pressure in this ACS model (over 600% more accurate). CONCLUSIONS: The MY01 device was the most accurate device in tracking pressure changes in this rat model of abdominal compartment syndrome.

Feasibility of ultrasound measurement in a human model of acute compartment syndrome.

BACKGROUND: Early diagnosis of acute compartment syndrome (ACS) of the leg is essential to improve the outcome. Direct invasive measurement is currently recommended to measure intracompartmental pressure. A non-invasive and reproducible means of making the diagnosis would be a step forward. The purpose of this exploratory study was to investigate the feasibility of non-invasive ultrasound-guided angle measurement as a surrogate of increased pressure in a model of ACS. METHODS: A model of ACS was generated by infusion of saline into the anterior compartment of the leg of human cadavers to incrementally increase the intracompartmental pressure from 10 to 100 mmHg. In 40 legs (20 cadavers), the angle (TFA, tibia-fascia angle) between the anterolateral cortex of the tibia and the fascia of the anterior compartment was measured at each 10 mmHg pressure increase using ultrasound in a standardized transversal plane. A multilevel linear regression model was used to estimate intracompartmental pressure from delta TFA (ΔTFA). RESULTS: TFA (mean [± SD]) increased from 61.0° (± 12.0°) at 10 mmHg up to 81.1° (± 11.1°) at 100 mmHg compartment pressure. Each increase ΔTFA by one degree was associated with an increase in pressure by 3.9 mmHg (95% CI, 3.8-4.0, p < 0.001). CONCLUSIONS: We found that intracompartmental pressure of the anterior compartment of the calf can be well estimated by ultrasound-based ΔTFA in this post mortem experiment. Our findings indicate that non-invasive TFA measurement is feasible and it is reasonable that this will hold true in real life, but the findings are too preliminary to be used in clinical practice now.

Compartment syndrome: pathophysiology, clinical presentations, treatment, and prevention in human and veterinary medicine.

OBJECTIVE: To review the human and veterinary literature pertaining to all forms of compartment syndrome (CS). DATA SOURCES: Data sources included scientific reviews and original research publications from the human and veterinary literature. HUMAN DATA SYNTHESIS: While CS affecting the extremities has been recognized in people for decades, other forms of CS in the abdominal and thoracic cavities are recently gaining more attention. The role of CS in critically ill people is a rapidly growing area of interest. More research on prevention and treatment of CS is being conducted in people because some studies have found mortality rates as high as 80% for those suffering from these conditions. VETERINARY DATA SYNTHESIS: While a significant amount of experimental studies of CS have been performed on small animals, there is a marked lack of primary veterinary studies. The majority of the veterinary literature includes case reports and series, and many of these studies were published over a decade ago. However, the increased recognition of CS in people has sparked an interest in veterinary critical care medicine and this has been demonstrated by the recent increased evaluation of compartment pressures in veterinary patients. CONCLUSIONS: CS is a complex clinical condition where increased pressure within a compartment can cause significant adverse effects within the compartment as well as throughout the body. Systemic inflammatory responses and local ischemia-reperfusion elements can contribute to the detrimental effects seen in CS. This cascade of events results in increased mortality rates and contributes to the development of CS elsewhere. A better understanding of CS will help veterinarians improve patient care and outcome. Future studies on incidence, prevention, and treatment of CSs in the critical care patient are needed in veterinary medicine.

[Monitoring of intraabdominal pressure in colonic obstruction].

Results of surgical treatment of 197 patients with acute colonic obstruction complicated by intraabdominal hypertension were analyzed. Monitoring of intraabdominal pressure was made in 101 patients at the pre- and postoperative periods. Compensated, sub- and decompensated forms of obstruction depending on the data of intraabdominal pressure were determined. The level and dynamics of the intraabdominal pressure are taken as criteria of severity of acute colonic obstruction, decision on the time and volume of surgical procedures. The medico-diagnostic algorithm of management of such patients is proposed. Lethality turned out to be decreased to 15.8% as compared with a control group (24%) due to the monitoring of intraabdominal pressure and improved surgical strategy.

The pathophysiology of ovarian hyperstimulation syndrome: an unrecognized compartment syndrome.

OBJECTIVE: To compare and contrast the pathophysiology of ovarian hyperstimualtion syndrome (OHSS) with known syndromes of increased intraabdominal pressure (IAP), and to explore the relationship of increased IAP with symptom severity in OHSS. DESIGN: Literature review. MAIN OUTCOME MEASURE(S): Correlation of OHSS symptoms with IAP; effects of paracentesis on IAP in patients with OHSS. SETTING: Academic Research Institution. INTERVENTION(S): None. RESULT(S): OHSS involves a rapid accumulation of volume (from 1.5-17 liters) in the peritoneal cavity that can lead to organ dysfunction, including respiratory impairment and oliguria. In published reports of 20 moderate-to-severe OHSS patients in whom IAP was measured, IAP was found to be elevated to a pathologic range. The increased IAP indicates that OHSS may be considered a compartment syndrome and meets criteria for abdominal compartment syndrome in advanced cases. For this reason, management of OHSS should include reduction of pressure by paracentesis to avoid morbidity and syndrome progression. In addition, measurement of IAP may help to classify the stage of OHSS. CONCLUSION(S): IAP was found to be elevated in the few cases of OHSS in which it was measured, substantiating the conclusion that OHSS may be considered a compartment syndrome. An understanding of the pathophysiology of increased intrabdominal pressure is useful in the management of OHSS.

Intra-abdominal hypertension: evolving concepts.

This article focuses primarily on the recent literature on abdominal compartment syndrome (ACS) and the definitions and recommendations published by the World Society for the Abdominal Compartment Syndrome. The definitions regarding increased intra-abdominal pressure (IAP) are listed and are followed by an overview of the different mechanisms of organ dysfunction associated with intra-abdominal hypertension (IAH). Measurement techniques for IAP are discussed, as are recommendations for organ function support and options for treatment in patients who have IAH. ACS was first described in surgical patients who had abdominal trauma, bleeding, or infection; but recently, ACS has been described in patients who have other pathologies. This article intends to provide critical care physicians with a clear insight into the current state of knowledge regarding IAH and ACS.

[Reconstructive surgery of sequelae of compartment syndrome of the lower leg and/or foot. Presentation of a new classification]. / Wiederherstellende Chirurgie der Folgezustände nach Kompartmentsyndrom des Unterschenkels und/oder Fusses. Vorstellung einer neuen Klassifikation.

The sequelae of an undiagnosed insufficiently treated or unpreventable (by crush injury) compartment or postischemic syndrome, most often after lower leg fracture or popliteal artery injury, are caused by necrosis and contracture of the extrinsic foot muscles. Therefore claw toes, pes equinus or other forms, such as a severe pes equino varus related to the compartment involved will decide the kind of foot deformity. In cases of a combined compartment syndrome of the lower leg and foot, not only the extrinsic but also the intrinsic muscles especially the short flexors are involved, leading to extensive claw toeing of the hallux and the lesser toes as well. In the case of an isolated compartment syndrome of the foot one will see contracted hammer toes most often after open or third degree closed calcaneal fractures. A new classification of all the different deformities of the foot and ankle as sequelae of a compartment and/or postischemic syndrome, is introduced distinguishing 5 degrees of deformity. Between 1994 and 2006, a total of 66 patients with sequelae of a compartment and/or postischemic syndrome were treated at the Department of Trauma and Reconstructive Surgery of the University Hospital"Carl Gustav Carus" of the Technical University of Dresden. Patients with contract hammer toes after calcaneal fractures were seen most often (n=26). Another large group of 24 patients suffered from the sequelae of a compartment and/or postischemic syndrome of the extrinsic muscles of the superficial and deeper compartment of the flexor tendons, producing a severe pes equino varus. Less common (n=16) were the deformities caused by an isolated compartment syndrome, such as necrosis of the anterior tibialis, long extensor muscles, peroneal muscles or a combined compartment syndrome of the lower leg and foot.

Abdominal compartment syndrome in patients with strangulated hernia.

BACKGROUND: Intestinal obstruction (IO) leads to increased intra-abdominal pressure and abdominal compartment syndrome. The purpose of this study was to investigate the characteristics of abdominal compartment syndrome in patients with IO secondary to strangulated hernia. METHODS: We studied 81 consecutive unselected patients presenting complicated hernias and IO. We measured intra-abdominal pressure using the intra-vesicular pressure method. RESULTS: Preoperative (15 min) intra-abdominal pressure was higher in patients with strangulated hernias. Postoperative (15 min) intra-abdominal pressure in both groups decreased to similar values. Intra-abdominal pressure was measured during the preoperative period in patients with strangulated hernias and during the postoperative period at 15 min (13.8 +/- 6.4 mmHg), 24 h (9.8 +/- 3.2 mmHg) and 48 h (7.4 +/- 2.4 mmHg). Abdominal compartment syndrome developed in 47% cases with strangulated hernias with a mortality of five patients. CONCLUSIONS: Serial measurements of intra-abdominal pressure evidenced the clinical severity of strangulated hernia. Intra-abdominal pressure measurement may be used as a predictor of intestinal strangulation in patients presenting acute abdominal compartment syndrome secondary to complicated hernia.

Validation and experience with a simple continuous intra-abdominal pressure measurement technique in a multidisciplinary medical/surgical critical care unit.

BACKGROUND: Raised intra-abdominal pressure (IAP) or intra-abdominal hypertension (IAH) may induce many adverse effects including the abdominal compartment syndrome. We evaluated a new technique for continuous monitoring of intra-abdominal pressure (CIAP) using a standard three-way bladder catheter in a diverse group of intensive care unit patients. METHODS: CIAP measured using a standard three-way bladder catheter was compared with five standard intermittent IAP (IIAP) measurements in 79 patients. RESULTS: Mean (standard deviation) CIAP was identical (15.4 mm Hg [5.8]) for CIAP and IIAP one minute after saline injection. Mean differences between methods were less than 1 mm Hg, and similar whether IIAP was measured at 1 minute, 2 minutes, 3 minutes, 4 minutes, or 5 minutes. Bland-Altman analysis comparing CIAP and IIAP (1 minute) revealed a mean difference (95% confidence interval) of -0.06 mm Hg (-0.51, 0.39). Limits of agreement were -4.12 mm Hg to 4.00 mm Hg. Considering gradations of IAH defined by the World Society of the Abdominal Compartment Syndrome, CIAP was sensitive for detecting slightly elevated IAP (>11 mm Hg) but is less sensitive for distinguishing between higher grades of IAH (e.g., pressures >20 mm Hg or 25 mm Hg). Limits of agreement were best for patients with IAP less than 20 mm Hg, surgical or traumatic diagnoses and for patients with BMI less than 26. CONCLUSIONS: Overall, CIAP is an accurate and simple means of measuring IAP when compared with the current standardized method. Elevated CIAP measurements should be confirmed with IIAP measurements if accurate grading is required until further validation and experience is obtained.

Use of near-infrared spectroscopy as a physiologic monitor for intra-abdominal hypertension.

BACKGROUND: Intra-abdominal hypertension (IAH) is increasingly recognized as an important parameter in critically ill (ICU) patients. IAH affects perfusion to all abdominal components including the abdominal wall (AW). Near infrared spectroscopy (NIRS) measures changes in three chromophores including oxygenated hemoglobin (HbO2), deoxygenated hemoglobin (Hb), and cytochrome aa3 (Cyt), providing information concerning dysoxia. We sought to examine whether NIRS measurement of the AW was safe, and correlated with intra-abdominal pressure (IAP) in ICU patients. METHODS: A NIU-Pro001 system recorded NIRS data over 24 hours from the AW of 9 ICU patients at risk for IAH. IAP was recorded from the bladder. Changes in chromophore values are interpolated from best-fit polynomial curves. RESULTS: Sixty-six paired IAP and NIRS readings were taken from 9 ICU (4-12 observations/patient) patients. No measurement related adverse reactions occurred. The mean (range) first values measured in these patients were; IAP 17.2 mm Hg (9-31); HbO2 0.41 micromol/L (-8.4 to 7.6); Hb 2.6 micromol/L (-3.1 to 12.2); and Cyt 0.65 micromol/L (-3.4 to 4.8). A significant, inverse (or negative) association was found between DeltaNIRS HbO2 level and DeltaIAP (coefficient, -0.1588; p = 0.008). No association was found between DeltaNIRS Hb or DeltaCyt and DeltaIAP. CONCLUSION: NIRS of the AW appears safe. NIRS measurement of changes in HbO2 appears to be associated with DeltaIAP, and warrant further study in greater numbers of ICU patients with more frequent IAP readings, over longer periods of critical illness.

Primary and secondary intra-abdominal hypertension--different impact on ICU outcome.

OBJECTIVE: To investigate the differences in incidence, time course and outcome of primary versus secondary intra-abdominal hypertension (IAH), and to evaluate IAH as an independent risk factor of mortality in a presumable risk population of critically ill patients. DESIGN: Prospective observational study. SETTING: General intensive care unit of a university hospital. PATIENTS: A total of 257 mechanically ventilated patients at presumable risk for the development of IAH were studied during their ICU stay and followed up for 90-day survival. INTERVENTIONS: Repeated measurements of intra-abdominal pressure (IAP). MEASUREMENTS AND RESULTS: IAP was measured intermittently, via bladder. IAH (sustained or repeated IAP > or = 12 mmHg) developed in 95 patients (37.0%). Primary IAH was observed in 60 and secondary IAH in 35 patients. Patients with secondary IAH demonstrated a significant increase of mean IAP during the first three days (mean DeltaIAP was 2.2 +/- 4.7 mmHg), whilst IAP decreased (mean DeltaIAP -1.1 +/- 3.7 mmHg) in the patients with primary IAH. The patients with IAH had a significantly higher ICU- (37.9 vs. 19.1%; P = 0.001), 28-day (48.4 vs. 27.8%, P = 0.001), and 90-day mortality (53.7 vs. 35.8%, P = 0.004) compared to the patients without the syndrome. Patients with secondary IAH had a significantly higher ICU mortality than patients with primary IAH (P = 0.032). Development of IAH was identified as an independent risk factor for death (OR 2.52; 95% CI 1.23-5.14). CONCLUSIONS: Secondary IAH is less frequent, has a different time course and worse outcome than primary IAH. Development of IAH during ICU period is an independent risk factor for death.

Management of forearm compartment syndrome.

Compartment syndrome of the forearm is a serious medical problem, and it is commonly associated with high-energy injuries to the upper extremity. Timely recognition and treatment are critical to ensuring a good outcome and avoiding permanent functional loss. The diagnosis is primarily based on clinical suspicion. Surgical intervention with fasciotomy is the mainstay of treatment.

Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions.

OBJECTIVE: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. The variety of definitions proposed has led to confusion and difficulty in comparing one study to another. DESIGN: An international consensus group of critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to standardize definitions for IAH and ACS based upon the current understanding of the pathophysiology surrounding these two syndromes. METHODS: Prior to the conference the authors developed a blueprint for the various definitions, which was further refined both during and after the conference. The present article serves as the final report of the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of Abdominal Compartment Syndrome (WSACS). RESULTS: IAH is redefined as an intra-abdominal pressure (IAP) at or above 12 mmHg. ACS is redefined as an IAP above 20 mmHg with evidence of organ dysfunction/failure. ACS is further classified as either primary, secondary, or recurrent based upon the duration and cause of the IAH-induced organ failure. Standards for IAP monitoring are set forth to facilitate accuracy of IAP measurements from patient to patient. CONCLUSIONS: State-of-the-art definitions for IAH and ACS are proposed based upon current medical evidence as well as expert opinion. The WSACS recommends that these definitions be used for future clinical and basic science research. Specific guidelines and recommendations for clinical management of patients with IAH/ACS are published in a separate review.

[The abdominal compartment syndrome (ACS) in general surgery]. / Abdominális kompartment szindróma (ACS) az általános sebészetben.

Mortality due to the abdominal compartment syndrome is extremely high (38-71%). It may be defined as adverse physiologic consequences that occur as a result of an acute increase in the intraabdominal pressure. The most common causes of abdominal compartment syndrome are retroperitoneal haemorrhage, visceral oedema, pancreatitis, bowel distension, venous mesenterial obstruction, tense ascites, peritonitis, tumor. The mostly affected organ systems include cardiovascular, pulmonary, renal, central nervous and splanchnic. The diagnosis depends on the recognition of the clinical syndrome followed by an objective measurement of intraabdominal pressure, preferably that of the urinary bladder. The treatment consist of adequate fluid resuscitation and surgical decompression when necessary.

Management of established Volkmann's contracture of the forearm in children.

As with many diagnoses in medicine, the best treatment for Volkmann's ischemic contracture is prevention. Early recognition and prompt treatment of impending Volkmann's ischemia should decrease the presentation and severity of late contracture and hand dysfunction. The authors have found the flexor muscle slide the best treatment option for mild and moderate deformity. This procedure can be combined with additional reconstructive procedures to maximize functional outcome. The authors believe this procedure results in the best preservation of the muscle resting length and limits the scarring around the adjacent muscles. For severe cases,early wide excision with functional free-muscle transfer may limit the injury to the nerves, decreasing the distal problems associated with mo-tor and sensory impairment in the hand.

Abdominal compartment syndrome.

Abdominal compartment syndrome may be defined as the deleterious pathophysiologic consequences of a significant increase in intra-abdominal pressure. These alterations can affect respiratory mechanics, cardiovascular system, regional blood flow, renal function, urine output, and intracranial pressure. Although the syndrome may be associated with many clinical situations, the most common are severe abdominal trauma and ruptured abdominal aortic aneurysm. Diagnosis depends upon recognition of the clinical syndrome followed by an objective measurement of intra-abdominal pressure, the most common being the measurement of bladder pressure. Treatment consists of adequate fluid resuscitation and surgical decompression when necessary.

[The compartment syndrome--still a threat in traumatology]. / Kompartment syndrom--stálá hrozba v traumatologii.

Paper presents current opinions on the definition, causes, classification, diagnosis and treatment of the compartment syndrome (CS). The development of CS after the long-bone fractures of the lower extremity and also after the limb operations or trauma without fracture is discussed. The importance of early and correct diagnostics and treatment is also revealed. Authors present several case reports and they stress the importance of early fasciotomy when necessary.