The Journal of Emergency Medicine, Vol. 49, No. 3, pp. e91–e92, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.02.003
Visual Diagnosis in Emergency Medicine
BLAST-INDUCED COMPARTMENT SYNDROME Ryan W. Stringer, DO, PGYII and Michelino Mancini, DO, FACOEP Lakeland Healthcare Emergency Medicine Residency, Michigan State University College of Osteopathic Medicine, St. Joseph, Michigan Reprint Address: Ryan W. Stringer, DO, PGYII, Lakeland Healthcare Emergency Medicine Residency, Michigan State University College of Osteopathic Medicine, 1234 Napier Avenue, St. Joseph, MI 49085
CASE REPORT A 23-year-old man presented to the Emergency Department with complaint of left upper-extremity pain immediately after detonation of a 6-inch ‘‘mortar’’ firework. The physical examination was significant for an obvious prominence over the medial dorsal forearm with overlying partial thickness burn (Figure 1). The patient demonstrated normal capillary refill and radial pulsation. Sensation and strength were grossly intact. He demonstrated significant limitation with active and passive range of motion to flexion, extension, supination, and pronation of his left wrist, with marked tenderness on passive stretch. An X-ray study of the forearm was performed and demonstrated no acute fracture or subcutaneous air. Compartment pressures were obtained in three forearm compartments (superficial volar, dorsal, and the mobile wad compartment, which includes the brachioradialis, extensor carpi radialis longus, and brevis muscles) using a Stryker needle. Dorsal compartment pressure was high at 44 mm Hg. Superficial volar and mobile wad compartment pressures were normal. The patient was taken to the operating room for urgent fasciotomy, where the orthopedic surgeon obtained a confirmatory pressure of the dorsal compartment of 43 mm Hg. DISCUSSION Figure 1. Obvious prominence over the medial dorsal forearm with suspected fracture and overlying partial thickness burn.
Blast injuries represent complex pathophysiology and may occur by several mechanisms, including injury
RECEIVED: 16 December 2014; FINAL SUBMISSION RECEIVED: 2 February 2015; ACCEPTED: 17 February 2015 e91
e92
resulting from direct energy transfer, flying fragments, bodily displacement, or indirect effects such as burns or crush injuries (1). Among the complications of blast injury is compartment syndrome, which is a potentially devastating disease process if not rapidly diagnosed and treated. Though most commonly associated with fracture, traumatic soft tissue inflammation and subsequent swelling within the enclosed fascial compartment may precipitate compartment syndrome (2). Pain out of proportion to the injury or with passive stretch is a characteristic sign, and late findings (often after established ischemic injury) include classic descriptions of pallor, paralysis, pulselessness, and paresthesia (3,4). Irreversible necrosis can occur quickly and without characteristic physical examination findings. Compartment syndrome in the absence of fracture is more likely to have muscle necrosis at fasciotomy than is seen in patients with compartment syndrome after a fracture (5). This case demonstrates the importance of maintaining high clinical suspicion and recognizing early signs of compartment
R. W. Stringer and M. Mancini
syndrome such as pain with passive stretch despite an absence of more commonly associated pathology such as fracture. When considering compartment syndrome during the evaluation of an extremity blast injury, it is prudent for the emergency physician to employ adjunctive diagnostic techniques such as compartment pressure measurement to expedite definitive treatment. REFERENCES 1. Bumbasirevic M, Lesic A, Mitkovic M, Bumbasirevic V. Treatment of blast injuries of the extremity. J Am Acad Orthop Surg 2006;14: S77–81. 2. Mabvuure NT, Malahias M, Hindocha S, Khan W, Juma A. Acute compartment syndrome of the limbs: current concepts and management. Open Orthop J 2012;6:535–43. 3. DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med 2005;352:1335–42. 4. Sirkin M. Compartment syndromes and open fractures. In: Sanders R, ed. Core knowledge in orthopedics: trauma. Philadelphia, PA: Mosby Inc; 2008:1–17. 5. Hope MJ, McQueen MM. Acute compartment syndrome in the absence of fracture. J Orthop Trauma 2004;18:220–4.
http://dx.doi.org/10.1016/j.jemermed.2015.02.003
Visual Diagnosis in Emergency Medicine
BLAST-INDUCED COMPARTMENT SYNDROME Ryan W. Stringer, DO, PGYII and Michelino Mancini, DO, FACOEP Lakeland Healthcare Emergency Medicine Residency, Michigan State University College of Osteopathic Medicine, St. Joseph, Michigan Reprint Address: Ryan W. Stringer, DO, PGYII, Lakeland Healthcare Emergency Medicine Residency, Michigan State University College of Osteopathic Medicine, 1234 Napier Avenue, St. Joseph, MI 49085
CASE REPORT A 23-year-old man presented to the Emergency Department with complaint of left upper-extremity pain immediately after detonation of a 6-inch ‘‘mortar’’ firework. The physical examination was significant for an obvious prominence over the medial dorsal forearm with overlying partial thickness burn (Figure 1). The patient demonstrated normal capillary refill and radial pulsation. Sensation and strength were grossly intact. He demonstrated significant limitation with active and passive range of motion to flexion, extension, supination, and pronation of his left wrist, with marked tenderness on passive stretch. An X-ray study of the forearm was performed and demonstrated no acute fracture or subcutaneous air. Compartment pressures were obtained in three forearm compartments (superficial volar, dorsal, and the mobile wad compartment, which includes the brachioradialis, extensor carpi radialis longus, and brevis muscles) using a Stryker needle. Dorsal compartment pressure was high at 44 mm Hg. Superficial volar and mobile wad compartment pressures were normal. The patient was taken to the operating room for urgent fasciotomy, where the orthopedic surgeon obtained a confirmatory pressure of the dorsal compartment of 43 mm Hg. DISCUSSION Figure 1. Obvious prominence over the medial dorsal forearm with suspected fracture and overlying partial thickness burn.
Blast injuries represent complex pathophysiology and may occur by several mechanisms, including injury
RECEIVED: 16 December 2014; FINAL SUBMISSION RECEIVED: 2 February 2015; ACCEPTED: 17 February 2015 e91
e92
resulting from direct energy transfer, flying fragments, bodily displacement, or indirect effects such as burns or crush injuries (1). Among the complications of blast injury is compartment syndrome, which is a potentially devastating disease process if not rapidly diagnosed and treated. Though most commonly associated with fracture, traumatic soft tissue inflammation and subsequent swelling within the enclosed fascial compartment may precipitate compartment syndrome (2). Pain out of proportion to the injury or with passive stretch is a characteristic sign, and late findings (often after established ischemic injury) include classic descriptions of pallor, paralysis, pulselessness, and paresthesia (3,4). Irreversible necrosis can occur quickly and without characteristic physical examination findings. Compartment syndrome in the absence of fracture is more likely to have muscle necrosis at fasciotomy than is seen in patients with compartment syndrome after a fracture (5). This case demonstrates the importance of maintaining high clinical suspicion and recognizing early signs of compartment
R. W. Stringer and M. Mancini
syndrome such as pain with passive stretch despite an absence of more commonly associated pathology such as fracture. When considering compartment syndrome during the evaluation of an extremity blast injury, it is prudent for the emergency physician to employ adjunctive diagnostic techniques such as compartment pressure measurement to expedite definitive treatment. REFERENCES 1. Bumbasirevic M, Lesic A, Mitkovic M, Bumbasirevic V. Treatment of blast injuries of the extremity. J Am Acad Orthop Surg 2006;14: S77–81. 2. Mabvuure NT, Malahias M, Hindocha S, Khan W, Juma A. Acute compartment syndrome of the limbs: current concepts and management. Open Orthop J 2012;6:535–43. 3. DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries. N Engl J Med 2005;352:1335–42. 4. Sirkin M. Compartment syndromes and open fractures. In: Sanders R, ed. Core knowledge in orthopedics: trauma. Philadelphia, PA: Mosby Inc; 2008:1–17. 5. Hope MJ, McQueen MM. Acute compartment syndrome in the absence of fracture. J Orthop Trauma 2004;18:220–4.
