Bedside Fasciotomy for Compartment Syndrome

Compartment syndrome remains a challenging problem for the clinicians. The diagnosis of compartment syndrome may be not that easy, and it may be confusing or not straight forward. In general, a high index of suspicion is necessary for the diagnosis of compartment syndrome. If the patient has pain more than what is expected from surgery or from an injury, or if there is an increase in narcotic requirements, and the patient has tense swelling and pain, with the pain increasing with passive stretch of the compartment muscles, then this is an indication that the patient may be suffering from a compartment syndrome. You like to see these patients and treat them during the impending stage, not during the well-established stage. You want to diagnose compartment syndrome early before the muscle dies, which will cause weakness to the muscle function. Diagnosis and treatment for compartment syndrome should be done early. Tight dressings should be removed. If there is a cast, the cast should be split or removed and examine the extremity. The extremity should be examined for pain and swelling. Do not wait for the classic, old teaching of the 5 P’s to appear as these findings are considered to be late findings. Do not wait for the paresthesia, the pulselessness, the pallor, and the paralysis. These represent irreversible damage to the muscles and the nerves. The patient may have good pulses even in the presence of compartment syndrome. Pulses will be normal in the presence of compartment syndrome. The combination of pain and swelling, and pain with passive stretch, is an indication of compartment syndrome. If you suspect compartment syndrome and you are not sure of the diagnosis, then measure the pressure of the compartments. If the compartment pressures is greater than 30mmHg or within 30mmHg of the diastolic pressure, then this is an indication that the patient is probably going in the direction of compartment syndrome and an immediate fasciotomy should be considered. Compartment syndrome can occur in any anatomical part in the upper extremity or the lower extremity. The most commonly involved anatomic part is the lower leg, and the most commonly involved compartment in the lower leg is the anterior compartment. The anterior muscle compartment of the lower leg contains the deep peroneal nerve. The deep peroneal nerve gives sensation in the first web space. When you examine the patient for compartment syndrome, check for numbness of the first web space. The elevated pressure affects the microcirculation and the perfusion of the tissues. The muscle compartment needs to be released within 6 hours. Irreversible damage can occur after 8 hours. Formal release of the muscle compartments in the operating room under general anesthesia continues to be the procedure of choice. You may not be able to do formal release of the muscle compartments due to being called to a patient in the intensive care unit, in the emergency room, or the patient may be in the floor. There may not be enough time to do the procedure in the operating room due to the patient’s condition or operating room conditions. Bedside fasciotomy under conscious sedation and local anesthesia was developed in order to avoid delay in fasciotomy surgery. Time is critical for the release of compartment syndrome. It is advisable to do fasciotomy early. If fasciotomy is done within 3-4 hours the damage is reversible. At 6 hours there will be variable muscle damage. Delay in fasciotomy can occur due to medical comorbidities, need clearance for general anesthesia and patient may be on anticoagulation (need to reverse and control that); polytrauma patient, need time for resuscitation; or recent oral intake, fluids or solid food. It is probably not easy to guess and to predict when the exact onset of increased pressure of compartment syndrome occurred in the extremity. Bedside fasciotomy is a good option for patients with delayed presentation or in those with anticipated time delay. The procedure can be done in the ICU, the ER, or on the floor. The patient can be given conscious sedation. Give the appropriate doses and some doses may be appropriate for a normal sized, healthy adult, but may not be appropriate for patients with sleep apnea or other medical comorbidities. You can also use 1% lidocaine without epinephrine to infiltrate the marked skin and subcutaneous tissue incision line. Bedside fasciotomy can be done for the arm, the forearm, hand, thigh, lower leg, and foot. It is good to train a diverse group of health professionals in how to do bedside fasciotomy. There are four compartments in the leg: the anterior, lateral, superficial, posterior, and deep posterior compartments usually are released through two incisions, one medial and one lateral. 1% lidocaine is used without epinephrine at the marked skin incision line. The lateral incision is made halfway between the tibia and the fibula for release of the anterior and lateral compartments. When you release the lateral compartment, avoid injury to the superficial peroneal nerve. The medial incision is made 2 cm posterior to the tibia. You can also do the procedure through one lateral incision.

Intersection Syndrome

Intersection syndrome is a painful tenosynovitis involving the tendons of the extensor carpi radialis longus and extensor carpi radialis brevis. There are six extensor compartments of the wrist. The pathology occurs due to stenosis of the second dorsal wrist compartment. The intersection syndrome is an overuse injury caused by repetitive wrist extension with pronation and supination. Intersection syndrome can occur in weight lifting, rowing, and in racket sports. The area of pain and tenderness is located at the intersection between the muscles of the abductor pollicis longus and extensor pollicis brevis, as these two muscles cross over the tendons of the extensor carpi radialis longus and brevis. The patient may describe a squeaking sensation with wrist motion. This intersection syndrome is sometimes called the squeakers wrist or the cross over tendonitis. When the first and second dorsal wrist compartments pass over each other, it will result in inflammation, muscle changes, fibrous and squeaking during wrist motion. These findings along with the site and location of the pain over the dorsal forearm and wrist, which is about 5 cm distal to the wrist joint, helps to differentiate De Quervain’s Syndrome from intersection syndrome. When the first dorsal wrist compartment tendons cross over the second compartment structures, the tenderness is palpated at the dorsoradial forearm, approximately 5 cm proximal to the wrist joint. The pain gets worse with resisted wrist extension and the x-ray will not show you anything. You will feel crepitus over the area with resisted wrist extension and thumb extension. MRI will probably show you edema or fluid surrounding the first and the second extensor compartments. To treat intersection syndrome, rest, do wrist splinting, and perhaps a steroid injection. Try to inject the second dorsal compartment; ultrasound guided injection may be helpful. Surgery is done as a last resort. Release the second dorsal compartment about 5-6cm proximal to the wrist joint.

Scaphoid Nonunion

Nonunion of the scaphoid could be an incidental finding after re-injury to the wrist. Risk fractures for nonunion include fractures with displacement more than 1mm, fractures that have inadequate treatment, fractures with instability, fractures that are displaced in a cast, proximal pole fractures, and delayed immobilization more than 4 weeks increases the rate of nonunion. An untreated scaphoid nonunion will have a high incidence of wrist arthritis. Early arthritis will start at five years. At 10 years, the patient will have significant arthritis. Arthritis will develop in stages: SNAC wrist (Scaphoid Nonunion Advanced Collapse). The three stages of arthritis: stage I arthritis is between the radial styloid and the scaphoid, stage II scaphocapitate arthritis in addition to stage I, and stage III periscaphoid arthritis including capitolunate arthritis. Scaphoid fractures that are left untreated will have carpal collapse and 100% development of degenerative arthritis. There is tendency for the fracture to gap open dorsally. Up to 35% of the patients have a humpback deformity and 40% have a DISI deformity. A CT scan along the scaphoid axis is the best test to check for nonunion of the scaphoid bone. Treat scaphoid fracture nonunion early (before 5 years) because the healing rate is much better. Correct the deformity and restore the scaphoid length and alignment. Use bone graft and do rigid internal fixation. Volar approach is used for waist fractures and fracture in the distal third of the scaphoid. You may want to remove the edge of the trapezium to place the screw in the volar approach. The humpback deformity is better corrected through the volar approach. The dorsal approach is better for proximal nonunion because of direct visualization of the nonunion. It helps reduction and also bone grafting can be done through the same incision from the distal radius if necessary. For a nonunion without AVN and no humpback deformity, do ORIF and bone graft or percutaneous technique. The Russe procedure is used for distal or waist fractures, patients with minimal deformity and no collapse, no excessive humpback deformity, and over 90% union rate. The dorsal approach can also be used for waist scaphoid fracture nonunion in addition to proximal nonunion. If the patient has a nonunion and no AVN, but there is a significant humpback deformity, there is a tendency of the fracture to pen dorsally. A significant number of patients will have a DISI deformity (there is association between a humpback deformity and DISI deformity). This patient will need an opening wedge interposition graft to restore the scaphoid length and alignment. The humpback deformity is best corrected from a volar approach (use interposition bone graft). Nonunion that is associated with AVN, but there is no humpback deformity, do ORIF and vascularized bone graft (1,2 ICSRA vascularized graft from the dorsal aspect of the distal radius). This technique can also be used for nonunion of the proximal pole. If the nonunion has an associated AVN and a major humpback deformity, because it is an AVN, you will use a vascularized graft, and because you have a humpback deformity, you will need a larger graft, so you will use a vascularized bone graft from the medial femoral condyle (use this technique if there is no arthritis, it utilizes the descending genicular artery pedicle). Punctate bleeding of bone during surgery may indicate good prognosis for healing of the nonunion. To treat a stage I SNAC wrist, do radial styloid excision plus bone graft for the nonunion. Do not remove more than 4mm of the radial styloid; avoid injury of the radioscaphocapitate ligament. To treat stage II & III SNAC wrist, do scaphoid excision and four corner fusion in younger patients; do proximal row carpectomy. Do not do proximal row carpectomy if the capitolunate joint is involved with arthritis. Preservation of the radioscaphocapitate ligament will prevent ulnar subluxation of the carpus (it is the primary stabilizer of the wrist following proximal row carpectomy). You can do arthrodesis for pancarpal arthritis.

Triceps Tendon Rupture

The triceps muscle is a powerful extensor of the elbow joint. The triceps muscle has three heads: the long head, the lateral head, and the triceps. All three heads of the triceps muscle share a common tendon that inserts into the olecranon process at the elbow. An injury to the triceps tendon can be missed. Rupture of the triceps muscle typically occurs in male athletes such as body builders, football players, and in athletes who lift heavy weights. The injury can also occur due to a fall onto an outstretched hand. The tear is usually seen in middle aged men. A rupture of the tendon can be either complete, or incomplete. The rupture occurs at the bony insertion of the tendon. The patient may have pain, swelling, and some ecchymosis around the posterior part of the elbow. Mechanisms of injury include stress from sudden increase in intensity of training, direct trauma to the tendon, and laceration of the tendon. Rupture of the tendon may also occur due to local steroid injection or it may be due to t a history of anabolic steroid use. Rupture may also occur due to systemic diseases such as renal disease, gout, or it may occur due to previous elbow surgery. Other risk factors include use of cipro (ciprofloxacin), diabetes mellitus, rheumatoid arthritis, osteoarthritis, and olecranon bursitis. There will be painful limitation of range of motion and the patient will not be able to extend the elbow against resistance. The patient may hear a “pop” and the tendon may retract upwards. A gap may be felt in the back of the elbow where the rupture occurs. There is a squeeze test for the distal biceps injury, achilles tendon injury, and also a squeeze test for the triceps injury. This test is completed when the patient is laying prone. The forearm will be hanging down with the elbow at the edge of the table and then squeeze the triceps. The inability of the patient to extend the elbow against gravity means that the patient has a complete tear of the triceps. X-rays may show a small bony avulsion. The “flake” sign identifies the avulsion and the position of the tendon on a lateral x-ray. 

Fracture Femur- Antegrade Rodding

The ideal treatment for a fractured femur is a statically locked, antegrade reamed nail of the appropriate diameter, which allows the patient immediate weight bearing after surgery. The starting point has to be ideal. You do not want to go too anteriorly because you will create iatrogenic fracture of the proximal femur. You do not want to go too posteriorly because this will create anterior perforation of the distal femur. The piriformis starting point is the gold standard. We can use a trochanteric entry especially in obese patients, but you then have to use a trochanteric nail. The ideal location for the trochanteric nail is medial to the tip of the trochanter. If you have a straight nail designed for a piriformis entry and you go through the greater trochanter, then you will get varus. The piriformis entry is collinear with the long axis of the femoral shaft. The greater trochanter entry site is lateral to the femur shaft axis, and this will create malalignment as you advance the rod. The two axis becomes collinear leading to a varus deformity. Try to avoid varus. After you make the entry hole, then you will put the guide wire. It is probably better to bend the guide wire tip. Make sure that you ream over a beaded guide wire and the guide wire must have a curve or a bend to help you in advancing to the distal fragment. Once you put the guide wire, you must see the knee in the lateral view and make sure the guide wire is not anteriorly. After you measure the guide wire, insert the guide wire, insert the guide wire a little bit distally so that it will hold in the bone and so that it does not come up with the reaming. Reaming probably increases the union rates and probably decreases the time to union. Make sure that you do not ream when there is an area of comminution (just push the reamer through the area of comminution). You may want to avoid reaming in somebody with bilateral fracture femurs. Reaming may increase the pulmonary complication rate, especially in bilateral femur fractures (can use unreamed nailing). Some may use retrograde nailing. You measure the proper length and then put the appropriate length rod. Always look at the handle of the insertion of the rod. Make sure that the c-arm in a lateral position is parallel to the insertion of the handle of the rod, then you will get the screw holes perfect. Once you get the holes perfect, then you will ask for magnification. Try to get perfect circles. If you have widening or overlap of the interlocking holes in the proximal/distal direction, then the leg needs adduction or abduction which will improve it. If the overlap is in the anterior/posterior plane, then it is a rotation problem, either internal or external. Make sure the rotation of the extremity is OK. There is a high incidence of malrotation after IM nailing of the femur. Try to get the difference between the two femurs to be within 10 degrees of each other, and the maximum is 15 degrees. Once the perfect circle is seen, then a drill or a handle with a k-wire is pointed at the circle and advanced parallel to the fluoroscopy beam. After that, you will put the proximal and distal screws. Make sure that you remove the guide wire before you put the screws. You can check the proximal screw is in its proper location by inserting a wire through the rod and see if it will stop at the screw or not. If it stops at the screw, then the screw is inserted properly, and then you do not need to get a lateral view to see it. Make sure you get internal rotation view after insertion of the screws in the distal femur to avoid having long screws.