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Selected Instructional Course Lecture   |    
Adult Trauma: Getting Through the Night
Andrew H. Schmidt, MD1; Jeffrey Anglen, MD2; Arvind D. Nana, MD3; Thomas F. Varecka, MD1
1 Department of Orthopedic Surgery, Hennepin County Medical Center, Mail Code G2, 701 Park Avenue, Minneapolis, MN 55415. E-mail address for A.H. Schmidt: schmi115@umn.edu
2 Department of Orthopaedic Surgery, Indiana University School of Medicine, 541 Clinical Drive, Suite 600, Indianapolis, IN 46202-5111
3 Department of Orthopaedic Surgery, University of North Texas Health Science Center, 855 Montgomery Street, 5th Floor, Fort Worth, TX 76107. E-mail address: anana@jpshealth.org
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his immediate family, received, in any one year, payments or other benefits or a commitment or agreement to provide such benefits from commercial entities (Smith and Nephew [in excess of $10,000] and Medtronic, DGIMed Ortho, Conventus Orthopaedics, Twin Star Medical, AGA, and Thieme, Inc. [less than $10,000]).

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in March 2010 in Instructional Course Lectures, Volume 59. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Feb 01;92(2):490-505
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Extract

There has been a dramatic change in the approach to the treatment of acute musculoskeletal injuries over the past decade. The previous emphasis on so-called "early total care," which advocated immediate definitive repair of all injuries, has shifted to an approach emphasizing "damage control orthopaedics" for a multiply injured patient. In this new paradigm, definitive repair of fractures is delayed until the patient is stabilized physiologically, associated soft-tissue injuries (if present) have healed, and optimum resources are available. However, there remain situations in which immediate treatment may be needed, such as in a patient with a pelvic ring injury and hemodynamic instability, a compartment syndrome, or an irreducible joint dislocation with associated neurovascular compromise. In these circumstances, there may not be time to safely transfer the patient to a specialized center, and emergent treatment directed at the specific problem must be provided. Emergent treatment of open fractures, compartment syndrome, and hemodynamic instability in a patient with a pelvic fracture as well as damage control in multiply injured patients should be understood by all who treat musculoskeletal injuries. Finally, a less-often discussed but no less important aspect of surgical care that may affect initial treatment decisions and outcome is sleep deprivation and fatigue of the members of the surgical team.
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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Andrew H. Schmidt, MD
    Posted on March 26, 2010
    Dr. Schmidt responds to Mr. Ferris
    Hennepin County Medical Center, Minneapolis, Minnesota

    In his letter, Mr. Ferris brings up some points that deserve further clarification regarding the clinical signs associated with compartment syndrome. As the author of the section regarding compartment syndrome that was published as part of our Instructional Course Lecture “Adult Trauma: Getting Through the Night” (1), I will address his comments.

    Firstly, Mr. Ferris points out that the “classic 5 P's usually refer to acute ischaemia of arterial origin”. Although this is undoubtedly true, and arterial insufficiency is perhaps a better pathophysiologic lesion to ascribe these findings to, at least in North America this same concept has been commonly applied to acute compartment syndrome (2-7). Regardless of their provenance, Mr. Ferris agrees with my assertion that these signs are generally ill-suited for the early diagnosis of acute compartment syndrome, which was my point. However, Mr. Ferris disagrees with my statement that altered sensation is useful as a diagnostic measure, considering that loss of sensation is a late sign indicative of nerve damage. On this point I must disagree, although the disagreement may be mostly semantic. Peripheral nerves are very sensitive to tissue ischemia (8), although there is controversy about whether muscle or nerve may be more sensitive to acute ischemia (9). Therefore, peripheral nerves traversing a compartment are fairly quickly affected by the microcirculatory failure that results from acute compartment syndrome, and loss of sensation in a specific peripheral nerve (such as the deep peroneal nerve within the anterior compartment of the leg) can be a very useful finding in the early stages of compartment syndrome. However, the practical use of this clinical sign is limited by its subtlety, and for obvious reasons it may be a very difficult sign to elicit. Patients with acute compartment syndrome are injured, distressed, sedated, often intoxicated or obtunded, and their leg is typically splinted and may not be available for detailed or repeated examination. Nevertheless, Mubarak et al. state that, “In our experience the most reliable physical finding is a sensory deficit. Although it appears early in a compartment syndrome, it may be manifest only as a paresthesia” (4, pages 1093-4), while Rorabeck noted that sensory deficit was the earliest neurologic sign in his series of patients, and was present in 12 of 16 cases (10). Therefore, clinicians should carefully examine and document the status of the peripheral nerves in their initial evaluation of a patient who is at risk for acute compartment syndrome, and remain alert for (and document) any changes in the sensory distribution of these nerves that develop over time. Corresponding motor changes are even more difficult to elicit due to the related injury, and are not considered very useful (10). The diagnosis of acute compartment syndrome relies as much as anything else on clinical suspicion, and the sensory examination is an important part of the overall clinical picture that must be considered.

    References

    1. Schmidt AH, Anglen J, Nana AD, Varecka TF. Adult trauma: getting through the night. J Bone Joint Surg Am. 2010;92:490-505.

    2. Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Ped Orthop. 2001;21:680-8.

    3. Heckman MM, Whitesides TE Jr, Grewe SR, Rooks MD. Compartment pressure in association with closed tibial fractures. The relationship between tissue pressure, compartment, and the distance from the site of the fracture. J Bone Joint Surg Am. 1994;76:1285-92.

    4. Janzing HM, Broos PL. Routine monitoring of compartment pressure in patients with tibial fractures: beware of overtreatment! Injury. 2001;32:415-21.

    5. Mubarak SJ, Hargens AR. Acute compartment syndromes. Surg Clin North Am. 1983;63:539-65.

    6. Mubarak SJ, Owen CA, Hargens AR, Geratto LP, Akeson WH. Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg Am. 1978;60:1091-5.

    7. Tiwari A, Haq AI, Myint F, Hamilton G. Acute compartment syndromes. Br J Surg. 2002;89:397-412.

    8. Bourne RB, Rorabeck CH. Compartment syndromes of the lower leg. Clin Orthop Rel Res. 1989;240:97-104.

    9. Pedowitz RA. Tourniquet-induced neuromuscular injury. A recent review of rabbit and clinical experiments. Acta Orthop Scand Suppl. 1991;245:1-33.

    10. Rorabeck CH. The treatment of compartment syndromes of the leg. J Bone Joint Surg Br. 1984;66:93-7.

    Barry D. Ferris
    Posted on March 13, 2010
    Divided by a Common Language
    Barnet Hospital, Barnet, Herts, United Kingdom

    To the Editor:

    I read this article (1) and was struck by the authors' repeated reference to emergent treatment when they mean emergency treatment. These malapropisms are becoming increasingly common. Emergent means the process of coming into being (Oxford English Dictionary), emerging (Cambridge dictionary) new, to come out or become noticeable (dictionary of American English) which I am sure is not what the authors mean. The bone transporters now have noun-verbs when they describe the regenerating bone as the regenerate. Will joint replacers start removing the degenerate?

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    Reference

    1. Schmidt AH, Anglen J, Nana AD, Varecka TF. Adult trauma: getting through the night. J Bone Joint Surg Am. 2010;92:490-505.

    Barry D. Ferris
    Posted on March 11, 2010
    Adult Trauma: Getting Through the Night
    Barnet Hospital, Barnet, Herts, United Kingdom

    To the Editor:

    In this article (1), the authors discuss the diagnosis and management of acute compartment syndrome. They quite rightly point out that the "5 P's" are late signs, and imply that pain and loss of sensation are better early signs. The classic 5 P's usually refer to acute ischaemia of arterial origin (in the UK we have a sixth "P" - perishing with cold) rather than compartment syndrome. Once altered sensation has occurred, this usually indicates nerve damage and should not be regarded as an early sign.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    Reference

    1. Schmidt AH, Anglen J, Nana AD, Varecka TF. Adult trauma: getting through the night. J Bone Joint Surg Am. 2010;92:490-505.

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