A SPORTS MEDICINE PHYSICIAN’S
PERSPECTIVE

DAVID CARFAGNO, D.O., CAQSM
SCOTTSDALE SPORTS MEDICINE


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23 year professional football player left the
game in the 2nd quarter due to lower leg pain
He doesn’t recall a sp...





Following the game, player returned home
Noticed an increase in pain as the night
progressed
Tried to sleep, but a...




Moore was transported to the University of
Colorado Hospital where he was diagnosed
with lateral compartment syndrom...
Q. Fractures are the cause in less than
25% of cases of compartment
syndrome.
A. True
B. False
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




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Acute Compartment Syndrome (ACS) is a
complication following fractures, soft tissue
trauma, and reperfusion ...
ACS is defined as a compartment pressure of >30
mmHg or within 30 mmHg of diastolic
pressure.

J Bone Joint Surg Br 1996;7...
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

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

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1/3 of all cases involve tibial shaft fractures
Young age: Patients <35 years old more likely
than older pat...






Following an injury
(e.g., fracture), muscl
e swelling
compresses VAN in
compartment
Intracompartmental
pressure ...




Bleeding: after vascular injuries or from cancellous
bone following fractures
Edema: from increased capillary permea...







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Delayed diagnosis often has limb- and lifethreatening consequences.
Despite the relative frequency with whic...








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Pain out of proportion to initial injury
Pain on passive stretch of muscles within affected
compartment
Pa...
6 “P’s”
1.
2.

3.
4.
5.

6.

Pain
Paresthesia
Paralysis/Paresis
Pulselessness
Pallor
Pressure
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Uncomplicated fracture
Cellulitis
Deep Venous Thrombosis
Peripheral Vascular Injuries
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Measure intracompartmental pressures with tonometer
Doppler (rule out DVT)
Serum chemistry studies (rule out rhab...




Perform
FASCIOTOMY when
difference between
compartment pressure
and diastolic blood
pressure is <30 mm
Hg or when cl...


May be significant

-Skin grafts over incisions often needed
-Muscle weekness in affected limb can persist


Overall c...




In patients with tibial fractures, McQueen et al.
demonstrated that the time between apparent
onset of compartment s...
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Infection
Contracture
Muscle necrosis
Amputation
Rhabdomyolysis
Renal failure
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PHASE I: Protection and Mobility (Surgery to 2-3 weeks).
Protection, Rest, Ice, Compression, and Elevation.
PH...
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Tibial Fracture: 12-13
weeks average
healing time, followed
by rehabilitation and
gradual increase in
exercise...
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

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Study: over a 23-year period, 6% of all
malpractice claims against orthopedic surgeons
were related to ACS and gr...
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



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ACS in children most common in leg
Classic signs and symptoms often present later
or are completely absent
Near...
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



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Compartment syndrome is a serious syndrome
that needs to be diagnosed early
Palpable pulses don’t exclude comp...
David Carfagno, D.O., C.A.Q.S.M.




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Board Certifications: Internal Medicine, Sports
Medicine (CAQ), Ringside Medicin...
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
Compartment Sydrome: A Sports Medicine Physician's Perspective
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Compartment Sydrome: A Sports Medicine Physician's Perspective

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Compartment syndrome is a complication that patients experience following fractures (most common cause), soft tissue trauma, or reperfusion injuries, which leads to arterial obstruction and muscle swelling. This presentation was given to the physicans at Banner Health in Feburary 2014 by David Carfagno, DO, of Scottsdale Sports Medicine

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  • Common/Frequently seen?Periods for sentences onlyFont problemsMore recent studies!Blame it on your crappy help 
  • Doppler
  • Arterial and venous
  • Outcome depends on underlying condition or causation of injury, whether there vascular disease, and time interval between onset and treatment
  • Compartment Sydrome: A Sports Medicine Physician's Perspective

    1. 1. A SPORTS MEDICINE PHYSICIAN’S PERSPECTIVE DAVID CARFAGNO, D.O., CAQSM SCOTTSDALE SPORTS MEDICINE
    2. 2.    23 year professional football player left the game in the 2nd quarter due to lower leg pain He doesn’t recall a specific injury Upon inspection, Team Physician felt that there were no broken bones, muscle weakness, sprains or strains and declared his discomfort was due to cramping and had the player benched
    3. 3.    Following the game, player returned home Noticed an increase in pain as the night progressed Tried to sleep, but awoke with severe lower leg pain which lead him to call the Team Physician for help
    4. 4.   Moore was transported to the University of Colorado Hospital where he was diagnosed with lateral compartment syndrome He underwent emergency surgery to have his fascia opened to relieve increasing pressure
    5. 5. Q. Fractures are the cause in less than 25% of cases of compartment syndrome. A. True B. False
    6. 6.      Acute Compartment Syndrome (ACS) is a complication following fractures, soft tissue trauma, and reperfusion injury after acute arterial obstruction. Common in participants of sports with high incidence of falls, fractures, contusions, etc. Difficult to diagnose without clinical testing Most often associated with fractures of long bones (e.g., tib-fib) Poor outcomes assoc. with delayed diagnosis
    7. 7. ACS is defined as a compartment pressure of >30 mmHg or within 30 mmHg of diastolic pressure. J Bone Joint Surg Br 1996;78:99–104.
    8. 8.      1/3 of all cases involve tibial shaft fractures Young age: Patients <35 years old more likely than older patients to develop ACS following same type of injury 10x more common in males Most cases associated with fractures of long bones, although 23.2% of cases associated with soft tissue injury only No difference in incidence of ACS in open compared to closed fractures J Bone Joint Surg Br. 2000;82:200–203.
    9. 9.    Following an injury (e.g., fracture), muscl e swelling compresses VAN in compartment Intracompartmental pressure rises Ischemia, followed by necrosis
    10. 10.   Bleeding: after vascular injuries or from cancellous bone following fractures Edema: from increased capillary permeability & fluid extravasation due to oxygen deprivation caused by bleeding     Increases perfusion barrier resulting in hypoxia + acidosis Hypoxia + acidosis further increase capillary permeability & fluid extravasation Increases intracompartmental pressure Restricted intracompartmental space: inelastic compartment cannot accommodate expansion due to finite borders defined by surrounding fascia and bone  Arterial compression, ischemia, then cellular death
    11. 11.      Delayed diagnosis often has limb- and lifethreatening consequences. Despite the relative frequency with which ACS is seen by orthopedic surgeons, the diagnosis is difficult. Clinical signs mimic other conditions Gold standard: assess intracompartmental pressure with tonometry; fasciotomy Refer to orthopedic specialist Curr Rev Musculoskelet Med. 2012 September; 5(3): 206–213.
    12. 12.       Pain out of proportion to initial injury Pain on passive stretch of muscles within affected compartment Palpably tense compartment Weakness and paresthesia of areas supplied by nerves crossing the compartment Late signs: loss of pulses (due to arterial occlusion), paralysis High index of suspicion for compartment syndrome must be maintained, even if all diagnostic criteria are not met Clin Orthop Relat Res. 2010 April; 468(4): 940–950.
    13. 13. 6 “P’s” 1. 2. 3. 4. 5. 6. Pain Paresthesia Paralysis/Paresis Pulselessness Pallor Pressure
    14. 14.     Uncomplicated fracture Cellulitis Deep Venous Thrombosis Peripheral Vascular Injuries
    15. 15.     Measure intracompartmental pressures with tonometer Doppler (rule out DVT) Serum chemistry studies (rule out rhabdomyolysis) Imaging (determine nature and severity of fractures)
    16. 16.   Perform FASCIOTOMY when difference between compartment pressure and diastolic blood pressure is <30 mm Hg or when clinical symptoms are obvious. Fasciotomy of all compartments is required. Clin Orthop Relat Res. 2010; 468(4): 940–950.
    17. 17.  May be significant -Skin grafts over incisions often needed -Muscle weekness in affected limb can persist  Overall complication rate is 10x higher if fasciotomy is delayed 12 hours from onset - amputation rate increased to over 50% - 8% of pts (untreated) vs 68% (treated) had limb function return to normal J Bone Joint Surg Br. 2000; 82 (2):200
    18. 18.   In patients with tibial fractures, McQueen et al. demonstrated that the time between apparent onset of compartment syndrome and surgical release influenced the outcome rather than the time between trauma and fracture stabilization. Documentation of clinical findings in ACS is important since serial examinations are necessary and the findings over time must be compared.
    19. 19.       Infection Contracture Muscle necrosis Amputation Rhabdomyolysis Renal failure
    20. 20.     PHASE I: Protection and Mobility (Surgery to 2-3 weeks). Protection, Rest, Ice, Compression, and Elevation. PHASE II: Light Strengthening (begin after meeting Phase I criteria, approximately 3-4 weeks following surgery). ROM, stretching. PHASE III: Progression of Strengthening (begin after meeting Phase II criteria, approximately 4-6 weeks following surgery). PHASE IV: Impact/Sport Training (Begin after meeting Phase III criteria, approximately 8-12 weeks following surgery) http://www.youtube.com/watch?v=hDHyrhbwq-M
    21. 21.     Tibial Fracture: 12-13 weeks average healing time, followed by rehabilitation and gradual increase in exercise intensity. Fibular Fracture: 8-12 weeks Tib-fib: 6 months or more High Ankle Sprain: weeks to months Int J Sports Phys Ther. 2011 June; 6(2): 126–141.
    22. 22.    Study: over a 23-year period, 6% of all malpractice claims against orthopedic surgeons were related to ACS and greater than 50% were ruled in favor of the patient. Linear relationship between the number of cardinal signs and the time from presentation to fasciotomy and payment size. Shadgan et al suggest that poor communication between physician, other members of the healthcare team, and the patient is associated with unfavorable outcomes. Bhattacharyya ‘04 Shadgan et al, ‘10
    23. 23.     ACS in children most common in leg Classic signs and symptoms often present later or are completely absent Nearly 1/3 of pediatric patients present only with pain Average normal resting intracompartmental pressure is slightly higher in children (13 to 16 mmHg) than in adults (8 mmHg) J Bone Joint Surg Br. 1996;78:95–98. Curr Rev Musculoskelet Med. 2012 September; 5(3): 206–213
    24. 24.     Compartment syndrome is a serious syndrome that needs to be diagnosed early Palpable pulses don’t exclude compartment syndrome If diagnosis and fasciotomy are done early, prognosis is good If delayed, complications will develop
    25. 25. David Carfagno, D.O., C.A.Q.S.M.    Board Certifications: Internal Medicine, Sports Medicine (CAQ), Ringside Medicine (ABRM) Medical Director, Ironman Arizona & Rock and Roll Marathon Arizona. Team physician, USA Boxing 10133 N. 92nd Street, Suite 102 Scottsdale, AZ 85258 Office – 480.664.4615 Email – david.carfagno@gmail.com

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