Eur J Orthop Surg Traumatol (2002) 12: 99–101 DOI 10.1007/s00590-002-0028-3
CASE REPORT
A. Mofidi Æ R. Sankar Æ J.P. McCabe
Compartment syndrome of the shoulder girdle CASE REPORT
Received: 17 December 2001 / Accepted: 22 April 2002 / Published online: 3 July 2002 Ó Springer-Verlag 2002
Abstract We report a case of subacute compartment syndrome involving the deltoid muscle of a young person. We discuss the presentation, predisposing factors, investigation and treatment of this otherwise rare condition. Keywords Compartment syndrome Æ Shoulder Æ Deltoid Syndrome des loges de la ceinture scapulaire Re´sume´ Nous rapportons un cas de syndrome des loges chronique du deltoı¨ de chez un sujet jeune. Nous discuterons de la pre´sentation, des facteurs pre´disposants ainsi que de l’exploration et du traitement de cette affection par ailleurs rare. Mots-cle´s Syndrome compartimental Æ E´paule Æ Deltoı¨ de
Case presentation A 29-year-old man presented to an orthopaedic surgeon complaining of a history of severe left-sided shoulder pain for 1 month. The pain was of gradual onset and involved the left shoulder and deltoid region. It was severe, aggravated by movement and required a significant amount of opiate analgesia for relief. The patient was an amateur athlete and an expert in martial arts who recently underwent the process of gender reassignment,
A. Mofidi Æ R. Sankar Æ J.P. McCabe Department of Orthopaedic Surgery, Merlin Park Regional Hospital, Galway, County Galway, Republic of Ireland R. Sankar (&) 45 Tudor Lawn, Newcastle, Galway, County Galway, Republic of Ireland E-mail: [email protected] Tel.: +353-877980345
changing from female to male. He was on 120 mg/day of testosterone undecanoate for this reason. One year previously he had subacromial decompression of the right shoulder for rotator cuff impingement, following which he had symptomatic relief. On admission for this latter episode, he was investigated with plain radiography followed by magnetic resonance imaging (MRI) of the left shoulder (Fig. 1). The plain film was normal and the MRI showed mild inflammation involving the deltoid muscle. He was treated with rest and non-steroidal anti-inflammatory medication and commenced on range of movement exercises. On the fifth day of admission, his shoulder and the deltoid region became swollen, unbearably painful and erythematous. He had measurement of pressures of anterior and posterior deltoid muscle compartments using portable tissue pressure monitor (Stryker Instruments, Kalamazoo, MI, USA) and was found to be 45 mmHg. The left deltoid muscle was decompressed under general anaesthesia through a longitudinal incision extending from just below the acromion process down to the insertion of the deltoid muscle. The incision showed tense deltoid fascia covering a severely inflamed, partly necrotic deltoid muscle (Fig. 2). This was confirmed after exposing the anterior, middle and posterior deltoid muscles. The deltoid muscle was debrided to remove all necrotic tissue. The remaining muscle was healthy and contractile. The wound was covered by primary intention. The left deltoid muscle was re-explored surgically through the same incision a week later and was found to have fully recovered after the initial decompression. The patient was commenced on rest in a sling followed by mobilisation after 5 weeks. He returned to full shoulder activity 3 months post decompression.
Discussion Compartment syndrome is defined as an increase in the hydrostatic pressure in a closed circular space of compartment resulting in decreased perfusion of
100
Fig. 1. T2-weighted magnetic resonance imaging (MRI) of left shoulder showing mild inflammation of deltoid muscle. Fenestrations of fascia through deltoid muscle are well appreciated
Fig. 2. Intra-operative picture showing severely inflamed, partly necrotic left deltoid muscle
intra-compartmental muscles and nerves [7]. This is due to a combination of an increase in compartment volume as well as decreased elasticity in the fascial envelope, leading to a cascade of events resulting in increase in intra-compartmental pressure causing muscle ischaemia. Increase in compartmental volume usually is caused by closed injury to a muscle compartment associated with haematoma from adjacent fracture of long bone and inelasticity of fascial coverage, which is potentiated by circumferential dressing or a cast [7]. Anatomical relationship between long bones of the forearm and the
leg, and frequency of associated injury, make these areas the commonest sites for compartment syndrome [7]. Physical exercise, large muscle bulk and use of anabolic steroids have been implicated as a risk factor for compartment syndrome [5]. This often involves the most actively exercised muscle groups [5, 2, 9, 6, 1]. The mechanism is thought to be a combination of hypertrophy of the muscle in a closed compartment associated with no change in vascularity of the muscle, causing increase in anaerobic muscle metabolism leading to muscle oedema and further increase in compartment pressure [5, 2, 3]. Compartment syndrome may be acute or chronic. Acute compartment syndrome of the deltoid is rare and is only reported twice in the literature [2, 4]. It was reported in patients with drug over-dosage and minor trauma. Other associations with compartment syndrome of the arm have been reported. They range from crush injury, minor trauma, avulsion of triceps or post tourniquet use [2, 9, 6, 1]. As in other areas, extreme pain, swelling, paraesthesia, numbness and weakness are presenting features. History is important, especially with increased incidence in patients with drug abuse. Chronic compartment syndrome is exercise or activity induced. It is also referred to as exertional compartment syndrome. Although reported to occur in the upper limbs it is more commonly reported in the lower extremities. Symptoms range from pain, tightness, aching, cramping, transient weakness and paraesthesia. Symptoms usually resolve in minutes, but reoccur when activity or exercise is resumed. The deltoid muscle is situated over the shoulder joint. It originates from the outer aspect of the acromion process, spine of the scapulae and clavicle and is inserted into the deltoid tubercle at the lateral aspect of the proximal humerus [8]. It is covered by delto-pectoral fascia, supplied by the posterior circumflex artery and deltoid branch of thoraco-acromial artery and innervated by the axillary nerve that runs on the inferior aspect of the distal part the deltoid muscle [8]. This fascial coverage sends multiple septa into the muscle belly [2, 8] (Fig. 1). It communicates with the pectoral fascia and fascial coverage of the infraspinatus muscle [2]. This leads to compartment syndrome spreading to communicating muscles [5, 2, 6]. Presentation of deltoid compartment syndrome is severe pain and tense swelling of the deltoid muscle [5, 2, 9]. One could postulate presence of axillary nerve neuropraxia causing paraesthesia over the shoulder, but this was not seen in our case nor has it been reported in the literature [5, 2, 9]. Our case demonstrated subacute presentation of compartment syndrome is gradual until critical compartment pressure is reached. After the critical pressure has been surpassed it behaves similarly to acute compartment syndrome with similarly devastating sequelae. Compartment syndrome of deltoid muscle is a rare condition. As a result, it can be easily mistaken for infection or neoplasm leading to investigation with radiology and MRI, which may be normal [5, 1].
101
Diagnosis is confirmed with intra-compartmental pressure studies, which will be elevated considerably similar to the compartment syndrome in forearm and calf muscles and more than 40 mmHg in all of the cases described [7, 5, 2, 9, 6, 1]. In conclusion, compartment syndrome should be considered as a possible diagnosis for a painful and swollen muscle compartment, especially in the presence of recent injury, heavy exercise, repeated intra-muscular injection and use of anabolic steroids. If the diagnosis is in doubt, pressure studies of the compartment using Whitesides method [7] or portable monitoring system should be part of the investigation [5, 2, 9, 6, 1].
References 1. Botte MJ, Fronek J, Pedowitz RA, Hoenecke HR Jr, Abrams RA, Hamer ML (1998) Exertional compartment syndrome of the upper extremity. In: Lovette, HS and Botte MJ (eds) Hand clinics – compartment syndrome and Volkmanns ischemic contracture, vol 14, Saunders, Philadelphia pp 477–482
2. Diminick M, Shapiro G, Cornell C (1999) Acute compartment syndrome of the triceps and deltoid. J Orthop Trauma 13(3): 225–227 3. Kupiers H, Peeze-Binkhorst FM, Hartgens F, Wijnen JA, Keizer HA (1993) Muscle ultra-structure after strength training with placebo or anabolic steroid. Can J Appl Physiol 18: 189– 196 4. Mubarack SJ, Owen CA, Hargens AR, Garetto LP, Akeson WA (1978) Acute compartment syndromes: Diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg [Am] 60: 1091–1095 5. Orava S, Laakko E, Mattila K, Makinen L, Rantanen, Kajala UM (1998) Chronic compartment syndrome of the quadriceps femoris muscle in athletes. Diagnosis, imaging and treatment with fasciotomy. Ann Chir Gynaecol 87(1): 53–58 6. Palumbo RC, Abrams JS (1994) Compartment syndrome of the upper arm. Orthopedics17(12): 1144–1147 7. Whitesides T, Heckman M (1996)\ Acute compartment syndrome update of diagnosis and treatment. J Am Acad Orthop Surg 4: 209–218 8. Williams PL (ed) (1995) Gray’s textbook of anatomy, 38th edn, London, Spalding 9. Yabuki S, Kikuchi S (1999) Dorsal compartment syndrome of the upper arm. A case report. Clin Orthop (336): 107–109
CASE REPORT
A. Mofidi Æ R. Sankar Æ J.P. McCabe
Compartment syndrome of the shoulder girdle CASE REPORT
Received: 17 December 2001 / Accepted: 22 April 2002 / Published online: 3 July 2002 Ó Springer-Verlag 2002
Abstract We report a case of subacute compartment syndrome involving the deltoid muscle of a young person. We discuss the presentation, predisposing factors, investigation and treatment of this otherwise rare condition. Keywords Compartment syndrome Æ Shoulder Æ Deltoid Syndrome des loges de la ceinture scapulaire Re´sume´ Nous rapportons un cas de syndrome des loges chronique du deltoı¨ de chez un sujet jeune. Nous discuterons de la pre´sentation, des facteurs pre´disposants ainsi que de l’exploration et du traitement de cette affection par ailleurs rare. Mots-cle´s Syndrome compartimental Æ E´paule Æ Deltoı¨ de
Case presentation A 29-year-old man presented to an orthopaedic surgeon complaining of a history of severe left-sided shoulder pain for 1 month. The pain was of gradual onset and involved the left shoulder and deltoid region. It was severe, aggravated by movement and required a significant amount of opiate analgesia for relief. The patient was an amateur athlete and an expert in martial arts who recently underwent the process of gender reassignment,
A. Mofidi Æ R. Sankar Æ J.P. McCabe Department of Orthopaedic Surgery, Merlin Park Regional Hospital, Galway, County Galway, Republic of Ireland R. Sankar (&) 45 Tudor Lawn, Newcastle, Galway, County Galway, Republic of Ireland E-mail: [email protected] Tel.: +353-877980345
changing from female to male. He was on 120 mg/day of testosterone undecanoate for this reason. One year previously he had subacromial decompression of the right shoulder for rotator cuff impingement, following which he had symptomatic relief. On admission for this latter episode, he was investigated with plain radiography followed by magnetic resonance imaging (MRI) of the left shoulder (Fig. 1). The plain film was normal and the MRI showed mild inflammation involving the deltoid muscle. He was treated with rest and non-steroidal anti-inflammatory medication and commenced on range of movement exercises. On the fifth day of admission, his shoulder and the deltoid region became swollen, unbearably painful and erythematous. He had measurement of pressures of anterior and posterior deltoid muscle compartments using portable tissue pressure monitor (Stryker Instruments, Kalamazoo, MI, USA) and was found to be 45 mmHg. The left deltoid muscle was decompressed under general anaesthesia through a longitudinal incision extending from just below the acromion process down to the insertion of the deltoid muscle. The incision showed tense deltoid fascia covering a severely inflamed, partly necrotic deltoid muscle (Fig. 2). This was confirmed after exposing the anterior, middle and posterior deltoid muscles. The deltoid muscle was debrided to remove all necrotic tissue. The remaining muscle was healthy and contractile. The wound was covered by primary intention. The left deltoid muscle was re-explored surgically through the same incision a week later and was found to have fully recovered after the initial decompression. The patient was commenced on rest in a sling followed by mobilisation after 5 weeks. He returned to full shoulder activity 3 months post decompression.
Discussion Compartment syndrome is defined as an increase in the hydrostatic pressure in a closed circular space of compartment resulting in decreased perfusion of
100
Fig. 1. T2-weighted magnetic resonance imaging (MRI) of left shoulder showing mild inflammation of deltoid muscle. Fenestrations of fascia through deltoid muscle are well appreciated
Fig. 2. Intra-operative picture showing severely inflamed, partly necrotic left deltoid muscle
intra-compartmental muscles and nerves [7]. This is due to a combination of an increase in compartment volume as well as decreased elasticity in the fascial envelope, leading to a cascade of events resulting in increase in intra-compartmental pressure causing muscle ischaemia. Increase in compartmental volume usually is caused by closed injury to a muscle compartment associated with haematoma from adjacent fracture of long bone and inelasticity of fascial coverage, which is potentiated by circumferential dressing or a cast [7]. Anatomical relationship between long bones of the forearm and the
leg, and frequency of associated injury, make these areas the commonest sites for compartment syndrome [7]. Physical exercise, large muscle bulk and use of anabolic steroids have been implicated as a risk factor for compartment syndrome [5]. This often involves the most actively exercised muscle groups [5, 2, 9, 6, 1]. The mechanism is thought to be a combination of hypertrophy of the muscle in a closed compartment associated with no change in vascularity of the muscle, causing increase in anaerobic muscle metabolism leading to muscle oedema and further increase in compartment pressure [5, 2, 3]. Compartment syndrome may be acute or chronic. Acute compartment syndrome of the deltoid is rare and is only reported twice in the literature [2, 4]. It was reported in patients with drug over-dosage and minor trauma. Other associations with compartment syndrome of the arm have been reported. They range from crush injury, minor trauma, avulsion of triceps or post tourniquet use [2, 9, 6, 1]. As in other areas, extreme pain, swelling, paraesthesia, numbness and weakness are presenting features. History is important, especially with increased incidence in patients with drug abuse. Chronic compartment syndrome is exercise or activity induced. It is also referred to as exertional compartment syndrome. Although reported to occur in the upper limbs it is more commonly reported in the lower extremities. Symptoms range from pain, tightness, aching, cramping, transient weakness and paraesthesia. Symptoms usually resolve in minutes, but reoccur when activity or exercise is resumed. The deltoid muscle is situated over the shoulder joint. It originates from the outer aspect of the acromion process, spine of the scapulae and clavicle and is inserted into the deltoid tubercle at the lateral aspect of the proximal humerus [8]. It is covered by delto-pectoral fascia, supplied by the posterior circumflex artery and deltoid branch of thoraco-acromial artery and innervated by the axillary nerve that runs on the inferior aspect of the distal part the deltoid muscle [8]. This fascial coverage sends multiple septa into the muscle belly [2, 8] (Fig. 1). It communicates with the pectoral fascia and fascial coverage of the infraspinatus muscle [2]. This leads to compartment syndrome spreading to communicating muscles [5, 2, 6]. Presentation of deltoid compartment syndrome is severe pain and tense swelling of the deltoid muscle [5, 2, 9]. One could postulate presence of axillary nerve neuropraxia causing paraesthesia over the shoulder, but this was not seen in our case nor has it been reported in the literature [5, 2, 9]. Our case demonstrated subacute presentation of compartment syndrome is gradual until critical compartment pressure is reached. After the critical pressure has been surpassed it behaves similarly to acute compartment syndrome with similarly devastating sequelae. Compartment syndrome of deltoid muscle is a rare condition. As a result, it can be easily mistaken for infection or neoplasm leading to investigation with radiology and MRI, which may be normal [5, 1].
101
Diagnosis is confirmed with intra-compartmental pressure studies, which will be elevated considerably similar to the compartment syndrome in forearm and calf muscles and more than 40 mmHg in all of the cases described [7, 5, 2, 9, 6, 1]. In conclusion, compartment syndrome should be considered as a possible diagnosis for a painful and swollen muscle compartment, especially in the presence of recent injury, heavy exercise, repeated intra-muscular injection and use of anabolic steroids. If the diagnosis is in doubt, pressure studies of the compartment using Whitesides method [7] or portable monitoring system should be part of the investigation [5, 2, 9, 6, 1].
References 1. Botte MJ, Fronek J, Pedowitz RA, Hoenecke HR Jr, Abrams RA, Hamer ML (1998) Exertional compartment syndrome of the upper extremity. In: Lovette, HS and Botte MJ (eds) Hand clinics – compartment syndrome and Volkmanns ischemic contracture, vol 14, Saunders, Philadelphia pp 477–482
2. Diminick M, Shapiro G, Cornell C (1999) Acute compartment syndrome of the triceps and deltoid. J Orthop Trauma 13(3): 225–227 3. Kupiers H, Peeze-Binkhorst FM, Hartgens F, Wijnen JA, Keizer HA (1993) Muscle ultra-structure after strength training with placebo or anabolic steroid. Can J Appl Physiol 18: 189– 196 4. Mubarack SJ, Owen CA, Hargens AR, Garetto LP, Akeson WA (1978) Acute compartment syndromes: Diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg [Am] 60: 1091–1095 5. Orava S, Laakko E, Mattila K, Makinen L, Rantanen, Kajala UM (1998) Chronic compartment syndrome of the quadriceps femoris muscle in athletes. Diagnosis, imaging and treatment with fasciotomy. Ann Chir Gynaecol 87(1): 53–58 6. Palumbo RC, Abrams JS (1994) Compartment syndrome of the upper arm. Orthopedics17(12): 1144–1147 7. Whitesides T, Heckman M (1996)\ Acute compartment syndrome update of diagnosis and treatment. J Am Acad Orthop Surg 4: 209–218 8. Williams PL (ed) (1995) Gray’s textbook of anatomy, 38th edn, London, Spalding 9. Yabuki S, Kikuchi S (1999) Dorsal compartment syndrome of the upper arm. A case report. Clin Orthop (336): 107–109
