Let's say you have a middle aged otherwise healthy patient who, after throwing back a few cold brewskis, decides to "kick it" with a group of skateboarding youths. We'll cut to the chase and state that it doesn't go well, he's now in your ED, and his left calf doesn't look too hot. Maybe he's got a tibial fracture, maybe not. Either way his leg is tense as can be, and despite getting an adequate dose of narcotics he is in E-X-Q-U-I-S-I-T-E pain. You do an exam, and note a tense extremity with pain during passive stretch, some decreased sensation, but a good distal pulse.
Just like Lloyd Bridges in Airplane, you should be shouting, "Stryker! Stryker! Stryker!" Stryker needle that is (it's the most commonly used product, so we'll only refer to that one), to rule out compartment syndrome.
The condition can occur in any extremity, but the most common presentation you'll see is the one stated above. It is an incredibly difficult diagnosis to make clinically, and it is a huge potential pitfall as correct identification can be delayed or even missed entirely. An interesting cohort study from the Canadian Journal of Medicine noted that patients at a hospital in Montreal who underwent fasciotomies noted a concerning "median event-to-operation" duration of 9 hours for traumatic cases and a shocking 34 hours for nontraumatic cases.
We are always taught the classic 5 Ps (pain/swelling, pallor, paresthesias, paralysis, pulselessness), but if you're noting these findings the cat is already out of the bag, and your patient will likely have permanent deficits as a result. If it's early, you'll have to trust your gut and go check the pressure.
The set-up for this one is pretty simple, and everything you'll need should be in the pre-packaged kit. It includes a side ported needle, a diaphragm chamber, a pre-filled 3 cc syringe, and the main monitoring unit. It is possible to jury rig a set-up to continuously transduce pressures like an arterial line, but it's beyond highly unlikely you would ever need to do this in the ED (more tailored for either the OR or a surgical ICU), we will include a video at the end of the post if you're interested.
Connect your needle to the diaphragm, and then screw in the syringe on the other side. Load this assembly by pushing it into the monitoring unit, with the black side of the diaphragm down. Snap the cover closed gently. To calibrate, hold the entire unit up at a 45 degree angle, and flush it to get the air out. Push the monitoring button to turn it on, then hold the monitor at the angle you're going to "Stryker" at and hold the zero button down. You should see "00" appear.
Next, you'll need to identify the appropriate site to target. It all depends on where you think the affected compartment is. For sake of discussion, and since it's the most common one, we'll focus on the anterior compartment of the calf. Here, you'll identify the area where the proximal and mid thirds of the tibia meet, and then move 1 cm lateral to this.
You'll want to give them adequate local anesthesia at the site of injection, but you need to take care not too inject too deeply so that you get a falsely elevated reading. Once this is done and the area has been properly cleaned, insert your needle 1-3 cm into the compartment, and then, very, very slowly inject like an aliquot of saline (they state no more than 0.3 cc) and wait for the reading to appear.
If the pressure is greater than 30 mmHg, or within 30 mmHg of the diastolic blood pressure, your patient needs to be evaluated for a fasciotomy.
- SoBroEm.com also features a nice step by step illustration here.
- Here's another demonstration of the assembly and procedure from the Plastic Surgery Project:
- If you haven't had a chance to check out the YouTube page of Dr. Nabil Ebraheim, go NOW. He's a veteran orthopedist with some incredibly high yield videos. Here's his clip on compartment syndrome (goes out of our scope but still a good watch):
- If you don't happen to have a Stryker kit, here is how to perform a compartment pressure measurement with an arterial line:
As always, these writings are for medical professionals, and are for EDUCATIONAL PURPOSES ONLY. This is probably one of the least invasive procedures we've covered thus far, but that doesn't mean you should go running into a patient's room to needle their calf.
Follow procedures club
Roberts and Hedges' Clinical Procedures in Emergency Medicine, 6th Edition. Chapter 54.
Messina et al. A human cadaver fascial compartment pressure measurement model. J Emerg Med. 2013 Oct;45(4):e127-31.
Vaillaincourt C. et al. Quantifying delays in the recognition and management of acute compartment syndrome. CJEM. 2001 Jan;3(1):26-30.
Dr. Nabil Ebraheim's YouTube Page
Plastic Surgery Project YouTube Page
Frank F's Vimeo Page