The ‘silent’ compartment syndrome
Introduction
All limb injuries, whether open or closed, can be complicated by compartment syndrome. Delayed diagnosis can lead to complications ranging from residual disability to amputation.3, 7, 8, 11, 13, 14, 15 A high index of suspicion is necessary to promote early diagnosis. The development of any of the classical signs (pain exacerbated by stretch, a tense swollen limb, pulselessness, paraesthesia, paresis or pallor) implies the development of underlying significant ischaemia. The diagnosis may be confounded by the presence of associated nerve injuries with loss of sensation,18, 20 in the unconscious or regionally anaesthetised patient4, 18 or in the patient rendered incompetent by the extremes of age, intoxication or psychopathology. However in the sensate and competent patient, the development of pain that is out of proportion to the injury sustained and is not relieved by analgesia is traditionally considered to be the earliest reliable indicator of the development of an underlying compartment syndrome in any limb.
We report 4 cases in which competent patients developed compartment syndromes in their sensate leg without any significant pain. The implications are discussed.
Section snippets
Patients and methods
The patients, all competent sensate young males, presented with single closed lower limb injuries between 2004 and 2005. All patients underwent pre- and postoperative non-invasive clinical surveillance based on routine pain checks and clinical examination. Reportage of either pain out of proportion to that expected for the given injury or a palpably tense limb, with positive passive stretch test provoked immediate bedside pressure-gauge measurement. The decision to perform decompressive
Case 1: Well leg compartment syndrome
An 18-year-old muscular male presented after a vehicular accident with a right sided closed high-energy femoral diaphyseal fracture. He underwent intramedullary nail fixation in the hemilithotomy position on the fracture table within 8 h of presentation. The patient's muscular status and the petrotic nature of the pertrochanteric region precluded closed antegrade nailing despite several attempts by the consultant led team using both manual and powered instruments. A retrograde nailing procedure
Case 2: Postoperative compartment syndrome
A 23-year-old powerfully built male rugby player presented with a closed short oblique tibial diaphyseal high-energy sports injury. He reported pain of an intensity of 5/10 on routine pain scale monitoring and was comfortable with routine analgesia. Uneventful intramedullary nailing was performed within 24 h with an operative time of 45 min. Postoperatively the patient was comfortable with analgesia. He was examined prior to discharge the following morning and found to have some blunting of
Case 3: Post-traumatic compartment syndrome
A 43-year-old male tree surgeon presented to the hospital as a tertiary referral 8 h after falling, harnessed, some 5 m from a broken bough and swinging against the tree-trunk sustaining a closed lateral tibial plateau fracture. The patient presented with visual analogue score of 5/10 and was comfortable with analgesia resting his splinted limb elevated on a Brauns frame and reading when routinely assessed by the senior resident on night rounds. Despite his relative comfort and sparse analgesic
Case 4
A 48-year-old male lorry driver sustained a closed, extra-articular multifragmentary fracture of the right proximal tibia and fibula when a large metal sheet fell onto his leg. Initial assessment revealed significant swelling of the right leg associated with fracture blisters, but no neurovascular deficit. He was managed with back-slab splintage, bilateral AV boots, Brauns frame elevation and routine analgesia with a view to surgical fixation when the swelling had sufficiently reduced. At 48 h,
Discussion
The diagnosis of compartment syndrome is traditionally considered to be a clinical one with intractable pain out of proportion to that expected for a given injury. The diagnosis is clinched if the pain is aggravated on passive stretching of the affected compartments. Diagnostic pressure monitoring confirms the diagnosis in those with clearly suggestive clinical symptoms and signs of compartment syndrome.
Some studies have advocated an intracompartmental pressure of greater than 30 mm Hg1, 5, 12 as
Conclusion
Occult compartment syndrome may occur in non-competent, distracted or insensate patients. We believe that a true ‘silent compartment syndrome’ occurs when a compartment syndrome is confirmed in a competent sensate patient in the absence of pain which is out of proportion to that expected for a given injury. Young super fit high muscle mass patients appear prone to compartment syndrome. We believe that a high index of clinical suspicion must prevail in association with either continuous
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2021, International Journal of Orthopaedic and Trauma NursingCitation Excerpt :Pain in ACS is considered the earliest and most reliable clinical finding which is commonly defined as being out of proportion and which is aggravated with passive stretching of the muscle compartment (Badhe et al., 2009). In a sensate patient, this can be severe and unrelieved by analgesia, but pain may sometimes be obscured by factors such as nerve injuries, anaesthesia or regional nerve blocks (Badhe et al., 2009; Taylor et al., 2012). Moreover, pain is a subjective clinical finding which has resulted in several false negative or missed ACS cases (Mauffrey et al., 2019; Prayson et al., 2006).
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2020, Emergency Medicine Clinics of North AmericaCitation Excerpt :A variety of surgical options may be used to repair this injury, including external fixators, open reduction, and arthroscopic techniques.157,158 Although the physical examination is often limited by pain, it is important to fully evaluate the injured extremity because compartment syndrome is common with tibial plateau fractures.159,160 Concurrent ligamentous injuries are also seen with tibial plateau fractures; typically the collateral ligament opposite the fracture is injured.