PubMed · 16945606
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Charles M Wiener, K Kwasind Huston, Matthew E Nielsen, Allan C Gelber. 2006. High pressure surgery.. https://doi.org/10.1016/j.amjmed.2006.07.013
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BACKGROUND: Changes in compartment pressures have been noted during traction, reduction, and intramedullary fixation of fractures. Changes in limb length and compartment volumes are suspected contributing factors. Pressure and volume changes are known to be related in animal models. If an acute increase in limb length can adversely affect compartment pressures, reversal or delay of such an increase in length may be of value in the treatment and prevention of compartment syndromes. METHODS: A clinical example is presented in which a documented anterior compartment syndrome was successfully treated by deliberate loss of fracture reduction, without fasciotomy. Fracture reduction was later restored when swelling subsided. Anterior compartment pressures were recorded in response to limb length changes in osteotomized cadaver limbs stabilized with external fixation. RESULTS: The pressure in the anterior compartment varies directly with acute changes in the length of the leg, in an experimental model. Mathematical analysis indicates that available volume within a compartment varies inversely with acute changes in its length. CONCLUSIONS: Fracture reduction that restores the length of an acutely injured extremity may increase pressure in the compartments by decreasing available volume. Deliberate loss of reduction can decrease pressure in the compartments, offering a potential alternative to fasciotomy in the care of compartment syndrome in cautiously selected, monitored patients. Early stabilization without reduction, followed by delayed reduction, may be preferable during treatment of fractures prone to compartment syndrome. Decreased available compartment volume may contribute to compartment syndrome after distraction with intramedullary rods or skeletal traction.
OBJECTIVE: This study describes a previously unpublished technique for compartment release that combines adjunctive transverse fasciotomies with a limited longitudinal dermatofasciotomy and compares its efficacy with a standard extensile longitudinal dermatofasciotomy. DESIGN: Limited 10-cm longitudinal dermatofasciotomies were performed bilaterally on 14 cadaveric specimens (28 legs). Next, we performed transverse fasciotomies on 1 limb and performed extensions of the longitudinal incision on the contralateral limb. Subsequent changes in compartment pressures were recorded after each release. Two-tailed paired and unpaired Student t tests were performed for statistical analysis with significance set at P < 0.05. SETTING: Anatomy laboratory. RESULTS: After a 10-cm longitudinal dermatofasciotomy, the average compartment pressure was 17 +/- 7.1 mm Hg proximally and 15.5 +/- 7.4 mm Hg distally. With an extensile 16-cm longitudinal incision, a significant decrease in compartment pressure was seen both proximally (6.5 +/- 3.1 mm Hg) and distally (4.7 +/- 4.7 mm Hg). With adjunctive transverse fasciotomies, a significant reduction in compartment pressure also was observed proximally (6.9 +/- 6.1 mm Hg) and distally (6.1 +/- 5.4 mm Hg). There was no statistically significant difference in compartment pressures between an extensile 16-cm incision and 10-cm incision combined with transverse fasciotomies both proximally and distally (P = 0.84 and P = 0.5, respectively). CONCLUSIONS: A combined approach of transverse fasciotomies with a limited longitudinal dermatofasciotomy in this in vitro compartment syndrome study is as effective as a standard 16-cm longitudinal release in the anterior compartment of this cadaveric leg model.
A compartment syndrome is an orthopaedic emergency which can result from a variety of causes, the most common being trauma. Rarely, it can develop spontaneously and several aetiologies for spontaneous compartment syndrome have been described. We describe a patient with diabetes who developed a spontaneous compartment syndrome. The diagnosis was delayed because of the atypical presentation.