Teaching Rounds from last month presented by Dr. Boulger
We had an inmate who had a previous GSW to the leg (9months prior to presentation) as a result of this previous injury patient had fasciotomy and skin graft for compartment syndrome.
He currently presented with 3 days of pain and swelling around the previous fasciotomy site.
He noted new paresthesias to his toes.
He denies fever, chills, drainage from site, malaise, myalgias.
He noted significant intractable pain.
He denied any new trauma
Patient had tight very painful anterior compartment and slight decreased sensation to dorsum of foot.
Immediately we were concerned for compartment syndrome. The question then arose as to would compartment pressures be the same range post fasciotomy. Also the question came up can you get recurrent compartment syndrome (the answer is yes there have been a handful of case reports)
Ortho and vascular surgery were consulted
Compartment pressures with stryker were 30s (elevated but low side of elevated)
Video how to (similar to ours) http://www.youtube.com/watch?v=hNa2yXCnixw
Given previous surgery and relatively new flap as well as subacute nature and unchanging exam they procededed cautiously and obtained and MRI after attending and senior resident evaluated patient.
MRI c/w myositis and herniation of muscle through the previous fasciotomy
1)Most common post traumatic (Tib/fib, distal radius/ulna) and can occur with open fracture, crush injuries(high risk)
-Drug injection is also a risk factor
2) Anterior compartment of the leg is most commonly affected
3) Intractable pain is first symptom followed about 30 minutes into ischemia by paresthesias
4) 4-8 h we begin to see irriversible muscle damage
5) Exam shows pain on passive stretching, decreased sensaion. Late findings are pallor and diminished pulses.
6) Labs are usually not helpful but get CPK and standard preop labs ( elevated CPK mean damage is done)
7) Normal compartment pressure is 10-12 mmHg, > 30 is the lower threshold
8) Limb elevation is a temporary solution while preparing for fasiotomy(can have full recovery if done within 6 hours)
9) Fasciotomy is definitive treatment( BE ABLE TO TALK THROUGH THIS FOR ORAL BOARDS)
Key point : In high risk injuries or those with intractable pain have a high index of suspicion do not have tunnel vision keep in mind other possible diagnoses such as myositis, cellulitis, fracture…