What is Hyperbaric Treatment of Crush Injury and Compartment Syndrome?
Our arms and legs are made up of different groups of muscles, separated by a type of membrane called fascia. If a limb gets hurt (from a severe blow, broken bone, too many injections, or overuse), it can quickly swell and become inflamed. This can sometimes lead to a condition called acute compartment syndrome (ACS). ACS happens when the pressure inside these muscle compartments becomes so high that it starts to interfere with blood flow to the tissues.
What Causes Hyperbaric Treatment of Crush Injury and Compartment Syndrome?
Acute compartment syndrome (ACS) can be caused by both accident-related and non-accident-related incidents. Breaking long bones, especially if they shatter, accounts for most ACS cases. This condition most commonly occurs following a severe injury to the leg. In one study, when examining 414 acute breaks to the tibia (the shin bone), the cases with the most risk of leading to ACS were those with breaks in the middle of the bone. These breaks made up 40% of all ACS cases related to injury.
Interestingly, you don’t need to have a fracture to develop ACS. It may also occur due to crushing injuries, serious burns, tight bandages, wounds from sharp objects, or damage to blood vessels. There are also non-injury-related causes such as blocked blood vessels, blood clots, injuries reoccurring after blood flow returns, bleeding disorders, vascular diseases (conditions that affect your blood vessels), nephrotic syndrome (a kidney disorder), snake or spider bites, leakage of fluids given intravenously (through an IV), drug misuse, and prolonged pressure on a limb from casts or tourniquets that are too tight.
ACS cases happen more frequently in younger individuals.
Risk Factors and Frequency for Hyperbaric Treatment of Crush Injury and Compartment Syndrome
ACS, or Acute Compartment Syndrome, often affects patients under 35 years old. It is frequently seen in young men, especially those who have had fractures in the long part of their shin bone or near the wrist. Often, this injury happens due to falls or during rescue efforts in situations like building collapses, earthquakes, civil unrest, explosions, or high-speed car accidents.
Signs and Symptoms of Hyperbaric Treatment of Crush Injury and Compartment Syndrome
When a patient might be at risk for Acute Compartment Syndrome (ACS), doctors will focus on their medical history. They’ll look for any events or conditions that could lead to ACS. These could include bleeding disorders, kidney disorders, peripheral vascular disease, heart rhythm problems, or a history of injecting drugs either into a muscle or a vein.
During a physical exam, doctors will look for five main signs of ACS. These are often referred to as the “5 Ps”. They include:
- Increasing Pain that doesn’t match the injury’s appearance
- Paresthesia, or a sensation of tingling or numbness
- Paresis, or weakness
- Pallor, or unusual paleness
- Distal Pulse deficit, or a weak or absent pulse below the injury
Additional signs can include discomfort when the muscles are gently stretched or a feeling of tightness in a muscle compartment. The leg and the forearm each have several compartments that can be affected.
In the leg, there are the following compartments:
- Anterior compartment: characterized by pain when pointing the toes. The muscles involved include the tibialis anterior, the extensor digitorum longus, the extensor hallucis longus, and the peroneus tertius.
- Lateral compartment: characterized by pain when turning the foot inward. The muscles involve are the peroneus longus and the brevis.
- Superficial posterior compartment: houses the soleus, gastrocnemius, and the plantaris muscles. The syndrome of this compartment involves pain when flexing the foot upward.
- Deep posterior compartment: contains the tibialis posterior, flexor hallucis longus, the flexor digitorum longus, and the popliteus muscles. Pain when extending the toes signifies this syndrome.
The forearm has two primary compartments:
- Volar compartment: This one causes pain when extending the wrist.
- Dorsal compartment: Here, the pain gets worse when flexing the wrist against resistance.
Testing for Hyperbaric Treatment of Crush Injury and Compartment Syndrome
When a doctor suspects Acute Compartment Syndrome (ACS), a condition involving increased pressure in a muscle compartment, they conduct laboratory tests. These tests aren’t directly for ACS, but they can detect other issues such as irregular heart rhythms, blood clotting disorders, high levels of nitrogen wastes in the blood, or hidden drug use. They may also show results such as high levels of serum creatine phosphokinase (an enzyme found in your body) and the presence of myoglobin in urine, which typically appear when muscles start breaking down.
The main way doctors diagnose ACS is by looking at the clinical symptoms and measuring the pressure inside the compartments of your muscles. The most reliable method for this is saline manometry, also known as the Whiteside procedure. In this test, doctors use devices called pressure transducers to measure this pressure. If a patient having ACS symptoms has a pressure higher than 30mmHg, ACS is confirmed. Likewise, patients with a difference (Delta Pressure) of less than 30 between the diastolic blood pressure and the compartment pressure are also confirmed to have ACS. If these findings are confirmed in a patient experiencing symptoms, the doctor must consult a surgeon immediately for the possibility of a surgical procedure called fasciotomy, which is used to relieve pressure.
The positioning of the needle for the saline manometry procedure depends on which muscle compartment is under suspicion. For instance, if the doctor suspects the anterior compartment of the leg, the needle would be placed about one third down the shinbone from the small bump on the tibia, and 1 cm from the edge of the tibia. The needle would go in approximately 1-3cm. The procedures for the lateral, superficial posterior, and deep posterior compartments have their specific needle placement and insertion depth.
Doctors have also tried to measure pressures inside muscle compartments using methods like ultrasound, laser-based techniques, and infrared spectroscopy, or examined directly muscle pH, glucose level, and oxygen level. However, the saline manometry method remains the gold standard. There is a chance of variation between the observations of different doctors, and continuous monitoring of compartments pressures may give more reliable results compared to a one-time measurement.
Treatment Options for Hyperbaric Treatment of Crush Injury and Compartment Syndrome
If a limb is at risk for Acute Compartment Syndrome (ACS), any restrictive coverings like a cast, or tourniquet, should be removed. The limb should also be placed level with the heart. This helps to prevent a decrease in blood flow and stop swelling. Regular checks are needed every few hours if ACS is suspected.
ACS can progress in three stages: ‘suspected,’ ‘impending,’ and ‘established.’ In cases where symptoms have been confirmed and pressure readings within the limb compartments are abnormal (‘established’ stage), urgent surgery is required to relieve the pressure. This procedure is known as a fasciotomy. However, some patients may display uncertain symptoms and have unclear pressure measurements, falling into the ‘suspected’ category.
Progression from the ‘suspected stage’ to the ‘impending stage’ occurs when these symptoms worsen or pressure readings show an intermediate risk. At this ‘impending’ stage, a treatment called hyperbaric oxygen therapy (HBOT) can be used as it might prevent the condition progressing to the ‘established stage.’ HBOT treatment involves breathing in pure oxygen in a pressurised room or tube. This treatment helps to increase oxygen supply to the tissues. HBOT therapy can also be used after a fasciotomy to help manage complications like unclear difference between healthy and dead muscle, extreme swelling, and nerve damage.
But, it’s important to remember that if a patient has progressed to ‘established’ ACS, immediate surgery should not be delayed, even when HBOT therapy is being considered. HBOT has been proven to boost tissue oxygen supply by 20 times and may play a role in promoting wound healing. Yet, large-scale review studies are lacking on the use of HBOT for crush injuries and ACS. Nonetheless, the Undersea & Hyperbaric Medical Society has approved it for treating ACS from crush injuries, and the European Committee for Hyperbaric Medicine has given it a moderate-level evidence grade rating for open fractures with crush injuries.
What else can Hyperbaric Treatment of Crush Injury and Compartment Syndrome be?
Here are some conditions that can cause similar symptoms and may need to be ruled out:
- Infection
- Rhabdomyolysis (breakdown of damaged muscle)
- Necrotizing fasciitis (flesh-eating disease)
- Myo-contusion (muscle bruise)
- Hematoma (blood clot)
- Myositis (inflammation of the muscles)
What to expect with Hyperbaric Treatment of Crush Injury and Compartment Syndrome
If Acute Compartment Syndrome (ACS) – a serious condition where pressure within a muscle compartment increases, is identified and treated early with a procedure called a decompressive fasciotomy, the chances of recovery are quite good. In a study conducted in 1976, it was found that if this surgery was performed within the first 12 hours after initial symptoms (like motor weakness or severe pain when the muscle is stretched), nearly 68% of patients were able to regain normal function. But if the surgery was delayed beyond 12 hours, normal function was restored in only 8% of patients.
However, it’s important to note that fasciotomies can come with their own set of complications, such as the need for additional surgeries to fully close the wound or carry out a skin graft, pain, cosmetic deformity, nerve damage, muscle weakness, and chronic venous insufficiency – a condition where the veins in your legs struggle to send blood back to your heart.
Possible Complications When Diagnosed with Hyperbaric Treatment of Crush Injury and Compartment Syndrome
Muscle damage might happen just a few hours after an injury. To handle this, medical professionals will repeatedly clean the wound every 48 to 72 hours until it becomes stable. Nerves might also get permanently damaged as early as an hour after injury. Other problems could include muscle contractions, severe infection, or even having to amputate a body part. Large areas of skin loss are often patched up with skin grafts, which may have poor blood supply.
Injuries associated with broken bones could possibly lead to a bone infection or healing failure. Other issues such as oxygen toxicity, collapsed lung, ruptured eardrum, sinus squeeze, and tooth squeeze can develop from Hyperbaric Oxygen Therapy (HBOT).
Experiencing sudden difficulty breathing along with chest pain is a signal of a possible collapsed lung. The reduction in pressure during the ascent from HBOT should be done carefully and slowly to avoid complications. If pressure equilibrium is achieved, the patient has to be assessed immediately for a possible collapsed lung or severe tension pneumothorax, and treated accordingly.
Common complications:
- Muscle damage
- Nerve damage
- Muscle contractions
- Serious infection
- Amputation
- Poor blood supply in skin grafts
- Bone infection
- Healing failure in broken bones
- Oxygen toxicity
- Collapsed lung
- Ruptured eardrum
- Sinus squeeze
- Tooth squeeze
- Collapsed lung or tension pneumothorax from HBOT
Preventing Hyperbaric Treatment of Crush Injury and Compartment Syndrome
It’s important for patients to understand what’s causing their disease and how it progresses over time. By having this knowledge, patients can play an active role in keeping an eye on their symptoms and letting their healthcare provider know about any changes they notice early on. This allows any necessary treatment adjustments to be made as soon as possible.