A Novel noninvasive technique for detecting Compartment
syndrome
Aravind Ravichandran,GMKMCH
INTRODUCTION:
Acute Compartment syndrome is one of surgical emergencies,
where early intervention can avert a devastating effect to the
patient. Compartment syndrome can be defined as declining
circulation and worsening of function of the tissues of limb due to
increasing pressure in a closed space, since leg and forearm
contains many compartments in a small area,compartment
syndrome commonly occurs in the legs(40%),followed by
forearm(18%), but can also occur in arms,thighs and abdomen
with lesser incidence(1).Traumatic injuries represents the main
cause for Acute Compartment Syndrome(ACS), but also ischemic
reperfusion injury and iatrogenic causes like compressive plaster
application also cause ACS.
The unattended compartment syndrome leads to a cascade of
deficits in the limb - neurological, muscular finally vascular
compromise resulting in amputation of limb, in some cases even
death due to rhabdomyolysis and renal shutdown.
Currently the detection of ACS depends on clinical suspicion only
in many trauma centres, while confirmed by direct measurement
of compartment syndrome using invasive approach like
Whitesides apparatus remains to be the gold standard. Newer
methods utilising NIRS and ultrasonic devices have been
proposed(2), but are not feasible in many trauma centers due to
high cost and availability factors.The clinical diagnosis of ACS is
simple but sensitivity for diagnosing compartment syndrome is
low (13% to 19%)(3),on the other hand whiteside method is
invasive, as noted by Shadgan et.all a reliable noninvasive
approach for early diagnosis of compartment syndrome would be
landmark achievement in Orthopaedics and what needed at
present(4)(5).Here in our study we propose a novel noninvasive
approach that is possible in every trauma centre to detect
compartment syndrome and thereby intervene at an earlier stage.
STUDY MATERIALS AND METHODS:
The study was planned as a prospective randomised experimental
cohort study on 50 patients admitted for closed forearm and leg
fractures in our trauma centre-Govt Mohan Kumaramangalam
Hospital,Salem.Patients satisfying the following criteria were selected
for the study.
Inclusion criteria:
• Age >18years <75 years
• Closed Forearm and leg fractures
Exclusion criteria:
• Age <18years >75 years
• Pre existing atherosclerotic & cardiac disease patients
• Peripheral vascular disease patients
• Associated major organ injuries
The patient checked for any other associated injuries and general
condition of the patient was stabilised before beginning the study, then
the patient consent was obtained in written.The clinical findings
regarding compartment syndrome were also noted. Both Whiteside
and the new technique was performed by the two examiners in both
the limbs and findings were documented separately. The data was
analysed in XPSS/Excel software.
Procedure for New non invasive technique:
1.The subject was made to lie down comfortably in bed in supine position.
2.The normal limb is first examined and distal pulse(Anterior tibial/Dorsalis
pedis/Posterior tibial) is palpated, Sphygmomanometer cuff is tied at the level
of thigh/proximal leg and cuff pressure is elevated above systolic pressure while
simultaneously palpating the any one of the distal pulse,now the pressure is
released slowly and the pressure at which the reappearance of the pulse is noted
down.
3.The same procedure is repeated for the limb for which compartment
syndrome is suspected.The sphygmomanometer cuff is tied around proximal
1/3rd of leg, if the fracture occurs in The pressure at which pulse reappear is
noted.
4.The Delta S is calculated by P(N)-P(S), where P(N) is the pressure of normal
limb at which pulse reappeared, P(S) is the pressure of suspected limb at which
pulse reappeared.The positive Delta S value represents the intracompartmental
pressure in the suspected limb
•The Delta S >30mmHg or increasing of Delta S values in serial monitoring
should alarm the ongoing of Compartment syndrome.
References
(1)Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. The Journal of bone and
joint surgery. British volume. 2003 Jul;85(5):625-32
(2)Walters TJ, Kottke MA, Hargens AR, Ryan KL. Noninvasive diagnostics for extremity
compartment syndrome following traumatic injury: A state-of-the-art review. Journal of Trauma and
Acute Care Surgery. 2019 Jul 1;87(1S):S59-66.
(3)Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings
predictive of the disorder?. Journal of orthopaedic trauma. 2002 Sep 1;16(8):572-7.
(4)Shadgan B, Menon M, O'Brien PJ, Reid WD. Diagnostic techniques in acute compartment
syndrome of the leg. Journal of orthopaedic trauma. 2008 Sep 1;22(8):581-7.
(5) McMillan TE, Gardner WT, Schmidt AH, Johnstone AJ. Diagnosing acute compartment
syndrome—where have we got to?. International orthopaedics. 2019 Nov 1:1-7.
