eMedicine Specialties > Orthopedic Surgery > Trauma

Compartment Syndrome, Lower Extremity: Workup

Author: Stephen Wallace, MD, Staff, Department of Emergency Medicine, Eastern Idaho Regional Medical Center
Coauthor(s): Stuart Goodman, MD, PhD, FRCSC, FACS, Associate Chairman, Professor, Department of Functional Restoration, Division of Orthopedic Surgery, Stanford University; Head, Division of Orthopedic Surgery, Stanford University Medical Center; Douglas G Smith, MD, Associate Professor, Department of Orthopedic Surgery, University of Washington, Harborview Medical Center
Contributor Information and Disclosures

Updated: Feb 9, 2009

Workup

Laboratory Studies

  • Hematology/chemistry laboratory studies – Serum myoglobin and CK measurements should be obtained to determine the degree of muscle necrosis.
    • Serial CK levels may show increases indicative of a developing CS.
    • High CK levels should alert the physician to possible rhabdomyolysis. 
  • Renal function/chemistry panel
    • Blood urea nitrogen (BUN) and creatinine are measured.
    • Potassium level is needed in cases of rhabdomyolysis.
    • Severe hyperkalemia may result in a wide complex and possibly fatal arrhythmia.
  • Complete blood cell count (CBC) and coagulation studies
  • Preoperative laboratory studies 
  • Urinalysis to determine myoglobin and CK (if available)
    • A urine dip may show blood but no red blood cells (RBCs), which indicates the presence of myoglobin.

Imaging Studies

  • Plain radiographs of the affected extremity are used to determine fracture pattern, soft-tissue injury, and radiographic clues that may indicate occult fractures.
  • MRI may show increased signal intensity in an entire compartment on T2-weighted, spin-echo sequences.
  • Computed tomography (CT) scanning is especially useful if pelvic or thigh compartment syndrome (CS) is in the differential diagnosis.
  • Lower extremity venous Doppler or arterial ultrasonography (US) is performed as needed to address possible DVT or arterial occlusion.

    • US alone is not useful in making the diagnosis of CS.

Other Tests

  • 12-Lead electrocardiography (ECG)

    • Use preoperatively if the patient is older than 45 years or has risk factors for coronary artery disease (CAD).
    • Use for evaluation in cases of patients with hyperkalemia.

Diagnostic Procedures

  • Injection technique of direct pressure measurement 
    • Direct compartment-pressure measurement is the diagnostic criterion standard and should be the first priority if the diagnosis is in question. A number of handheld devices are available. The Stryker pressure tonometer is widely used, and pressure measurements from the Stryker device are within 5 mm Hg of the slit catheter for 95% of all readings (direct communication with Stryker Corporation, April 2007).
    • The device measures the pressure that is necessary to inject a small quantity of fluid. This technique often overestimates low pressures but is generally reliable.
    • Supplies needed to make a pressure transducer are as follows:
      • 1 sterile 20-mL Luer-Lok tip syringe (BD Medical Systems, Sandy, Utah)
      • 1 4-way stopcock
      • 1 18-gauge, 1.25-inch Angiocath intravenous catheter (BD Medical Systems)
      • 2 89-cm–long extension tube sets
      • 2 18-gauge needles
      • 1 Telfa adhesive dressing pad (Kendall Healthcare Products Co, Mansfield, Mass)
  • Instructions for measuring intracompartmental pressure22 :

    1. Clean and prepare the area.
  • 2. Assemble the 20-mL syringe with the plunger at the 15-mL mark, and connect it to an open end of the 4-way stopcock.
  • 3. Connect the sterile plastic IV extension tube and an 18-gauge needle on 1 end of the stopcock; connect a second IV extension tube at the opposite end of the stopcock to a blood pressure manometer.
  • 4. Insert the tip of the 18-gauge needle into the saline bag, and open the stopcock to allow flow only through the needle end of the IV tubing. Aspirate the saline solution without bubbles into about half the length of the extension tube. Turn the 4-way stopcock to close off this tube so that the saline solution is not lost during transfer of the needle.
  • 5. Insert the 18-gauge needle into the muscle of the compartment in which the tissue pressure is to be measured. In the lower leg, the myofascial compartment becomes least compliant at the level of the musculotendinous junction and the extensor retinaculum. Alternatively, the myofascial pressures at several locations may be obtained and the results pooled.
  • 6. Turn the stopcock so that the syringe is open to both extension tubes, forming a T connection. This produces a closed system in which the air is free to flow into both extension tubes as the pressure within the system is increased.
  • 7. Increase the pressure in the system gradually by slowly depressing the plunger of the syringe while watching the saline/air meniscus. The mercury manometer rises as the pressure within the system rises. When the pressure in this system has just surpassed the tissue pressure surrounding the needle, a small amount of saline solution is injected into the tissue, and the meniscus is observed to move. When the column moves, stop the pressure on the syringe plunger and read the level of the manometer. The manometer reading at the time the saline column moves is the tissue pressure in mm Hg.
  • Wick technique of direct compartment-pressure measurement
    • The wick technique employs strands of a wettable material that extend from the tissue to a fluid-filled catheter that is connected to a pressure transducer.
    • As long as the wick catheter patency is checked, the wick method is as reliable as continuous-infusion techniques.

Histologic Findings

Histology is usually not helpful. If necrotizing fasciitis is in the differential diagnosis, intraoperative cultures and a Gram stain may be of benefit.

More on Compartment Syndrome, Lower Extremity

Overview: Compartment Syndrome, Lower Extremity
Workup: Compartment Syndrome, Lower Extremity
Treatment: Compartment Syndrome, Lower Extremity
Follow-up: Compartment Syndrome, Lower Extremity
Multimedia: Compartment Syndrome, Lower Extremity
References
Further Reading
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Keywords

compartment syndrome, CS, chronic CS, chronic exertional CS, exertional CS, recurrent CS, subacute CS, Volkmann ischemia, chronic exertional compartment syndrome, exertional rhabdomyolysis, recurrent compartment syndrome, subacute compartment syndrome, fasciotomy, compartment release

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Contributor Information and Disclosures

Author

Stephen Wallace, MD, Staff, Department of Emergency Medicine, Eastern Idaho Regional Medical Center
Stephen Wallace, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Stuart Goodman, MD, PhD, FRCSC, FACS, Associate Chairman, Professor, Department of Functional Restoration, Division of Orthopedic Surgery, Stanford University; Head, Division of Orthopedic Surgery, Stanford University Medical Center
Stuart Goodman, MD, PhD, FRCSC, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, California Medical Association, Canadian Medical Association, College of Physicians and Surgeons of Ontario, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Douglas G Smith, MD, Associate Professor, Department of Orthopedic Surgery, University of Washington, Harborview Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Steven I Rabin, MD, Clinical Associate Professor, Loyola University Medical Center; Chair, Department of Orthopedic Surgery, Dreyer Medical Clinic
Steven I Rabin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Fracture Association, AO Foundation, and Orthopaedic Trauma Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Samuel Agnew, MD, FACS, Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center
Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Jason H Calhoun, MD, FAAOS, Chairman, J Vernon Luck Distinguished Professor, Department of Orthopedic Surgery, University of Missouri
Jason H Calhoun, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and American Orthopaedic Foot and Ankle Society
Disclosure: Nothing to disclose.

 
 
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