JBJS | Perioperative Compartment Syndrome. A Report Of Four Cases*

The Journal of Bone & Joint Surgery, Volume 78, Issue 4

Articles | April 01, 1996

Perioperative Compartment Syndrome. A Report Of Four Cases*

JOHN GRAY SEILER III, M.D.†; ARTHUR L. VALADIE III, M.D.†; DAVID M. DRVARIC, M.D.†; ROBERT W. FREDERICK, M.D.†; THOMAS E. WHITESIDES, JR., M.D.†, ATLANTA, GEORGIA

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Investigation performed at the Department of Orthopaedic Surgery, Emory University, Atlanta

The Journal of Bone & Joint Surgery. 1996; 78:600-2

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Introduction

Introduction | Case Reports | Discussion | References

Compartment syndromes are usually seen following trauma to or arterial reconstruction of an extremity^{13,14,17,21,26,27}. Since the mid-1970's, major improvements have been made in the devices used to irrigate wounds and joints and to infuse fluids. Occasionally, the use of pressurized devices to enhance the flow of fluid may be associated with the development of acute compartment syndromes.

We report the cases of four patients in whom an acute compartment syndrome developed during an operative procedure and in whom a large amount of extravasated fluid was found in the soft tissue of the extremity that had been operated on. The compartment syndromes were believed to have resulted from the use of a pressurized pulsatile irrigation system (two patients), the use of a pump for the infusion of fluids into the joint during an arthroscopic procedure (one patient), and the use of a device for the pressurized intravenous infusion of parenteral fluids (one patient).

We retrospectively reviewed the hospital records for each patient and obtained information about the nature of the original injury, the interval of time before the compartment syndrome developed, the reasons that a compartment syndrome was suspected, the method for the measurement of tissue pressure, and the treatment of the compartment syndrome. At the most recent follow-up evaluation, all four patients were examined by one of us to determine the functional outcome.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Emory University, 1365 Clifton Road, N.E., Atlanta, Georgia 30322.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Emory University, 1365 Clifton Road, N.E., Atlanta, Georgia 30322.

Case Reports

Introduction | Case Reports | Discussion | References

CASE 1. A fifty-seven-year-old man who was right-hand dominant sustained a direct blow to the ulnar aspect of the right forearm, resulting in an open fracture of the diaphysis of the ulna; the defect of the skin was less than two centimeters. There was no clinical evidence of a compartment syndrome at the time of presentation. Approximately twelve hours after the injury, the patient was taken to the operating room for irrigation and débridement of the open fracture. A tourniquet was not used. The wound was irrigated with a pressurized pulsatile irrigation system (Simpulse Irrigator, model 0037590; Davol, Cranston, Rhode Island). For a brief period during the process of irrigation, the nozzle of the irrigation instrument was placed into the wound. The forearm rapidly became swollen and tense. Although the irrigation was discontinued, the forearm remained tense. Because of the amount of swelling, intracompartmental pressures were measured with the method of Whitesides et al.²⁸. The pressures were seventy-two millimeters of mercury (9.60 kilopascals) in the volar compartment, twenty millimeters of mercury (2.67 kilopascals) in the dorsal compartment, and less than ten millimeters of mercury (1.33 kilopascals) in the mobile wad of Henry. The diastolic blood pressure was ninety millimeters of mercury (12.00 kilopascals). A fasciotomy of the volar side of the forearm was performed, with immediate reduction of intracompartmental pressures to less than ten millimeters of mercury (1.33 kilopascals). Postoperatively, the patient had no neurological deficit. The fasciotomy wound was closed on the fourth postoperative day. At the most recent follow-up examination, the fracture had healed and the patient had no residual neurological deficit or soft-tissue contracture.

CASE 2. A forty-six-year-old man sustained an open fracture of the distal parts of the right radius and ulna, with transection of the ulnar nerve, in a motorcycle accident. In addition, he had a fracture of the proximal part of the left humerus and of the left tibial plateau. The initial treatment at a local hospital consisted of irrigation and débridement of the wound and immobilization of each injured extremity in a splint.

Two weeks after the injury, the patient was transferred to our institution for definitive treatment. On admission, he had mild swelling of the injured extremities but no evidence of a compartment syndrome. External fixation of the radius was performed after irrigation and débridement of the wound. Three days later, the wound was debrided again and the ulnar nerve was repaired. A tourniquet was inflated at the start of the procedure. The wound was irrigated with a pressurized fluid irrigation system (Orthotec 203-1; Stryker, Kalamazoo, Michigan). After repair of the ulnar nerve, the wound was irrigated a second time with use of the irrigation device. The forearm rapidly became tense and swollen. The tourniquet was deflated, but the forearm remained tense. Diminished arterial inflow was evident, as demonstrated by capillary refill and by needle sticks in the fingertip. Because of these findings, a fasciotomy of the volar side of the forearm was performed immediately. The compartment pressures were not measured. After the fasciotomy, the distal capillary refill improved substantially. The wound was left open, and skin-grafting was performed at a later date. At the time of the most recent follow-up examination, the function of the median and radial nerves was intact but the ulnar nerve had no recovery of function.

CASE 3. A twenty-six-year-old man sustained a laceration of the posterior aspect of the knee with an injury of the posterior cruciate ligament when the left knee was caught between the bumpers of two vehicles. There was no neurovascular injury. Symptomatic posterior instability of the knee developed, and it did not respond adequately to non-operative treatment. Nine months after the injury, arthroscopic reconstruction of the posterior cruciate ligament was performed. An arthroscopic infusion pump (model 60-5175-005; Linvatec, Largo, Florida) was used during the arthroscopy, and a tourniquet was used for most of the procedure. After the reconstruction, the calf was noted to be tense and swollen. The intracompartmental pressures, as measured with the method of Whitesides et al.²⁸, were forty to fifty millimeters of mercury (5.33 to 6.67 kilopascals) in the superficial and deep posterior compartments and twenty millimeters of mercury (2.67 kilopascals) in the anterior and lateral compartments. The diastolic blood pressure was seventy millimeters of mercury (9.33 kilopascals). Exploration of the popliteal fossa revealed extensive extravasation of fluid from the knee joint into the calf muscles. A four-compartment fasciotomy was done with use of two incisions. The skin wounds were closed primarily. Postoperatively, the patient reported paresthesias in the left leg that lasted for two weeks. At the most recent follow-up examination, the neurological status of the limb was normal and there were no soft-tissue contractures.

CASE 4. A forty-four-year-old woman had decompression and arthrodesis of the cervical spine for a complex spinal deformity. Preoperatively, a 16-gauge intravenous catheter had been placed in the dorsum of the right hand. In order to improve the rate of fluid infusion, a pressure infusion bag (Infusible, United States patent number 4,735,613; Vital Signs, Totowa, New Jersey) was used. During the operation, an unknown volume of crystalloid had extravasated into the interstitial tissues of the hand. The anesthesiology staff noted that the pulse oximeter was not recording the degree of oxygen saturation in that hand. The entire hand was swollen and pale. The pressure in the interosseous compartments was seventy millimeters of mercury (9.33 kilopascals). Fasciotomies were performed, and severe interstitial muscle edema was noted. Postoperatively, the patient had normal capillary refill in the fingers. When the patient was extubated two days later, she had normal sensation in the involved hand. She had delayed primary closure of the wounds. At the three-month follow-up examination, the range of motion and sensation in the hand were normal.

Discussion

Introduction | Case Reports | Discussion | References

Acute compartment syndrome develops when an increase in the pressure within a closed muscle compartment impedes arterial perfusion. The resultant ischemia can have permanent and disabling sequelae^13,26,27. Early diagnosis and decompression of the compartment have been shown to be effective in preventing the soft-tissue dysfunction that results from an untreated compartment syndrome.

A variety of causes, including the pressurized intravenous infusion of fluid, have been implicated in the development of perioperative compartment syndromes^12,23. Maor et al. reported the case of a patient in whom a compartment syndrome of the forearm developed after the transfusion of fluids under pressure. The patient awoke from anesthesia with pain and sensory loss in the arm and needed an immediate fasciotomy to restore perfusion. Sneyd et al. reported on two patients in whom a compartment syndrome developed in the forearm after the intraoperative use of a device for the pressurized intravenous infusion of fluids. Postoperatively, both patients had a swollen forearm. One patient needed a fasciotomy, and the other was managed with observation and elevation of the upper extremity. Both were reported to have recovered full function of the limb.

Extravasation of fluid into the adjacent soft tissues after an arthroscopic procedure on the knee has been reported to be associated with perioperative compartment syndromes^2,4,20. Bomberg et al. reported the cases of two patients in whom a compartment syndrome developed after the extravasation of irrigation fluid. In both patients, the muscle compartments of the lower extremity became tense intraoperatively and a fasciotomy was performed. Bamford et al. reported on three patients in whom a compartment syndrome developed during an arthroscopic procedure on the knee. The surgeons were alerted to the possibility of a compartment syndrome by the presence of tense muscle compartments. Two of the three patients had a fasciotomy. The position of the extremity during an operation has been associated with the development of acute compartment syndromes. In several reports, the lithotomy and hemilithotomy positions have been implicated in the development of perioperative compartment syndromes of the lower extremity^{1,3,6,10,11,18,22}. In most of these reports^1,3,10,11,18, postoperative pain in the lower extremity was the first abnormality noted by the physicians. Typically, intraoperative swelling of the extremity was not noticed. Despite the lack of substantive data to establish causality, a variety of other perioperative events also have been cited in association with acute compartment syndromes^{5,7-9,15,16,19,24,25,29}.

The diagnosis of compartment syndrome in the perioperative period may be difficult because of the use of anesthetic agents or the presence of concomitant injuries. The patient may be unable to report characteristic symptoms associated with compartment syndrome, and clinical examination may be difficult to perform. Postoperative pain in the extremity is the most frequent finding to alert the surgeon to the development of a compartment syndrome.

In our four patients, the diagnosis of compartment syndrome was made intraoperatively. In three patients, a compartment syndrome was suspected because the extremity was tense and swollen. The diagnosis was suspected in the fourth patient because of abnormal pulse-oximetry readings. The diagnosis was confirmed by the measurement of intracompartmental pressures in three of the four patients. All of the patients had an immediate fasciotomy, and there were no residual neurological deficits related to the compartment syndrome.

On the basis of the findings in our four patients, we recommend that pressurized irrigation devices be used with caution when irrigating small wounds. We also recommend caution with regard to the use of any other devices that may cause excessive infiltration of fluid into muscle compartments. Careful intraoperative examination should be performed for any extremity in which there is a risk of excessive infiltration of fluid. The intraoperative measurement of compartment pressures is a useful adjunct to physical examination in the diagnosis of perioperative compartment syndrome. If a perioperative compartment syndrome is present, a fasciotomy should be performed immediately.

The development of a perioperative compartment syndrome is related to several diverse circumstances. Therefore, prompt recognition and treatment are necessary to avoid the disastrous sequelae of a missed diagnosis.

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Introduction | Case Reports | Discussion | References

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