Compartment Syndrome of the Thigh- Thigh Fasciotomy

The condition of increased pressure within the muscle compartment is called compartment syndrome. Acute compartment syndrome of the thigh is rare. In this case, fracture of the femur causes increased pressure of the thigh that requires fasciotomy. High suspicion for thigh compartment syndrome is recommended even in cases of minor trauma when anticoagulation therapy or hemophilia is involved. The anterior compartment of the thigh is the most commonly involved compartment. Fasciotomy is often necessary when the pressure within the muscle compartment is increased. Increase pressure is defined as an increase of absolute pressure to 30 mmHg or the pressure of the compartment is within 30 mmHg of the diastolic pressure. If the surgeon suspects compartment syndrome during surgery, the preoperative diastolic pressure and not the intraoperative diastolic pressure, is used as a guide. Once the compartmental pressure becomes elevated as mentioned before, fasciotomy becomes necessary. Fasciotomy should be done urgently within a reasonable period of time in order to avoid ischemia of the muscles.

Distal Third Clavicle Fracture

Fracture of the distal third of the clavicle is a problem fracture. Its management and its outcome can be complicated. There are some ligaments called the coracoclavicular ligament that goes between the coracoid and the clavicle. These ligaments are called the conoid and trapezoid ligaments. The conoid is medial (inserts about 4.5cm from end of clavicle). The trapezoid is lateral (inserts about 3 cm from the lateral end of clavicle). The integrity of the conoid and trapezoid ligaments (coracoclavicular ligaments) is important. The coracoclavicular ligaments provide the primary resistance to superior displacement of the lateral clavicle. The ligaments are holding the clavicle down. If fracture of the lateral third of the clavicle occurs and the medial part is not attached to the ligaments, then the medial part of the clavicle will become displaced superiorly by the pull of the sternocleidomastoid muscle. When you assess the fracture of the lateral or distal third of the clavicle, you assess the stability of this fracture. The stability of this fracture is based on the location of the fracture in relationship to the coracoclavicular ligaments, the AC joint, and the fracture pattern. Is the fracture pattern simple or comminuted which could be unstable. There are several types, and they can be summed up as two types: stable fractures and displaced fractures with coracoclavicular ligament not attached to the proximal fragment. In displaced fractures, the proximal fragment will displace superiorly. This type will have delayed union up to 50% and nonunion approximately 20%. Because the proximal fragment is not attached to any ligaments, it is just displaced superiorly. The distal segment continues to be attached to the coracoid by the coracoclavicular ligament. Some physicians believe that the displacement of the fracture, and the fracture stability is usually decided in surgery, but you do not want to do that, you want to decide the stability and the displacement of the fracture before surgery so that you can make the proper decision for treatment and also to select the proper implant for dealing with this problem. The Zanca view x-ray may be needed. 15 degrees cephalic tilt to show the superior inferior displacement. A fracture that is lateral to the ligament makes the fracture stable, you will treat the patient conservatively with a sling. A fracture that is medial to the ligament and makes the fracture unstable is treated by open reduction internal fixation. You can use the guideline of the ligament insertion, which is 4.5cm from the AC joint, can use the Zanca view to help you in visualizing the displacement superiorly or inferiorly, and when the fracture is medial to the ligament that is unstable, this means that you need to do ORIF because if you treat it conservatively, there will be a high incidence of nonunion. You can use multiple techniques for reduction and fixation of the distal clavicle fracture. One of these techniques is plates and screws called a “cluster plate” that has multiple holes which allows you to put small screws and lock the screws to the plate. Another technique is the hook plate which is used when there is insufficient bone in the distal segment for fixation with plates and screws. Not every hospital has the hook plate. You may not be able to fix the distal clavicle fracture with plate and screws in surgery. Make sure you have the hook plate in house in case it is needed (hook plate is a backup plan). Most hook plates will require removal after healing of the fracture (secondary surgery). If the fracture is a nonunion and the patient has symptoms, you need to fix this fracture with a plate and bone graft if the fracture is atrophic. This problem is very difficult to treat, and it does not matter what type of fixation that you use, there will be a high incidence of failure in the treatment of nonunion of the distal clavicle. The patient may require two types of stabilization for this nonunion. The patient may require two types of stabilization for this nonunion. The first type is a plate and bone graft fixation. The second type is additional help to the plat and bone graft by stabilizing the coracoclavicular area. You can use a tendon allograft, or you can use anchors in the coracoid or a tight rope fixation. Fracture distal to the line drawn vertically to the coracoid process is probably a stable fracture. You will give the patient a sling for comfort and give a structured PT program when the pain is less, starting with pendulum exercises and progress to active assisted when the pain is manageable. In a child, a distal clavicle fracture could be a periosteal sleeve fracture which will remain attached to the intact coracoclavicular ligament.

Seymour Fracture

Seymour fracture is a complex pediatric fracture of the fingers or the toes. It is an extra articular transverse Salter Type I or Type II fracture at the base of the distal phalanx of the fingers or the toes. There is a flexion injury that leads to physeal separation between the extensor tendon dorsally and the flexor digitorum profundus volarly. This flexion injury which causes flexion of bone also causes avulsion of the proximal edge of the nail from the nail fold. In addition to disruption of the nail plate, there is a disruption of the germinal matrix. The patient will have pain, swelling, and deformity. The finger will appear flexed, and it will look like a mallet finger with the nail appearing too long compared to the nail on the other side. There is blood coming from the root of the nail. This injury is an open fracture, it is not a mallet finger fracture, and it should not be treated with a splint alone. When you see bleeding around the nail bed in a child, be suspicious of a Seymour fracture. If the fracture is missed, there may be complications such as infection and finger deformity. Because this is an open fracture, you must give the patient antibiotics. The patient will need to go to the operating room for nail removal and debridement of the wound. Reduce the fracture, fix it with a K-wire and repair the nail bed. Splint the fracture or use a cast for protection.

Posterior Dislocation Sternoclavicular Joint

The SC joint is supported by strong ligaments. Dislocations of the SC joint can occur due to injury to these strong ligaments. Dislocation of the sternoclavicular joint can be an anterior dislocation, which means the clavicle moves to the front or anteriorly (common) and this dislocation is benign and does not cause any problems in the majority of patients.  The posterior dislocation is dangerous, it can affect the trachea, esophagus, veins and arteries.  If you suspect posterior dislocation of the SC joint because of pain or swelling in this area, the CT scan is the best study for assessment of this joint and for establishing the diagnosis and for assessment of any associated injuries. In Figure 1, the CT scan showed posterior dislocation of the clavicle in a patient who sustained a shoulder injury 3 days prior to obtaining the CT scan. This injury was occult and not seen on the routine x-rays of the chest. The patient was evaluated because of swelling of the upper extremity. The Doppler showed DVT of the left upper extremity and a CT scan with contrast was ordered. Unexpectedly, the CT scan showed the clavicle to be posteriorly dislocated, compressing the vein and causing the DVT. Closed reduction with backup from a cardiac surgeon is the usual treatment, however, you may need to do open reduction in some cases with repair of the ligaments. Once you reduce the joint, the joint is usually stable. Posterior dislocation can be a difficult diagnosis. It could be associated with more serious problems such as dyspnea, dysphagia, tachypnea, and compression of the great vessels. Sometimes it may be associated with DVT of the upper extremity. The good news is that posterior dislocation is not common. On the other hand, the anterior dislocation is common, obvious bump, benign injury and does not affect the function. If you try to do a closed reduction on an anterior dislocation, you will not be able to maintain that reduction. On the other hand, posterior dislocation will be stable after reduction.   

Types and Mechanisms of Fractures

There are many types of fractures. The main types of fractures are described as either displaced, non-displaced, open, or closed. Displaced and non-displaced refer to the way the bone breaks.  Incomplete fractures such as a hairline fracture usually results from a minor trauma and the fracture does not go all the way through the bone. It is a very small crack in the bone.  A Greenstick fracture is an incomplete fracture in which the bone is bent. This fracture type most often occurs in children. The Toddler fracture is an incomplete or undisplaced fracture that is difficult to see. You may need an internal oblique view of the tibia to see this fracture. Complete fracture means that the bone is completely fractured through its entire width. Transverse fracture occurs due to tension of the bone (such as a patellar fracture).  Transverse diaphyseal fracture in children can be successfully treated by flexible IM nails. Oblique fracture occurs due to compression force. There is slight obliquity of the fracture.  In a bending fracture pattern, part of the bone is subjected to tension force and the other part of the bone is subjected to compression force. The part of the fracture that is subjected to tension force will be transverse. The part of the fracture that is subjected to compression force will be oblique. You can tell from which side that the extremity was hit to create this fracture. Another type of complete fracture is the Butterfly fracture pattern. If the fracture is subjected to a bending force as well as axial loading, this will create the butterfly fracture pattern. With the bending force there is a tension force on one side creating a transverse fracture and a compression force on the other side creating a short oblique fracture, and the addition of an axial load force will create another oblique fracture. This is how the butterfly fracture is created (small transverse fracture and two oblique fracture).  Segmental fractures may occur from four point bending. Segmental open fracture is considered to be a Grade III open fracture even if the wound is 1 cm. Antibiotic coverage will include Ancef and Gentamicin. A spiral fracture occurs due to torsion or twisting force. There is a high association of posterior malleolus fractures with spiral distal tibial fractures and a CT scan of the ankle may be needed to diagnose and ankle fracture. A comminuted fracture or explosion fracture occurs due to high energy force. With this fracture type, there is a concern for the development of compartment syndrome. Examine the patient carefully for neurovascular deficit. The treatment of this fracture may be difficult. The skin may be compromised and the soft tissue is probably badly injured. The blood supply of the bone itself may be affected which may affect healing of the bone. When the fracture is comminuted, the most current treatment is to use a bridge plate to bridge the fragments and not to try to organize them and fit the pieces together because you may compromise the circulation of these fragments which may lead to nonunion or infection. The tendency is not to touch these fragments, but to line the axis of the limb carefully and to check the rotation and use a bridge plate. Fractures that penetrate the skin are open. Fractures that do not penetrate the skin are closed. Open fracture are more serious than closed fractures. Open fractures need an antibiotic immediately once the patient arrives to the hospital. Adequate debridement of the compromised, contaminated soft tissue should be done. Open fractures have a higher risk of infection and nonunion than closed fractures. Open fracture of the tibia can develop compartment syndrome. Open fracture of the humerus with radial nerve palsy, you have to explore the nerve because the nerve can be transected. Open fracture and radial nerve palsy is not a case for observation, it is a case for exploration.

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.