Under pressure: a case of compartment syndrome secondary to crushing injury utilizing Whitesides’s apparatus

Correspondence to Dr Arden Aron Labro Asuncion; [email protected]

A patient who underwent fasciotomy of the left arm and forearm for compartment syndrome secondary to a crushing injury is now in his second hospital day. However, you note that the arm appears more edematous than usual and tenser than the previous day, though not as tense as before the procedure. Palpable pulses were present but weaker than the contralateral, unaffected arm.

What would you do in this situation?

• Observe, as this may be just postprocedural tissue edema.

• Extend fasciotomy incisions on all compartments without objective measurements.

• Objectively measure the pressures of the compartments and compare them to the contralateral, unaffected arm. Analyze which compartment needs an extension of fasciotomy incisions.

• Perform Doppler ultrasound, and if unequal signals are found, extend fasciotomy incisions on all compartments.

What we did and why

Correct answer C

Choice C offers a more objective measure of assessing inadequate fasciotomy in this patient, allowing for the localization of compartments that need additional release. In resource-limited settings where manometric devices are unavailable, what alternative measures can be used?

Case scenario

An adult was brought to the emergency department after being trapped for hours under the rubble of their home. The house had collapsed after being struck by a large tree. The rescuers faced logistic challenges during the rescue, leaving the patient trapped for approximately 8 hours.

On arrival, the patient was tachycardic, normotensive, and alert. The left upper extremity was numb, tense, and erythematous (figure 1). Oximetry showed oxygen saturation of 82% in the left arm compared with 98% to 100% in the unaffected contralateral arm. Doppler ultrasound failed to detect pulsations in the affected limb.

Figure 1. The patient presented with a tense, discolored left upper extremity, and pressure necrosis of the forehead. There were no extremity or facial fractures on imaging.

Pressure necrosis of the forehead was observed due to the prolonged pressure of the overlying rubble. Foley catheter insertion showed no hematuria. Chest X-ray, pelvic X-ray, and a Focused Assessment with Sonography for Trauma were unremarkable. X-rays of the left upper extremity and shoulder showed no fractures. Arterial blood gas analysis was normal; however, there were elevated urine myoglobin and creatine kinase myocardial band (CKMB) levels. Creatinine levels were within the normal range at the time of presentation.

The constellation of signs and symptoms led to the diagnosis of compartment syndrome, prompting an emergency bedside fasciotomy (figure 2). The procedure involved releasing the edematous muscles in the left forearm’s superficial volar, dorsal, and mobile wad compartments. Additionally, we decompressed the anterior and posterior compartments of the arm. We observed no signs of muscle necrosis in any of the affected compartments. The patient’s pulse improved after the procedure, and oxygen saturation in the left upper extremity increased to 94% to 96%.

Figure 2. The images above show the wound after performing fasciotomy.

Is it compartment syndrome again?

On the second hospital day, however, the left proximal arm became more edematous and slightly tense. Pulses were palpable, though decreased compared with the contralateral extremity. We measured compartment pressure using a makeshift device based on Whitesides’s 2012 technique from the Journal of Orthopedic Trauma (Hammerber, 2012).

The device consisted of a manometer, a 20 cc syringe, a three-way stopcock, tubing/macroset, and saline solution (figure 3). We connected a rubber tube to the needle and half-filled it with saline. We securely positioned the prefilled syringe with air before inserting the needle 1 cm perpendicular to the surface into the compartment. We opened the three-way stopcock to equalize the pressure within the system. Compressing the syringe gradually increased the pressure in the system. As the pressure inside the system surpassed that of the muscle compartment, a sufficient pressure gradient caused the water column to move into the compartment. The manometer measures the pressure of the compartment of interest as the water column moves.

Figure 3. A makeshift manometer to measure the compartment pressures was assembled.

We used a new needle for each measurement to ensure accuracy and to prevent blockages. In this patient, the left deltoid compartment recorded 40 mm Hg compared with 20 mm Hg in the contralateral arm. We extended the fasciotomy incision into the lateral forearm based on this difference. We reduced the pressure to 20 mm Hg after the fasciotomy. We continued daily measurements and performed additional releases if the difference between compartments exceeded 10 mm Hg.

Management of rhabdomyolysis and wound care

On the second day of hospitalization, the creatinine levels dramatically rose from 26 umol/L to 334 umol/L and further increased to 441 umol/L on the third day. We diagnosed acute kidney injury due to acute tubular necrosis secondary to rhabdomyolysis and initiated hemodialysis. Creatinine levels began to decline after the second session of hemodialysis and normalized on the patient’s 29th day of hospitalization.

The patient received twice-daily to thrice-daily wound care with half-strength sodium hypochlorite and negative pressure wound therapy. After four applications of negative pressure therapy, healthy granulation tissue developed. Wound culture revealed pan-resistant Acinetobacter baumannii, and thus grafting was delayed until the wound bed was negative for contamination. Antibiotics were given under the guidance of the infectious disease service.

We performed a split-thickness skin graft after the antibiotic course and a negative wound culture. We requested an electromyography-nerve conduction velocity (EMG-NCV) to assess the nerve injury by day 30 postinjury, which revealed neuropraxia of the C8-T1 trunk. Rehabilitation exercises are then continued.

Preventing complications through accurate diagnosis

Early diagnosis of acute compartment syndrome is critical to prevent loss of function, limb, or life. Immediately on diagnosis, one should perform fasciotomy. Incomplete fasciotomy can lead to disastrous consequences, and objective measurement of compartment pressures after fasciotomy can prevent this.¹ Measuring compartment pressure complements clinical evaluation in deciding on performing fasciotomy. The Whitesides’s apparatus, a simple and accessible system, is invaluable in low-resource settings. Its use in clinical practice may aid decision-making and reduce complications from delayed or incomplete procedures.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants. The study was approved by the IRB of Jose R. Reyes Memorial Medical Center (IRB code 2023-077). Participants gave informed consent to participate in the study before taking part.

Footnote

Contributors AA was the primary author of this article and led the team during the patient’s admission. CA contributed to the authorship as well. AM provided the team with valued guidance on effective management practices. J, T, C, and S contributed to the successful execution of team plans.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Reference

¹ Hammerberg EM, Whitesides TE, Seiler JG. The Reliability of Measurement of Tissue Pressure in Compartment Syndrome. J Orthop Trauma 2012; 26: e166. doi:10.1097/BOT.0b013e3182673a3f