BJA Advance Access published online on November 19, 2008
British Journal of Anaesthesia, doi:10.1093/bja/aen330
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Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis
Department of Anaesthesia, St Vincent's Hospital, Melbourne, PO Box 2900, Fitzroy, 3065 VIC, Australia
* Corresponding author. E-mail: gjpmar{at}yahoo.com.au
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Abstract |
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 Top Abstract IntroductionClinical presentation,...Systematic reviewDiscussionConclusionAcknowledgementsReferences |
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Acute compartment syndrome can cause significant disability if not treated early, but the diagnosis is challenging. This systematic review examines whether modern acute pain management techniques contribute to delayed diagnosis. A total of 28 case reports and case series were identified which referred to the influence of analgesic technique on the diagnosis of compartment syndrome, of which 23 discussed epidural analgesia. In 32 of 35 patients, classic signs and symptoms of compartment syndrome were present in the presence of epidural analgesia, including 18 patients with documented breakthrough pain. There were no randomized controlled trials or outcome-based comparative trials available to include in the review. Pain is often described as the cardinal symptom of compartment syndrome, but many authors consider it unreliable. Physical examination is also unreliable for diagnosis. There is no convincing evidence that patient-controlled analgesia opioids or regional analgesia delay the diagnosis of compartment syndrome provided patients are adequately monitored. Regardless of the type of analgesia used, a high index of clinical suspicion, ongoing assessment of patients, and compartment pressure measurement are essential for early diagnosis.
Keywords: anaesthetic techniques, regional; analgesia, postoperative; complications, compartment syndrome; complications, trauma; position, lithotomy
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Introduction |
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TopAbstractIntroductionClinical presentation,...Systematic reviewDiscussionConclusionAcknowledgementsReferences |
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Compartment syndrome is a condition in which increased pressure within a closed compartment compromises the circulation and function of the tissues within that space.65 It occurs most commonly in an osseofascial compartment of the leg or forearm, but it may occur in the upper arm, thigh, foot, buttock, hand, and abdomen. The most common cause of compartment syndrome is trauma, usually after a fracture.11 In an audit, 4.3% of all patients with tibial shaft fractures, 3.1% of diaphyseal fractures of the forearm, and 0.25% fractures of the distal radius developed acute compartment syndrome.36 It is seen more commonly in patients <35 yr of age34 and in male patients.36 42 Compartment syndrome also occurs in the context of reperfusion, ischaemia, burns, and poor positioning for prolonged surgical procedures (particularly lithotomy position)55 and in drug-affected individuals (Table 1).28 The incidence of compartment syndrome is up to 20% in acutely ischaemic limbs that have been revascularized.7 Acute compartment syndrome requires prompt diagnosis and management. Delays in treatment can result in significant disability including neurological deficit, muscle necrosis, amputation, and death. The diagnosis requires a high index of suspicion and is challenging. Pain is thought to be a cardinal feature of compartment syndrome and it has been claimed that analgesia may delay its diagnosis resulting in a poor patient outcome.
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The primary objective of this review was to undertake a systematic review of articles relating postoperative analgesia to a delay in diagnosis of compartment syndrome. In addition, a literature review was performed to detail the pathophysiology, clinical presentation, and role of compartment pressure manometry. The focus was on compartment syndrome of the lower limbs after trauma and surgery.
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Clinical presentation, diagnosis, and monitoring |
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TopAbstractIntroductionClinical presentation,...Systematic reviewDiscussionConclusionAcknowledgementsReferences |
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The underlying pathophysiology of acute compartment syndrome is an ischaemia–reperfusion–ischaemia cycle. Ischaemia can be precipitated by remote perfusion failure (vascular obstruction or trauma, systemic hypotension) or by increased resistance to flow within the compartment itself.31 The ischaemia results in tissue membrane damage and leakage of fluid through capillary and muscle membranes. With arterial reperfusion, the damaged membrane continues to leak, increasing oedema formation and the pressure in the closed compartment. The clinical signs and symptoms of acute compartment syndrome are known to be unreliable.1 11 27 28 35 66 The symptoms of compartment syndrome are severe pain and paraesthesia. This is difficult to assess at the extremes of age or in those with central nervous system (CNS) compromise.28 CNS compromise can be a particular issue after general anaesthesia and in sedated patients in an intensive care setting. Difficulties with sedation or pain management may be the only clinical indicator of compartment syndrome in this group.16 However, pain may be an unreliable symptom as it is subjective and variable. It may be absent in established acute compartment syndrome associated with nerve injury, or minimal in deep posterior compartment syndrome.35 The signs of compartment syndrome are tense, swollen compartments, pain on passive stretching of the muscle, and sensory loss. Pulselessness is not common and generally implies a late stage.62 In a review examining the clinical signs and symptoms of compartment syndrome, the false-positive rate was shown to be high in relation to the true-positive rate.66 That is, clinical findings of compartment syndrome were more likely to be present in patients who do not have compartment syndrome than in those who do. A lack of clinical signs and symptoms was more helpful in excluding the diagnosis than was the presence of findings for confirming compartment syndrome. In a prospective study using a pre-determined screening protocol for lower extremity compartment syndrome in critically ill trauma patients, physical examination was considered inaccurate for diagnosis. On completion of the study, it was decided not to use physical examination as part of the screening protocol.27
Compartment syndrome must be treated urgently as the extent of injury is mainly determined by the duration of ischaemia and the pressure in the osseofascial compartment. In a canine model of compartment syndrome, significant muscle necrosis occurs after 8 h with a compartmental pressure of 30 mm Hg.20 In a clinical setting, it is not possible to pinpoint the precise time compartment syndrome develops. The incidence of complications is related to the time from diagnosis to fasciotomy.37 42 Catastrophic outcomes were inevitable if fasciotomies were delayed for more than 12 h, whereas a full recovery was achieved if decompression was performed within 6 h of making a diagnosis.11 In addition to poor clinical outcome, a delayed diagnosis has medico-legal ramifications. In a review of closed claims in a state in the USA spanning 23 yr, out of 1515 cases involving orthopaedic surgeons, 19 claims related to compartment syndrome in 16 patients. Nine cases were resolved in favour of the patient and seven in favour of the surgeon with poor surgeon–patient communication being a reason for compensation in six instances. Defence was always successful when a fasciotomy was performed within 8 h of the first presenting symptom.5 Patients at risk of compartment syndrome are often poorly assessed. In a retrospective study of preoperative medical records of 30 consecutive patients who underwent fasciotomies for compartment syndrome, documentation was inadequate for 21 (70%) patients.9
Compartment pressure monitoring
Compartmental pressure measurement is recommended in high-risk patients as an adjunct to clinical diagnosis27 35 except where the diagnosis is obvious.28 Normal pressure in the muscle compartment is below 10–12 mm Hg.65 The compartmental perfusion pressure is the difference between the diastolic arterial pressure and the compartmental pressure. The diagnostic pressure difference in one study was 21 mm Hg.27 Absolute compartment pressures of 4532 and 30 mm Hg40 have been suggested as thresholds for compartment syndrome. Needle manometers are commonly utilized for compartment pressure measurement. They are cheap and easy to use, but have been shown to have inaccuracies and cannot be used continuously.11 Catheter techniques are effective for continuous compartmental pressure measurement but require accurate placement of the external transducer, have more complex equipment, and fragments of tissue or clots can obstruct the tip affecting accuracy. In Figure 1, the position of the various osseofascial compartments of the calf and the approach when inserting a needle manometer are demonstrated. All compartments in a limb suspected of having compartment syndrome should be measured.28 The compartment with the highest initial pressure reading should be used for continuous pressure measurement.11 It should be noted that neuromuscular damage is caused by ischaemia rather than elevated pressure alone.
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Other monitors and investigations
Near-infrared spectroscopy (NIRS) measures tissue oxygenation and shows promise in monitoring for compartmental ischaemia. It has an advantage over needle and catheter techniques in that it measures tissue hypoxia directly using a principle similar to pulse oximetry.14 Muscle oxyhaemoglobin (StO2) levels measured by NIRS strongly reflect compartment pressure, perfusion pressure, and loss of myoneural function. StO2 was a more consistent predictor of neuromuscular dysfunction than compartment perfusion pressure.13 It is non-invasive and can be used continuously, thus allowing duration of ischaemia to be measured. Unfortunately, the equipment is expensive and only measures to a limited depth, not reaching the deep posterior compartment of the calf. Another technique under evaluation is pulsed phase-locked loop ultrasound, which can analyse fascial displacement waveforms which correspond to arterial pulsations and change with increased compartmental pressure.67 MRI can show the tissue changes in established compartment syndrome but is not good for diagnosing an evolving compartment syndrome.28 Its use is limited by the time taken to perform the scan, potentially delaying management. Serum creatine phosphokinase (CK), which reflects muscle necrosis, has been used as an indicator of compartment syndrome. Significantly elevated CK levels may be useful in diagnosis where the clinical picture is not obvious and compartmental pressure measurement devices are not available.47
Monitoring may increase clinical awareness and aid diagnosis in the presence of equivocal clinical findings.11 In a retrospective review of the use of compartment pressure monitoring in tibial diaphyseal fractures, the average delay from fracture manipulation to fasciotomy was 7 h in the monitored group and 24 h in the non-monitored group. The complication rate in those without monitoring (10/11) was higher compared with those in the monitored group (0/12).35 Lack of compartment pressure monitoring and inadequate assessment and observation are the most common factors associated with a missed diagnosis.63 Most surgeons accept that compartmental pressure measurement is important for the diagnosis of compartment syndrome,28 and invasive arterial pressure transducers are widely available and can be attached to a saline-filled catheter placed in a compartment as a monometer.
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Systematic review |
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TopAbstractIntroductionClinical presentation,...Systematic reviewDiscussionConclusionAcknowledgementsReferences |
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A systematic review of articles relating postoperative analgesia to the diagnosis of acute compartment syndrome of the limb was conducted. The Pubmed, MEDLINE and EMBASE databases, Cochrane Library, and Google Scholar were searched from 1986 to present. We used a combination of search terms: compartment syndrome/epidural/extradural/analgesia/an(a)esthesia/an(a)esthetic/nerve block/regional/diagnosis/surgery. The search was restricted to articles published in the English language and letters of correspondence and surveys were excluded. The reference sections of relevant articles were hand searched for further publications. Reports were included if they related postoperative analgesia to the management and diagnosis of acute compartment syndrome. Two case reports described the same patient, so only the earlier report was included.45 46 The reports were examined by all the authors.
A total of 28 case reports (n=20) and case series (n=8) were identified which referred to the influence of analgesic technique on the diagnosis of compartment syndrome. These techniques were patient-controlled analgesia (PCA; n=3), peripheral nerve block (PNB; n=2), and epidural analgesia (n=23), respectively. A large audit of epidural use in the UK and Ireland also analysed the diagnosis of acute compartment syndrome in children.30 There were no randomized controlled trials or any other outcome-based comparative trials to include. All the evidence is Level 3.19
Analgesia and diagnosis of compartment syndrome
PCA was implicated in a delay in the diagnosis of acute compartment syndrome of the lower limb in three reports describing six male patients with tibial fractures. Two case reports detail patients with traumatic mid-shaft tibial fractures who had PCA morphine for analgesia after intramedullary nailing (90 mg over 24 h and 131 mg over 36 h, respectively).21 46 The first patient complained of reduced sensation and foot movement prompting a diagnosis of compartment syndrome. The other patient had no pain observations from 6 h post-surgery and compartment syndrome was an incidental finding when the patient returned to theatre for scheduled wound closure 36 h after the original procedure. A case series of four patients who had compartment syndrome after tibial fractures where it was thought that PCA opioids delayed the diagnosis has been reported.50 The patients in these reports had doses of 0.5–1 mg h–1 of PCA morphine. These are small doses,64 suggesting that the patients did not have severe pain. The case reports provide limited detail on the clinical care provided to these patients in the lead up to the diagnosis of compartment syndrome. Other clinical features like paraesthesia and swelling were not mentioned. Two authors recommend avoiding PCA in favour of intermittent i.m. morphine injections.21 46 The preference for this modality was that it facilitates nursing contact with patients who can be avoided with PCA.
We did not find any case reports suggesting PNB delayed the diagnosis of upper limb compartment syndrome. In a literature review to establish whether a femoral nerve block may mask the signs and symptoms of thigh compartment syndrome, there was no evidence of an association between a femoral nerve block and a delayed or missed diagnosis.25 However, a postoperative single shot 3-in-1 block using bupivacaine 0.5% may have led to a delayed diagnosis of calf compartment syndrome after intramedullary nailing of a tibial fracture.23 However, femoral nerve block would not have completely removed the pain associated with a tibial injury as much of the pain will have been in the sciatic nerve distribution. In a report of foot compartment syndrome after a forefoot arthroplasty, the author suggests an ankle block delayed the diagnosis, yet pain was a significant clinical feature in the postoperative period.44
Many authors state that the presence of epidural analgesia did not contribute to a delay in the diagnosis of compartment syndrome.2 10 15 22 24 30 38 58 65 There were four cases of compartment syndrome in a large multicentre prospective audit of the use of epidural analgesia in children in the UK and Ireland. Each case was diagnosed without delay, despite highly effective analgesia in two patients and less effective analgesia in the others.30 Classic signs and symptoms were present when compartment syndrome developed in 32 of 35 patients discussed in the case reports (n=16) and series (n=7) relating to epidural analgesia. This includes 18 patients with documented breakthrough pain (Table 2). In contrast, there was a delay in diagnosis in three patients with dense bilateral motor blocks.26 57 60 In one report,60 the patient had ‘complete anaesthesia’ from the waist down in the postoperative period, implying a complete motor and sensory block, and in the others,26 57 the patients had dense motor and sensory blocks for more than 18 h after operation. These patients did not have breakthrough pain due to their dense blocks, which is in contrast to the majority of case reports where pain was present (Table 2). Table 3 details the similarities and differences between the features of compartment syndrome and epidural analgesia.
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Discussion |
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TopAbstractIntroductionClinical presentation,...Systematic reviewDiscussionConclusionAcknowledgementsReferences |
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The importance of pain in the diagnosis of compartment syndrome is controversial. Virtually, all analgesic modalities have been linked to a delayed diagnosis of compartment syndrome; however, only Level 3 evidence is available. Reports commonly misattribute analgesia as the cause rather than an association with a delayed diagnosis. In addition, reports consistently reveal opportunities for improved clinical care including improvements in documentation and postoperative monitoring for compartment syndrome. Reference to the signs and symptoms of compartment syndrome should be in the immediate vicinity of any patient at risk. This could be on a designated orthopaedic observations chart alongside pain (including analgesic requirements), neurovascular, and vital signs. Risk assessment tools have been described which may aid monitoring patients at high risk of developing acute compartment syndrome.27 Written protocols detailing appropriate care including the management of adverse events and triggers for medical review are important.
Pain may be an unreliable symptom as it is subjective and variable. However, in many of the case reports reviewed, pain was present but compartment syndrome not considered for a period of time.3 10 15 18 24 43 57 59 Increasing demands for analgesia should trigger clinical review because these events have preceded neurovascular changes by 7.3 h.1 PCA and continuous infusions of local anaesthetics may aid the diagnosis of compartment syndrome when patients analgesic requirements are observed appropriately. The view that analgesia should be withdrawn or an inferior mode of analgesia be used to facilitate diagnosis of compartment syndrome should be discouraged. Withholding analgesia to patients with acute abdominal pain for fear of masking pathology was once common clinical practice, but now it is considered safe and humane to administer narcotic analgesia to patients presenting with acute abdominal pain.33 Analgesia is required after trauma and surgery on humane grounds alone and pain management is a core responsibility of our specialty.
There is a lack of appreciation by some authors of the importance of the pharmacology of epidural analgesia in the clinical presentation. For example, a report of four patients who developed gluteal compartment syndrome in the context of postoperative epidural analgesia does not describe the clinical examination or drugs used.29 The fourth patient in this series was noted to have complete ankle paralysis 4 h after cessation of 43 h of continuous epidural analgesia. This suggests that either it was a new sign or the patient's motor function was not being monitored during the epidural infusion. Local anaesthetics and opioids are considered to have similar pharmacological activities by some authors. For example, a 16-yr-old male complained of discomfort and numbness in the leg after an osteotomy of the distal femur and proximal tibia which the author attributes to the pharmacological effects of an epidural fentanyl infusion.49 Epidural opiates do not lead to numbness, paraesthesia, or motor block.41 The symptoms may well have been the clinical features of compartment syndrome.
Dense local anaesthetic blocks can influence the assessment of pain and movement making the diagnosis of compartment syndrome difficult without invasive pressure monitoring. Dilute concentrations of local anaesthetics avoid motor and dense sensory blocks. For example, the optimal concentration of ropivacaine for epidural analgesia and avoidance of motor block is 0.2%.52 This is often combined with an opioid such as fentanyl 4 µg ml–1 to improve analgesia.53 The pathological pain of compartment syndrome is unlikely to be masked by analgesia produced by dilute concentrations of local anaesthetic. One example is the report where compartment syndrome was promptly diagnosed and treated in the presence of an epidural infusion with bupivacaine 0.125% and fentanyl.2 In contrast, the hazards of dense epidural block are highlighted in three reports of compartment syndrome in which patients had dense bilateral motor blocks.26 57 60 Epidural analgesia provides effective pain relief after lower limb surgery, but should be supervised by an acute pain or anaesthetic service in order to derive the greatest benefit and avoid potential complications.61 An alternative to epidural analgesia is continuous PNB (CPNB) and probably represents the gold standard for postoperative analgesia after major unilateral surgery. CPNB is associated with a reduced incidence of side-effects when compared with epidural analgesia.12 The use of CPNB is increasing as the evidence for their efficacy increases. In a meta-analysis, perineural analgesia provided postoperative analgesia that was superior to opioids for all time periods and all catheter locations.51 Ultrasound imaging aids precise perineural injection and may also facilitate the use of dilute concentrations of local anaesthetics for both the primary block and the subsequent infusion through the catheter in patients at risk of compartment syndrome. Local anaesthetics used with CPNB have included ropivacaine 0.2% or bupivacaine 0.25%8 and in a comparative study ropivacaine 0.2% was as effective as ropivacaine 0.3%.6
A limitation of this review was that the data available were mainly from case reports and therefore statistical analysis was not possible. There may also be significant underreporting of complications like compartment syndrome, especially where medico-legal proceedings may be involved.
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Conclusion |
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TopAbstractIntroductionClinical presentation,...Systematic reviewDiscussionConclusionAcknowledgementsReferences |
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Compartment syndrome is challenging to diagnose and requires urgent treatment in order to avoid disastrous complications. This systematic review does not provide convincing evidence that PCA opioids or regional analgesia delay the diagnosis of compartment syndrome. Whatever the mode of analgesia used, a high index of clinical suspicion, ongoing assessment of patients, and compartment pressure measurement are essential for early diagnosis.
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Acknowledgements |
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The authors acknowledge the advice of Dr Steven J. Fowler FANZCA, Alfred Hospital, Melbourne, and the Librarians at Australian and New Zealand College of Anaesthetists for assistance with references.
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Footnotes |
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Presented as a poster at the European Society of Regional Anaesthesia and Pain Therapy, XXVII Annual Congress, Genoa, Italy, in September 2008 and published in part as an abstract in Reg Anesth Pain Med 2008; 33: e185. 
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References |
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