Ortho Blog - CMC COMPENDIUM

COMPARTMENT SYNDROME

6/25/2018

Authored by Dr. Angie Rombola

Background:

Occurs when high compartment pressure prevent adequate perfusion
Irreversible muscle and nerve damage after 4-6 hrs
Most commonly: lower leg (40%)
Can occur anywhere skeletal muscle is surrounded by fascia (forearm, thigh, hand, foot, buttock)

Mechanism:

Fractures (69%)
- Increased incidence with openfractures
- Tibial fracture (most common)
Soft tissue injury
- Crush Injuries
- Contusions
- Burns
- Prolonged limb compression
External compression
- Tight casts, dressings
Vascular
- Hemorrhage
Ischemic-reperfusion injury
- Arterial injury

Clinical Features:

Common
- Pain out of proportion (earliest)
- Pain with passive stretch (most sensitive)
- Rapidly increasing & tense swelling
Paresthesias (early)
- Uncommon
- Decreased sensation
- Motor weakness (late)
- Pulselessness (uncommon)

Diagnosis:

Primarily a clinical diagnosis
Measure of tissue pressures is confirmatory
Measuring compartment pressure indicated in polytrauma, sedated/AMS patients

Compartment Pressure:

Intra-compartment pressure: > 30mm Hg
Delta pressure (DBP – compartment p) < 30 mmHg
- Better measurement
- Helps avoid unnecessary fasciotomies

Management:

Remove external compressive wrappings
Address underlying cause
Surgical consult for fasciotomy
Supplemental Oxygen
Correct hypotension
Reverse patients on anticoagulants

4 Compartments of the lower leg

Anterior
Lateral
Superficial posterior
Deep posterior

Need to measure all 4 compartments

The FOot

6/12/2018

By: DR. AUSTIN COSTA

When to order foot X-rays?:

Ottawa midfoot rules
- Pain with palpation of base of 5thmetatarsal
- Pain with palpation of navicular
- Inability to bear weight both at time of injury and in ED
Suspected injury with high energy mechanism

Anatomy (From proximal to distal):

Hindfoot
- Calcaneus and talus
Chopart joint
Midfoot
- Navicular, medial cuneiform, middle cuneiform, lateral cuneiform, and cuboid
Lizfranc joint
- Lizfranc ligament connects medial cuneiform and 2ndMT on plantar aspect of foot
Forefoot
- Metatarsals, phalanges

Standard Views:

AP
- Forefoot
- Midfoot
- Lizfranc injury
  - Alignment of 1stMT and medial cunneaform
  - Alignment of 2ndMT and middle cunneaform

Oblique

Forefoot
Midfoot
Calcaneus
Alignment for 3rdMT with lateral cuneiform
Alignment of 4thMT with cuboid

Lateral
- Hindfoot
  - Boehler’s angle
    - upper edge of the calcaneal body posteriorly to the upper edge of the posterior articular facet of the calcaneus (red)
    - upper edge of the posterior articular facet of the calcaneus to the upper edge of the anterior process of the calcaneus (blue)
    - Normal is 25-40 degress

Dorsal foot arch
- Weight bearing films (if able to tolerate)
- Allows spreading of metatarsals

1. Approach to foot X-rays:
- Assess cortical disruption for fractures in area of tenderness
  - Forefoot
    - AP, oblique
  - Midfoot
    - AP, oblique
  - Hindfoot
    - Oblique, lateral
    - Boehler’s angle < 25 degress = calcaneal depression fracture

2. Lizfranc Injury
- Plantar ecchymosis
- Stress tarso-MT joint
- Get weight bearing films!
- Instability ED Ortho consult

3. Base of 5thMetatarsal
- Pseudo-Jone(Zones)
  - Ankle inversion
  - Peroneus brevis insertion
- Jones (Zone II)
  - Metaphyseal-diaphyseal junction
  - At level of 4th-5thmetatarsal joint
  - High risk of non-union
- Diaphyseal Stress Fracture (Zone III)
  - Repetitive microtrauma

Management:

Hindfoot: Splint (Bulky Jones), NWB
- Boehler’s angle
- Look for spinal injuries
Midfoot: Splint (sugar tong w/ posterior slab), NWB
- Lizfranc. -> Weight bearing films
Forefoot:
- Metatarsals: CAM boot, NWB -> WBAT. Except 1stand base of 5th zones 2&3
- Phylanges: Buddy tape, post op shoe, unless significantly displaced/rotated

References

Londner M, Hammer D, Kelen GD. Foot injuries. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli’s Emergency Medicine. 8 th ed. New York: McGraw-Hill; 2004; (cited 2017, Sep 08)
Smith, M. S., Hatch, R., & Eiff, M. (2012). Calcaneous and Other Tarsal Fractures; Metatarsal Fractures; Toe Fractures; . In Fracture Management for Primary Care (3rd ed., pp. 276-326). Philadelphia, PA: Saunders.
Weatherford, B. (n.d.). 5th Metatarsal Base Fracture. Retrieved September 08, 2017, from http://www.orthobullets.com/foot-and-ankle/7031/5th-metatarsal-base-fracture
Hatch, R. L., & Hacking, S. (2003, December 15). Evaluation and Management of Toe Fractures. Retrieved September 08, 2017, from http://www.aafp.org/afp/2003/1215/p2413.html
Foot Fracture Treatment & Management. (2017, August 03). Retrieved September 08, 2017, from http://emedicine.medscape.com/article/825060-treatment#d10

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CMC ER Residents
(for learning purposes, imagine all cases present to a free standing ED for dispo and treatment options)

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Disclaimer: All images and x-rays included on this blog are the sole property of CMC EM Residency and cannot be used or reproduced without written permission. Patient identifiers have been redacted/changed or patient consent has been obtained. Information contained in this blog is the opinion of the author and application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.