Acute compartment syndrome risk in fracture fixation with regional blocks

Abstract

Acute compartment syndrome is a surgical emergency that most commonly occurs after trauma or reperfusion after prolonged arterial occlusion. It is caused by a build-up of blood and oedema fluid within a closed muscle compartment, and can be limb and life-threatening. It is therefore imperative that a prompt diagnosis is made. The risk of developing this condition is <1% in patients with distal radius fractures and 4-5% in those with tibial diaphyseal fractures. Pain management is an important aspect of treatment following any fracture. Regional anaesthesia can be used during surgical fixation of the fracture and has the potential to reduce the need for specialist postoperative care and analgesia, as well as to shorten the length of hospitalisation. With this case report, we hope to highlight the potential risk of masking symptoms of compartment syndrome while using regional blocks, as this can cause a delay in diagnosis and treatment, leading to associated complications.

Regional Anesthesia and Compartment Syndrome

“…A similar case is reported by Ganeshan et al 13 A 75-year-old patient with a complicated forearm fracture underwent ambulatory surgical revision using axillary brachial plexus blockade (without a description of the type, volume, and concentration of the local anesthetic solution). Subsequently, the patient developed a compartment syndrome during the next 24 hours and was readmitted after 24 hours with severe pain.…”

“…In fact, only a very few cases were published where diagnosis of compartment syndrome was delayed in the presence of regional anesthesia. 13 These cases should rather emphasize that our management to detect compartment syndromes should be improved. Optimal pain management is the anesthesiologist’s responsibility, detection of compartment syndrome mainly that of the surgeons.…”

Pro-Con Debate: Peripheral Nerve Blockade Should Be Provided Routinely in Extremity Trauma, Including in Patients At Risk for Acute Compartment Syndrome

“…Case reports and expert opinion have established a norm disapproving PNB in patients at risk for ACS. 3,4,20,22 Long-lasting single injections or continuous PNB often provide prolonged dense analgesia and an insensate extremity with patients and their care providers unaware of a developing ACS before irreversible damage occurs. 42 Short-acting PNB can lead to rebound pain, which may be confused with disproportionate pain and lead to either an unnecessary fasciotomy or to rapid administration of multiple analgesics that again risk masking a developing ACS.…”

“…17 Multiple case reports attribute missed diagnosis of ACS to various analgesic modalities, with the preponderance implicating neuraxial anesthesia and nerve blocks. [20][21][22][23] Yet, recent literature shows that PNB analgesia enables detection of sudden changes in ischemic pain with potentially an earlier diagnosis of ACS considered. [5][6][7][8][9][10][11][12] Amid increasing administration of PNB in trauma patients, the controversial role of PNB in patients at risk for ACS is herein discussed (Table ).…”

Reply to Letter to the Editor: Preoperative Peripheral Nerve Blocks in Orthopaedic Trauma Surgery: A Guide to Diagnosis-Based Treatment

“…Furthermore, it is not only the masking of pain that confounds the clinical evaluation of compartment syndrome but also the masking of sensorimotor function. 6 Ischemia time of just 4 hours has been shown to lead to irreversible axonotmesis and 6 hours for irreversible necrosis. 7 Therefore, a timely physical examination that is monitored over time is crucial in the diagnosis of ACS, and inability to assess sensorimotor function due to PNBs that may last 8 to 18 hours eliminates these crucial data points.…”