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Acute Compartment Syndrome Workup

  • Author: Abraham T Rasul, Jr, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: May 06, 2016
 

Approach Considerations

In a patient with the classic compartment syndrome presentation and physical examination findings, no laboratory workup is needed. Laboratory results are often normal, are not necessary to diagnose compartment syndrome, and are not helpful to rule out compartment syndrome. However, in acute compartment syndrome, especially with trauma, consider performing a workup for rhabdomyolysis, with measurement of the following:

  • Creatine phosphokinase (CPK)
  • Renal function studies
  • Urinalysis
  • Urine myoglobin

A CPK concentration of 1000-5000 U/mL or greater or the presence of myoglobinuria can suggest compartment syndrome. Serial CPK measurements may show rising levels indicative of a developing compartment syndrome. Urinalysis may be used to help identify causes of acute renal failure.

Patients with rhabdomyolysis should have serum chemistry studies done. Complete blood cell count and coagulation studies should be part of the preoperative workup. Anemia worsens tissue oxygenation. Disseminated intravascular coagulation is a rare but possible complication.

Measurement of intracompartmental pressures remains the standard for diagnosis of compartment syndrome. Perform this procedure as soon as a diagnosis of compartment syndrome is suspected.

Imaging studies are usually not helpful in making the diagnosis of compartment syndrome. However, such studies are used in part to eliminate disorders in the differential diagnosis. Standard radiographs are obtained to determine the occurrence and nature of fractures. Stress fractures and periostitis can be diagnosed with plain radiographs, bone scans, computed tomography (CT) scans, or magnetic resonance imaging (MRI) scans.[52] CT scanning may be useful if pelvic or thigh compartment syndrome is part of the differential diagnosis.

Muscle tears can be observed using MRI or ultrasonography.[53] MRI may show increased signal intensity in an entire compartment on T2-weighted, spin-echo sequences. Doppler ultrasound may be used to evaluate arterial flow and to rule out deep venous thrombosis, particularly in the lower extremities. In addition, the loss of normal phasic patterns of tibial venous blood flow has been shown to accurately predict the need for surgical fasciotomy.[54] Ultrasonography alone is not useful in diagnosing compartment syndrome, but it aids in the exclusion of other disorders.

In the lower leg, partial vascular occlusion may cause a pseudo–compartment syndrome. Angiography may be needed to exclude adductor canal compression syndrome and popliteal artery entrapment. Pulse oximetry is helpful in identifying limb hypoperfusion. However, it is not sensitive enough to exclude compartment syndrome. In unusual cases, muscle biopsies may be necessary in primary muscle disorders. Histology is usually not helpful, but if necrotizing fasciitis is in the differential diagnosis, intraoperative cultures and a Gram stain may be of benefit.

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Renal Function and Serum Chemistry Studies

Blood urea nitrogen (BUN) and creatinine levels are used to assess the patient's hydration status in cases of rhabdomyolysis. Measurement of the potassium level is needed in cases of rhabdomyolysis, as severe hyperkalemia may result in a wide-complex, possibly fatal arrhythmia. Purines released from cell nuclei result in hyperuricemia and nephrotoxicity. Coexisting oliguria, aciduria, and uricosuria worsen nephrotoxicity.

An anion gap (see the Anion Gap calculator) may indicate other underlying etiologies (eg, drug overdose) for the compartment syndrome. Sodium, potassium, bicarbonate, and phosphate levels are used to assess lactic acidosis and other metabolic acids. In addition, hyperphosphatemia aggravates hypocalcemia. Metastatic calcification is possible.

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Compartment Pressure Measurement

Various methods and equipment can be used for compartment pressure measurement. A transducer connected to a catheter usually is introduced into the compartment to be measured. This is the most accurate method of measuring compartment pressure and diagnosing compartment syndrome. Measurement of the compartment pressure then can be performed at rest, as well as during and after exercise. With the acute syndrome, the exact pressure threshold is controversial, but typical ranges are from 30-45 mm Hg at rest. Some sources state that it is better to associate this pressure to diastolic pressure (that is, within 10-30 mm Hg of diastolic pressure).

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 Stryker STIC device is shown in the image below.

Stryker STIC Monitor. Image courtesy of Stryker Co Stryker STIC Monitor. Image courtesy of Stryker Corporation, used with permission.

If a commercial device is unavailable, it is possible to assemble a device to measure intracompartment pressure. 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:

  • One sterile 20-mL Luer-Lok tip syringe (BD Medical Systems)
  • One 4-way stopcock
  • One 18-gauge 1.25-in Angiocath IV catheter (BD Medical Systems)
  • Two 89-cm–long extension tube sets
  • Two 18-gauge needles
  • One bag of sterile normal saline for intravenous infusion
  • One Telfa adhesive dressing pad (Kendall Healthcare Products Co)
  • One blood pressure manometer

A diagram of the device is shown in the image below.

Picture of compartment pressure measuring device f Picture of compartment pressure measuring device for use when commercial devices are unavailable.

Instructions for measuring intracompartmental pressure are as follows[49] :

  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 bag of saline, and open the stopcock to allow flow through the needled IV tubing only. 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.
  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 will rise 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 will be seen 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.[55]

As long as the wick catheter patency is checked, the wick method is as reliable as continuous-infusion techniques.

Other measurement techniques

Other less-invasive compartment blood flow measurement techniques that have been studied but are not commonly used in clinical practice include the following:

  • Laser Doppler ultrasound
  • Methoxy isobutyl isonitrile enhanced magnetic resonance imaging (MRI)
  • Phosphate-nuclear magnetic resonance (NMR) spectroscopy
  • Thallous chloride-201 ( 201 Tl ) and technetium-99 ( 99 m Tc) sestamibi, and xenon (Xe) scanning
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Contributor Information and Disclosures
Author

Abraham T Rasul, Jr, MD Medical Director for Rehabilitation, Specialty Hospital of Washington; Founder, Arizona Golf Medicine Institute

Abraham T Rasul, Jr, MD is a member of the following medical societies: American College of Sports Medicine, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; 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.

Jason H Calhoun, MD, FACS Frank J Kloenne Chair in Orthopedic Surgery, Professor and Chair, Department of Orthopedics, The Ohio State University Medical Center

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Missouri State Medical Association, Musculoskeletal Infection Society, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, and Texas Orthopaedic Association

Disclosure: Nothing to disclose.

William K Chiang, MD Associate Professor, Department of Emergency Medicine, New York University School of Medicine; Chief of Service, Department of Emergency Medicine, Bellevue Hospital Center

William K Chiang, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Patrick M Foye, MD Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Stuart B Goodman, MD, PhD, FRCS(C), FACS, FBSE Robert L and Mary Ellenburg Professor of Surgery, Professor, Department of Orthopedic Surgery, Fellowship Director, Orthopedic Adult Reconstruction, Affiliated Faculty, Department of Bioengineering, Affiliated Faculty, Stanford Center on Longevity, Stanford University School of Medicine, Stanford University Medical Center

Stuart B Goodman, MD, PhD, FRCS(C), FACS, FBSE 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.

Mary Ann E Keenan, MD Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

Disclosure: Nothing to disclose.

Rick Kulkarni, MD

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard Paula, MD Assistant Professor of Emergency Medicine, Director of Research, University of South Florida College of Medicine

Richard Paula, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

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.

Douglas G Smith, MD Associate Professor, Department of Orthopedic Surgery, Harborview Medical Center, University of Washington School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Drug Reference Salary Employment

Jeffrey L Visotsky, MD Assistant Professor, Department of Clinical Orthopedic Surgery, Northwestern University, The Feinberg School of Medicine

Jeffrey L Visotsky, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American College of Physician Executives, American College of Surgeons, American Medical Association, American Society for Surgery of the Hand, Arthroscopy Association of North America, Chicago Medical Society, and Illinois State Medical Society

Disclosure: Depuy Consulting fee Speaking and teaching; Pegasus Honoraria Board membership

Stephen Wallace, MD Staff Physician, Department of Emergency Medicine, Memorial Hospital of Sweetwater County

Stephen Wallace, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Rajesh R Yadav, MD Associate Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas Medical School at Houston

Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

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(Click Image to enlarge.) Volar release in the forearm. The upper illustration shows the incision that is used. The lower left picture depicts the relevant incisional anatomy. The lower right picture depicts the cross-sectional anatomy.
Surgical anatomy of the volar forearm. Photo courtesy of Dr. Smith, Harborview/UW Medical Center, Department of Orthopaedics, Seattle, Wash.
(Click Image to enlarge.) Two-incision anterolateral fasciotomy. Photographs courtesy of DG Smith, MD, Harborview Hospital, Seattle, WA.
(Click Image to enlarge.) Two-incision posteromedial fasciotomy. Photographs courtesy of DG Smith, MD, Department of Orthopedics, Harborview Hospital, Seattle, WA.
(Click Image to enlarge.) Single-incision fasciotomy. Photographs courtesy of DG Smith, MD, Harborview Hospital, Seattle, WA.
Picture of compartment pressure measuring device for use when commercial devices are unavailable.
Stryker STIC Monitor. Image courtesy of Stryker Corporation, used with permission.
 
 
 
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