Risk factors for acute compartment syndrome in one thousand one hundred and forty seven diaphyseal tibia fractures.

PURPOSE: Acute compartment syndrome (ACS) remains a devastating complication of orthopaedic trauma. The tibial diaphysis is especially implicated in the development of ACS, both at the time of injury and after operative management. Identification of risk factors for ACS for these distinct scenarios has been investigated in a large cohort of patients. METHODS: This is a retrospective cohort study of all adults (age 18 years and older) presenting to a level 1 trauma centre with a diaphyseal tibia fracture. ACS was determined by a combination of clinical signs and symptoms and compartmental pressure monitoring. Potential risk factors were subject to univariate analysis with significant variables undergoing binary logistic regression analysis. RESULTS: 1147 tibial diaphyseal fractures over a twelve year period were studied. Age, multifragmented fracture pattern, male gender, high energy mechanism and intra- articular extension all showed a statistically significant association for ACS. Increasing body mass index (BMI) and treatment with an intramedullary nail favoured development of ACS post-operatively. CONCLUSION: Risk factors for the development of ACS specifically in tibial diaphyseal fractures have been highlighted. Patients managed with IMN or high BMI may warrant particular observation following operative intervention.

Suprapatellar tibial fracture nailing is associated with lower rate for acute compartment syndrome and the need for fasciotomy compared with the infrapatellar approach.

BACKGROUND: Intramedullary tibial nailing (IMN) is the gold standard for stabilizing tibial shaft fractures. IMN can be performed through an infra- or suprapatellar approach. PURPOSE: The aim of this study is to compare the rate of fasciotomies for acute compartment syndrome between infra- and suprapatellar approaches. METHODS: A total of 614 consecutive patients who were treated with IMN for tibial fracture between October 2007 and February 2020 were included in the study. The approach used for IMN was determined by the operating surgeon. Infrapatellar IMN was performed with the knee in deep flexion position, with or without calcaneal traction. Suprapatellar IMN was performed in straight or semiflexed position. The diagnosis of compartment syndrome was based on clinical analysis, but for some patients, a continuous compartment pressure measurement was used. The primary outcome was the rate of peri- and postoperative compartment syndrome treated with fasciotomies. RESULTS: The study sample included 513 patients treated with infrapatellar IMN and 101 patients treated with suprapatellar IMN technique. The mean age of the patients was 44.7 years (infrapatellar technique) and 48.4 years (suprapatellar technique). High energy trauma was seen in 138 (27%) patients treated with infrapatellar technique and in 39 (39%) patients treated with suprapatellar technique. In the suprapatellar group (n = 101), there were no cases of peri- or postoperative compartment syndrome treated with fasciotomies. In the infrapatellar group (n = 513), the need for fasciotomies was stated in 67 patients, 31 patients (6.0%) perioperatively and in 36 patients (7.0%) postoperatively. The rate of fasciotomies (0/101 versus 67/513 cases) differed significantly (p < 0.001). There were no significant differences in the fracture morphology or patient demographics between the study groups. CONCLUSIONS: The suprapatellar technique is recommended over the infrapatellar approach in the treatment of tibial shaft fractures. The rate of peri- and postoperative compartment syndrome and the need for fasciotomies was significantly lower with the suprapatellar technique. The major cause of increased rate of peri- or postoperative acute compartment syndrome with infrapatellar IMN technique is presumably associated with the positioning of the patient during the operation.

The mechanism of the Nfe2l2/Hmox1 signaling pathway in ferroptosis regulation in acute compartment syndrome.

Acute compartment syndrome (ACS) is a life-threatening orthopedic emergency, which can even result in amputation. Ferroptosis is an iron-dependent form of nonapoptotic cell death. This study investigated the mechanism of ferroptosis in ACS, explored candidate markers, and determined effective treatments. This study identified pathways involved in the development of ACS through gene set enrichment analysis (GSEA), Gene Ontology, Kyoto Encyclopedia of Genes and Genomes (KEGG), and GSEA of heme oxygenase 1 (Hmox1). Bioinformatics methods, combined with real-time quantitative polymerase chain reaction, western blot analysis, and iron staining, were applied to determine whether ferroptosis was involved in the progression of ACS and to explore the mechanism of nuclear factor erythroid-2-related factor 2 (Nfe2l2)/Hmox1 in ferroptosis regulation. Optimal drugs for the treatment of ACS were also investigated using Connectivity Map. The ferroptosis pathway was enriched in GSEA, KEGG of DEGs, and GSEA of Hmox1. After ACS, the reactive oxygen species content, tissue iron content, and oxidative stress level increased, whereas glutathione peroxidase 4 protein expression decreased. The skeletal muscle was swollen and necrotized; the number of mitochondrial cristae became fewer or even disappeared, and Nfe2l2/Hmox1 expression increased at the transcriptional and protein levels. Hmox1 was highly expressed in ACS, indicating that Hmox1 is a possible marker for ACS. we could predict 12 potential target drugs for the treatment of ACS. In conclusion, Hmox1 was a potential candidate marker for ACS diagnosis. Ferroptosis was involved in the progression of ACS. It was speculated that ferroptosis is inhibited by the Nfe2l2/Hmox1 signaling pathway.

A practical nomogram for predicting amputation rates in acute compartment syndrome patients based on clinical factors and biochemical blood markers.

BACKGROUND: Amputation is a serious complication of acute compartment syndrome (ACS), and predicting the risk factors associated with amputation remains a challenge for surgeons. The aim of this study was to analyze the risk factors for amputation in patients with ACS and develop a nomogram to predict amputation risk more accurately. METHODS: The study population consisted of 143 patients (32 in the amputation group and 111 in the limb preservation group) diagnosed with ACS. LASSO and multivariate logistic regression were used to screen predictors and create a nomogram. The model's accuracy was assessed by receiver operating characteristic (ROC) curves, C-index, calibration curves, and decision curve analysis (DCA). RESULTS: The predictors included cause of injury, vascular damage, shock, and fibrinogen in the nomogram. The C-index of the model was 0.872 (95% confidence interval: 0.854-0.962), and the C-index calculated by internal validation was 0.838. The nomogram's area under the curve (AUC) was 0.849, and the calibration curve demonstrated a high degree of agreement between the nomogram's predictions and actual observations. Additionally, the DCA indicated good clinical utility for the nomogram. CONCLUSION: The risk of amputation in ACS patients is associated with the cause of injury, vascular damage, shock, and fibrinogen. Our nomogram integrating clinical factors and biochemical blood markers enables doctors to more conveniently predict the risk of amputation in patients with ACS.

Predictors of muscle necrosis in patients with acute compartment syndrome.

PURPOSE: The predictors of muscle necrosis after acute compartment syndrome (ACS) remain debated. This study aimed to investigate the predictors for muscle necrosis in ACS patients. METHODS: We collected data on ACS patients following fractures from January 2010 to November 2022. Patients were divided into the muscle necrosis group (MG) and the non-muscle necrosis group (NG). The demographics, comorbidities, and admission laboratory indicators were computed by univariate analysis, logistic regression analysis, and receiver-operating characteristic (ROC) curve analysis. RESULTS: In our study, the rate of MN was 37.6% (83 of 221). Univariate analysis showed that numerous factors were associated with muscle necrosis following ACS. Logistic regression analysis indicated that crush injury (p = 0.007), neutrophil (NEU, p = 0.001), creatine kinase myocardial band (CKMB, p = 0.047), and prothrombin time (PT, p = 0.031) were risk factors. Additionally, ROC curve analysis identified 11.415 109/L, 116.825 U/L, and 12.51 s as the cut-off values for NEU, CKMB, and PT to predict muscle necrosis, respectively. Furthermore, the combination of NEU, CKMB, and PT had the highest diagnostic accuracy. CONCLUSIONS: Our findings showed that crush injury and the level of NEU, CKMB, and PT were risk factors for muscle necrosis after ACS. Additionally, we also identified the cut-off values of NEU, CKMB, and PT and found the combination of crush injury, PT, and NEU with the highest diagnostic accuracy, helping us individualize the assessment risk of muscle necrosis to manage early targeted interventions.

Predictors of acute compartment syndrome in patients with tibial fractures: a meta-analysis.

STUDY DESIGN: This is the first meta-analysis focusing on the risk factors related to ACS after tibial fractures. BACKGROUND: Acute compartment syndrome (ACS) is a serious complication that affects 2-9% of tibial fracture patients. It is importance of identifying the predictors of ACS in patients with tibial fractures. QUESTIONS/PURPOSES: We performed a meta-analysis to identify the risk factors of ACS after tibial fracture. METHODS: We searched articles in the English databases, such as PubMed, Embase, and the Cochrane Library and the Chinese databases including CNKI and WAN FANG. We collected data related to ACS from included studies and analyzed data by RevMan 5.3 and STATA 12.0. RESULTS: The rate of ACS was 2.7% (10,708 of 398,414 patients) from 16 included articles. Our data showed that younger age (p < 0.00001, OR = - 7.93, 95% CI [- 9.34, - 6.25]), male patients (p < 0.00001, OR = 2.17, 95% CI [2.07, 2.28]), patients without a history of hypertension (p < 0.00001, OR = 0.69, 95% CI [0.64, 0.74]), with a history of smoking (p < 0.00001, OR = 1.38, 95% CI [1.30, 1.46]), and patients with fibular fractures (p = 0.001, OR = 2.68, 95% CI [1.47, 4.87]), closed fracture (p = 0.02, OR = 0.86, 95% CI [0.75, 0.98]), high-energy injury (p = 0.003, OR = 0.37, 95% CI [0.19, 0.71]), motorized accident (p = 0.0009, OR = 0.41, 95% CI [0.24, 0.69]), proximal fracture, AO-C-type fracture, comminuted fracture, and Schatzker grade IV-VI fracture were associated with the development of ACS. Additionally, femoral displacement ratio and tibial widening ratio in the ACS groups were significantly higher than in the non-ACS group. CONCLUSION: Many factors were found to be associated with the development of ACS following tibial fractures. We provide references when we met the above characteristics of patients to rapidly identify and highly concern ACS.

Mini approaches fasciotomy combined with vacuum sealing drainage for acute compartment syndrome caused by fractures in children.

PURPOSE: Acute compartment syndrome (ACS) is an urgent, critical condition that requires immediate fasciotomy once diagnosed. Traditionally, fasciotomy of the forearms and lower leg involves one or two long approaches. Our previous study demonstrated that mini approaches fasciotomy was an effective method to treat ACS. This study is aimed at further evaluating the limb functions and complications of mini approaches combined with vacuum sealing drainage (VSD) for treating ACS caused by fractures in the forearms and lower legs. METHODS: This was a retrospective cross-sectional study, and after applying the inclusion and exclusion criteria, we reviewed 126 children who underwent mini treatment approaches for ACS from Jan 2008 to Jan 2022. The selected patients were divided into two groups: group A (ACS group; 58 patients aged 7.77±3.45 years) and group B (ACS combined with VSD; 68 patients aged 7.17±3.55 years). Patients' clinical data were collected. The patients were followed up, and muscle function in the forearms and lower legs was evaluated. RESULTS: The overall incidence of lower legs and forearms ACS was 126/29642 (0.425%). The most common mechanisms of injury were fractures of the forearm (39/74, 52.7%), supracondylar humerus (31/74 41.9%), and elbow (4/74, 5.4%), while those for the lower legs were fractures of the proximal tibia (19/52, 36.5%), midshaft of tibia (25/52, 48.1%), and distal tibia (7/52, 13.5%). According to Flynn's assessment, no significant difference was observed between the two groups (p=0.151). However, the two groups showed significant differences in the hospitalization time (p=0.002) and incision infection rate (0.043). CONCLUSIONS: Mini approaches fasciotomy combined with VSD is an effective and safe method to treat ACS of the forearms and lower legs caused by fractures in children. This method involves a single-stage surgery and is associated with shorter hospitalization time and incision infection.

Predictors of Foot Acute Compartment Syndrome: Big Data analysis.

Acute compartment syndrome (ACS) in the foot is a challenging diagnosis and can lead to significant disabilities to patients. The present study aims to investigate the incidence, risk factors, demographics and association in the analysis of acute compartment syndrome (ACS) of the foot. We performed a retrospective review of the Trauma Quality Programs data from the American College of Surgeons including 70,525 patients who sustained a fracture of the foot from 2015 to 2018 (4 calendar years). Fasciotomies were performed in 0.7% of all foot fractures. Open fractures, crush injuries and multiple foot fractures were the strongest predictors of fasciotomies, with odds ratios of 2.38, 2.38 and 2.33 respectively. Being a male was associated with an increased likelihood of fasciotomies of 64% (p < .0001 O.R. = [1.42-1.90]), while a dislocation in the foot increased likelihood of fasciotomies by 48% (p = .0008 O.R. = [1.18-1.86]). Trauma centre level III had higher rate of fasciotomy than Tertiary Trauma centers. Multiple other factors were addressed while controlling for cofounders. This big data analysis provided information not previously reported on the risk factors, demographics, and clinical association of ACS in the foot.

Characteristics and outcomes of patients who undergo fasciotomies for upper arm compartment syndrome.

PURPOSE: Describe the demographic, injury-related, treatment-related, and outcome-related characteristics of patients who undergo fasciotomies for acute upper arm compartment syndrome (ACS). METHODS: From January 1, 2006, to June 30, 2015, 438 patients with a diagnosis code of upper extremity (including hand, forearm, arm, and shoulder) compartment syndrome at two tertiary care centers were identified. Of those patients, 423 were excluded for a diagnosis other than upper arm ACS or incomplete documentation. A final cohort of 15 adult patients with acute upper arm compartment syndrome treated with fasciotomy was included. The electronic medical record for patient-related variables, lab data, mechanism of injury, presence of additional injuries, and treatment-related variables were reviewed. RESULTS: The mean age of our cohort was 52 years, and 73% were male. The most common mechanisms of injury were blunt trauma (20%), vascular injury (20%), oncologic resection (13%), and infection related to intravenous drug use (13%). Humerus fractures and biceps tendon ruptures were associated with 13 and 27% of the cases, respectively. More than two-thirds of the patients had elevated international normalized ratios (INR). While 27% of cases underwent fasciotomy within 6 h after injury, seven patients (47%) underwent fasciotomy more than 24 h after injury. Six patients had no major deficits, while 7 patients had long-term deficits. CONCLUSION: Upper arm ACS is a potentially devastating condition that can be seen after blunt trauma, vascular injury, oncologic resection, and intravenous drug use. Clinicians should have high suspicion in cases of elevated INR and biceps tendon rupture.

Randomized controlled trial: neostigmine for intra-abdominal hypertension in acute pancreatitis.

BACKGROUND: Intra-abdominal hypertension (IAH) in acute pancreatitis (AP) is associated with deterioration in organ function. This trial aimed to assess the efficacy of neostigmine for IAH in patients with AP. METHODS: In this single-center, randomized trial, consenting patients with IAH within 2 weeks of AP onset received conventional treatment for 24 h. Patients with sustained intra-abdominal pressure (IAP) ≥ 12 mmHg were randomized to receive intramuscular neostigmine (1 mg every 12 h increased to every 8 h or every 6 h, depending on response) or continue conventional treatment for 7 days. The primary outcome was the percent change of IAP at 24 h after randomization. RESULTS: A total of 80 patients were recruited to neostigmine (n = 40) or conventional treatment (n = 40). There was no significant difference in baseline parameters. The rate of decrease in IAP was significantly faster in the neostigmine group compared to the conventional group by 24 h (median with 25th-75th percentile: -18.7% [- 28.4 to - 4.7%] vs. - 5.4% [- 18.0% to 0], P = 0.017). This effect was more pronounced in patients with baseline IAP ≥ 15 mmHg (P = 0.018). Per-protocol analysis confirmed these results (P = 0.03). Stool volume was consistently higher in the neostigmine group during the 7-day observational period (all P < 0.05). Other secondary outcomes were not significantly different between neostigmine and conventional treatment groups. CONCLUSION: Neostigmine reduced IAP and promoted defecation in patients with AP and IAH. These results warrant a larger, placebo-controlled, double-blind phase III trial. Trial registration Clinical Trial No: NCT02543658 (registered August /27, 2015).

Atraumatic acute compartment syndrome - case report.

INTRODUCTION: The publishing of our case report on an idiopathic compartment syndrome of both upper limbs after icing a contusion trauma was motivated by another article on the acute spontaneous compartment syndrome of upper limb published in Rozhledy v chirurgii 8/2021. CASE REPORT: We present the case of a 43-year-old man admitted in the evening for painful massive swelling of both upper extremities. The swelling developed immediately after icing his bruises suffered due to a probable fall on the previous day in a state of inebriety. Compartment syndrome of the left hand and right forearm was diagnosed; subsequently, adequate dermatofasciectomy resulted in normalization of the condition in both upper limbs. The patients condition was cured to a full extent without any disorders of perfusion, mobility or sensation in both upper extremities. CONCLUSION: Only few reports on the atraumatic compartment syndrome of upper extremity can be found in the literature and it is an acute condition encountered quite rarely at outpatient offices of surgery. Nevertheless, we need to be able to recognize this nosological unit and provide proper treatment in time, otherwise the patient may suffer serious permanent damage.

Regional analgesia for lower leg trauma and the risk of acute compartment syndrome: Guideline from the Association of Anaesthetists.

Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. We offer a multi-professional, consensus opinion based on an objective review of case reports and case series. The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party. Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other.

Brachial muscle injury resulting in acute compartment syndrome of the upper arm: a case report and literature review.

BACKGROUND: Acute compartment syndrome (ACS) is a potentially devastating condition. ACS is rare in the upper arm. CASE PRESENTATION: We report a case of acute compartment syndrome of the anterior compartment of the upper arm due to brachial muscle injury. The patient experienced abnormal progressive swelling and pain in his right upper arm, and passive pulling pain of the right wrist and right hand. It was highly suspected to be right upper arm compartment syndrome, and was confirmed by surgery. The patient transferred to the emergency operating room for fasciotomy that was performed under general anesthesia using the anterolateral approach. The brachial muscle was found to be heavily swollen and had the greatest tension. The brachial muscle fibers were split lengthwise, and a large amount of hematoma was cleared. The brachial muscles were injured and partly ruptured. After full decompression, a negative pressure drainage device was used to cover the wound in the first stage. Ten days after injury, the swelling of the affected limb subsided and the wound was sutured. The patient's limbs completely recovered to normal. The shoulder and elbow joints could move freely and the patient resumed normal farming work ability. CONCLUSION: Clinicians should fully recognize the fact that acute compartment syndrome can occur in the upper arm, rather than only the forearm and leg, and therefore avoid serious consequences caused by missed diagnosis and misdiagnosis.

An exploratory study of two-dimensional shear-wave elastography in the diagnosis of acute compartment syndrome.

BACKGROUND: Two-dimensional shear-wave elastography (2D-SWE) is an ultrasound elastography technique that uses shear waves to quantitatively measure tissue stiffness and it has recently been developed as a safe, real-time, and noninvasive imaging technique. The purpose of this study was to investigate the value of 2D-SWE in the diagnosis and treatment of acute compartment syndrome (ACS). METHODS: 2D-SWE was used to measure the elasticity values of the main muscles in the superficial compartments of the calf in 212 healthy volunteers, and the difference in the muscle elasticity values between different gender and age groups were analyzed. Nine patients with clinical suspicion of ACS were included in this study and 2D-SWE was used to measure the elasticity values of the muscles on the affected and unaffected sides, and a comparative analysis was performed. RESULTS: The mean elasticity values of the tibialis anterior (TA), peroneus longus (PL), and gastrocnemius medialis (GA) muscles in the relaxed state of the 212 healthy volunteers were 25.4 ± 3.2 kPa, 15.7 ± 1.5 kPa, and 12.1 ± 2.1 kPa, respectively. No statistically significant differences was observed in the elasticity values of the same muscle under the state of relaxation in different gender and age groups (p > 0.05). A statistically significant difference in the elasticity values of the muscle between the affected and unaffected sides in the fasciotomy group (p < 0.05, n = 5) was observed. In contrast, no difference in the elasticity values of the muscle between the affected and unaffected sides in the conservative group (p > 0.05, n = 4) was observed. There was a statistically significant difference in the elasticity values of the muscle on the affected side in the two treatment groups (p < 0.05). CONCLUSIONS: When the ACS occurs, the muscle elasticity of the affected limb increases significantly. 2D-SWE is expected to be a new noninvasive technique for the assessment of ACS and may provide a potential basis for clinical diagnosis and treatment.

The blister occurring in severe tibial plateau fractures (Schatzker V-VI) decreases the risk of acute compartment syndrome.

BACKGROUND: Severe tibial plateau fractures may result in acute compartment syndrome (ACS) of the leg, which is always considered to be an orthopaedic emergency. Blistering is not an uncommon sign and may be related to decreased compartment pressure. No experiments on the risk of ACS based on the presence of blisters after tibial plateau fractures have been conducted, and controversies about the high rate of ACS in patients with tibial plateau fractures still exist. QUESTIONS/PURPOSES: This research retrospectively followed the bicondylar tibial plateau fractures treated with locking plates and verified if the risk of ACS was decreased after a blister was observed. METHODS: A total of 100 patients with closed tibial fractures (63 men and 37 women) were included and divided into with blister (group A, 40) and without blister groups (group B, 60). The creatine kinase (CK), BUN, and chloride levels were recorded on the first day after hospitalization. The hospitalization costs and injury to operation time were collected in the two groups. The Lysholm knee score and a visual analogue scale (VAS) for pain were used to assess the rehabilitation after follow-up. Clinical and serological results of ACS in the two groups were compared. RESULTS: There was significant delay in the time from injury to operation (11.0 ± 3.5 VS 7.6 ± 7.2, Z = - 3.771, P < 0.001) in the with blister (group A) and without blister groups (group B). The levels of chloride and BUN were significantly lower in the with blister group than in the without blister group (102.7 ± 3.0 VS 104.7 ± 2.57 mg/dL, Z = - 3.33, P = 0.001) (10.3 ± 2.5 VS 10.3 ± 2.8 mg/dL, Z = - 2.366, P = 0.018). There were no significant differences in the CK levels in the with blister and without blister groups (285.8 ± 202.6 VS 408.4 ± 633.6 U/L, Z = - 1.379, P = 0.168), but a trend of decreasing to normal was obvious in patients with blisters. There were no significant differences in the Lysholm knee score (40 VS 60, 80 ± 4.9 VS 79.8 ± 3.0, Z = - 0.872, P = 0.383), or the VAS (40 VS 60, 1.6 ± 0.7 VS 2.2 ± 1.3, Z = - 1.568, P = 0.117) for pain compared with patients without blisters. CONCLUSION: In conclusion, the presence of blisters in patients with severe tibial plateau fractures decreases the pressure in the compartment. There was a significant improvement in serological results after blisters appeared, which may be related to the reason for the decreased pressure decreased, and conservative management is recommended for these patients.

Spontaneous compartment syndrome of the forearm - case report.

INTRODUCTION: Acute compartment syndrome is a serious complication of trauma and pathological disorders. Non-traumatic acute compartment syndrome is very rare and has no coherence with trauma. The case report demonstrates diagnostics difficulties and the treatment strategy. CASE REPORT: We present a 36-year-old man with acute onset of pain after manual labor with a shovel. He had been treated with anticoagulation therapy due to a heart valve replacement. Blood clotting test showed prolongation of prothrombin time of more than four times due to iatrogenic bleeding disorder. Symptoms were considered consistent with the diagnosis of tendovaginitis, however the worsening of the symptoms was underestimated. Four days after the onset of the first symptoms, the acute compartment syndrome developed and urgent fasciotomy of the forearm and hand was performed. The convalescence lasted 10 months with restoration of the function and range of motion of the hand. The patient was able to fully self-service and manually work with a light load. The permanent consequence remained a limitation of the hand grip strength and paresthesia and neuropathic pain due to median nerve impairment. CONCLUSION: Spontaneous compartment syndrome of the upper extremity is a rare but very dangerous entity requiring thorough understanding. It should be considered in the case of non-traumatic limb pain that does not respond to analgesics in patients receiving systemic anticoagulation. Only early diagnosis and immediate fasciotomy can prevent catastrophic permanent consequences.

Clinical and radiographic predictors of acute compartment syndrome in the treatment of tibial shaft fractures: a retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate the association between epidemiological, clinical and radiographic factors of patients with tibial shaft fractures and the occurrence of acute compartment syndrome. METHODS: 270 consecutive adult patients sustaining 273 tibial shaft fractures between January 2005 and December 2009 were included in this retrospective cohort study. The outcome measure was acute compartment syndrome. Patient-related (age, sex), fracture-related (high- vs. low-energy injury, isolated trauma vs. polytrauma, closed vs. open fracture) and radiological parameters (AO/OTA classification, presence or absence of a noncontiguous tibial plateau or pilon fracture, distance from the centre of the tibial fracture to the talar dome, distance between tibial and fibular fracture if associated, and angulation, translation and over-riding of main tibial fragments) were evaluated regarding their potential association with acute compartment syndrome. Univariate analysis was performed and each covariate was adjusted for age and sex. Finally, a multivariable logistic regression model was built, and odds ratios and 95% confidence intervals were obtained. Statistical significance was defined as p < 0.05. RESULTS: Acute compartment syndrome developed in 31 (11.4%) cases. In the multivariable regression model, four covariates remained statistically significantly associated with acute compartment syndrome: polytrauma, closed fracture, associated tibial plateau or pilon fracture and distance from the centre of the tibial fracture to the talar dome ≥15 cm. CONCLUSIONS: One radiological parameter related to the occurrence of acute compartment syndrome has been highlighted in this study, namely a longer distance from the centre of the tibial fracture to the talar dome, meaning a more proximal fracture. This observation may be useful when clinical findings are difficult to assess (doubtful clinical signs, obtunded, sedated or intubated patients). However, larger studies are mandatory to confirm and refine the prediction of acute compartment syndrome occurrence. Radiographic signs of significant displacement were not found to be correlated to acute compartment syndrome development. Finally, the higher rate of acute compartment syndrome occurring in tibial shaft fractures associated to other musculoskeletal, thoraco-abdominal or cranio-cerebral injuries must raise the level of suspicion of any surgeon managing multiply injured patients.

Nerve Lesions in Volkmann Ischemic Contracture.

Volkmann ischemic contracture (VIC) is a late sequela of acute compartment syndrome and consists of extensive muscle necrosis, fibrosis, contracture, and variable degrees of neural dysfunction. The outcome depends on successful restoration of muscle and neural function. The timing of surgery is often determined by the development of contractures and is delayed in the interest of observing some spontaneous recovery and infarct maturation. This period of observation may be detrimental to nerve function with gradual formation of scar tissue and worsening constrictive neuropathy. Early intervention appears to be more effective in preventing further nerve damage and restoring protective sensation. In this article, common features of compartment syndrome, frequently seen nerve lesions, and the effect of timing of surgical intervention on the outcome of VIC were reviewed in the light of the current basic and clinical science literature.

Guidewire perforation and compartment syndrome after lower extremity angioplasty.

Chronic total occlusion remains one of the most challenging lesions to treat despite continuing developments in medical devices and increasing operator experience. Guidewire perforation complications are being increasingly observed. Early recognition and timely institution of appropriate treatment are essential to prevent potentially devastating sequelae.

Increased morphine requirements are predictive of acute compartment syndrome in adults with tibia fractures.

PURPOSE: The purpose of this study was to determine if increased milligram morphine equivalent (MME) requirements are a predictor of adult compartment syndrome in patients with tibia fractures. METHODS: A retrospective case-control study at a level-1 trauma center was performed over a five year period. Patients with tibia fractures who had acute compartment syndrome (ACS) requiring fasciotomy (n = 26) were matched with controls (n = 25). MME and pain scores were assessed within the 24 hour period preceding fasciotomy (cases) or fixation (controls). The presence or absence of the "6 Ps" and other clinical signs (diastolic blood pressure [DBP]) were also analyzed. RESULTS: Mean MMEs two hours before surgery was 25.5 ± 39.2 for ACS patients versus 8.6 ± 11.1 in controls (P = 0.043), while the mean pain scores were 8.8 ± 1.8 and 7.0 ± 2.5 (P = 0.049), respectively. Multivariable regression showed patients with ACS consumed 16.9 MME more than controls within two hours of surgery (P = 0.043) and scored 1.8 points higher on the numeric pain rating scale (P = 0.049). The mean number of clinical signs of compartment syndrome in the ACS patients was 3.4 ± 1.3 compared to 0.84 ± 0.85 in controls (P < 0.001). DBP was significantly higher in ACS patients within two to four hours of surgery (P = 0.005). CONCLUSION: Increased MME requirements and pain scores within two hours of surgery were significant predictors of ACS following tibia fracture. Increased narcotic requirements, pain scores, and DBP may be useful objective indicators of evolving ACS, in addition to the traditional signs, and should be closely monitored in the at-risk patient.