Friday, May 13, 2005

Go, Alyca, Go...

Go me. I did a good job at work Thursday. I had a patient with a bad lisfranc fracture/dislocation (midfoot fracture, where the top of your foot meets the ankle). They tried to manipulate it back into place in the ER, but couldn't, so he was rushed off to surgery to have an external fixator placed. This is a sort of erector set where there are pins drilled into various bones above and below the massively broken area, and they are all connected together with a metal framework that sticks out of your leg. Hard to describe....maybe I will find a picture to post. Anyway, so he had this done, and got out of the OR around 5am and I picked him up at 7am.
The fixator was wrapped in a sort of ace wrap. The docs like to do this when they first send these guys up from surgery, since the pin sites where they enter your leg tend to have some drainage the first day or so, and they want to keep it contained and protect the areas from the rest of the world. I took a peek at the foot to check out circulation, sensation, movement, etc, and it was really swollen. Really swollen. There was a whole swollen roll of skin all puffed up right at the spot where the top of the foot meets the ankle.
I guess I should say something about compartment syndrome. Basically, compartment syndrome is when a compartment (which is any contained area that has a muscle, vein, artery and nerve all contained inside a fascia), gets really bumped hard but not broken, and the blood vessel bleeds, but since the fascia is intact, there is nowhere for the blood to go, so it just builds up the pressure in that compartment which makes the nerves function get cut off, so you have some numbness, and also the area gets really swollen and the skin gets really shiny and discolored, and certain movements can cause severe pain. They are most common in the calf--this is why soccer players wear shin guards. So the main thing to assess if a patient has swelling or if they have compartment syndrome is to passively (meaning I do it and the patient just relaxes and does not help) move their toes towards their head. If the scream and try to kick you with their good foot, that is not a good sign.

So, this guy is really swollen, and I am not sure if there ARE susceptible compartments in the foor, but I really wanted someone else to look at it. I had a few of the nurses on the floor take a peek, then called the ARNP to look. Took her like 3 hours to come up--she kept saying she was coming, but did not show up. Actually, I called her at like 8:30am and she showed up when I was on my lunch break at 1pm, so I guess it was a bit longer than 3 hours. Not so good. She looked at it and said hmmm, then had Moe, the wonderful very ortho experienced ARNP look at it, and SHE said to call the docs to have them look at it. Through all of this we gave the patient tons of pain meds and anxiety meds to 'snow' him so you could touch his foot without horrible terrible pain. But even then, he would wake up and moan a ton if you messed with his foot. We could use a doppler (like what they use in ultrasounds) to hear the pulses in his foot, and those were good, but not necessarily a sign that there was no compartment syndrome.

The compartments felt very firm, almost like pushing on bone, rather than tissue. So the MD's came up and they unscrewed the external fixator and adjusted it a bit which was pretty painful for the patient, but once they moved it a few centimeters, the compartments were much softer and we could wiggle his toes for him and he did not really notice (gorked from all the meds). So all was better. We kept him NPO (nothing by mouth, actually nil per os, it is latin---don't ask me) in case he needed further OR, but since he didn't want anything to eat or drink anyway, he didn't care.
So, the day goes on and I am being diligent.
Remember, we very rarely see compartment syndrome. Maybe 3-4 times a year, and always (almost) in the calf. No one can remember seeing it in a foot.
Anyway, I kept checking and checking, and around 5pm I feel like the foot is getting firmer. I feel a definite change, so I called the ARNP and eventually she called the MD and he came to the floor, messed with the patient for a second and we whisked him away for emergency surgery to have a fasciotomy done so his foot would not need to be amputated.
A fasciotomy is basically cutting a big slice through your skin all the way down to the fascia layer that surrounds the muscle capsule. Once the fascia is cut open, the muscle will literally blow out of the hole with all the pressure behind it. So now he has a muscle, or a group of muscles bulging out the top of his foot, and we keep special dressings on it and once the swelling goes down enough they will try to stick it back inside where it belongs, although many times they can not do that, so they take some skin from somewhere else to cover up the hole and you end up with a really funky looking but fairly functional foot.

Anyway, I was really excited about catching this. This is the sort of thing that gets missed--he had a dressing wrapped over it in the morning, which restricted seeing it somewhat, he was totally still with a bunch of anaesthesia in his system, and on a bunch of pain meds which makes it hard to wake him up enough to get good answers from him about his pain and sensation etc. I had him again today, and he totally did not remember me at all from the 12 hours I had him yesterday. And, we were all not entirely sure you could GET compartment syndrome in a foot. Apparantly, you can. So. Go me!


Mama-Beans said...

Wellthat's totally interesting! GO YOU! Kind neat to have the patient with the nifty not-often-seen-but-cool-that-you-recognised it complication!
More stories like this, please!!

jc_people said...

That is totally cool! So, when you see this kind of thing in the calf is it usual to have to get skin from somewhere else or are you able to use skin from the area? Also, if the muscle blows out the hole, does it damage the muscle to the extent that the person doesn't regain normal function or is it possible for it to go back to normal? Do they do lots of physical therapy? And why can't it be drained or something like fluid in a joint? Have you ever seen one on an ultra-sound or anything? What does that look like? Really enjoying these stories!!!!

alyca said...

Hmm...okay, this is much more common in the calf. If you catch it very early on (like if you were playing soccer or something and you got kicked really hard and had someone look at it right away), they can just punch a few holes into the compartment to relieve the pressure, and all is good in just a few days.

In the hospital it is different, since there are broken bones involved. Also, because the bones are broken, the patient is getting a bunch of pain medication which makes him loopy and not really able to tell you much about his pain or help you by moving his toes, etc so you can assess what is going on. And the swelling is much more.
Getting kicked hurts and can cause compartment syndrome, but having a broken AND dislocated joint in your foot causes much more trauma, so there is a lot more damage. To the point where by the time we figure out that something is wrong, a lot of times there is some amount of dead muscle and/or skin there, which must be removed. Usually, after 3 or 4 days they can get the swelling down enough in the muscle and push the part that is sticking out back inside. THey can close the hole if there wasn't too much tissue that died, but if not, they will take a layer of skin (usually from your thigh) and use that to cover the area that needs a bit more. The muscle goes basically back to normal if there wasn't too much lost when it was being squashed, but it takes time and lots of range of motion and stretching and general physical therapy to be all the way back.

You can't drain out the fluid. Well, I guess you sort of DO drain out some of the fluid when you cut a hole and open up the compartment, but what comes out is all the blood that was building up in the compartment. THe blood squishing the muscle damages the muscle, so your body send white blood cells and fluids to the area to investigate and try to help, which just makes the swelling worse. Until you can convince your body that everything is okay, you will have fluids being sent there, and you can't do much about it other than wait.

So, a 4-compartment fasciotomy of the calf (when there is a ton of swelling from a pretty bad injury) is a mangled mess. They make four or more incisions up and down your calf on every side, up to about 6 inches long each. Looks like someone tried to fillet your leg. And they drain a lot--reddish fluid that is a mix of blood and the fluid that your body sends to the injury.

Usually if you get injured pretty bad, your skin splits open, which sucks, but prevents compartment syndrome. If the skin doesn't open, that makes compartment syndrome possible. So sometimes these are crush injuries, but sometimes also car wrecks, etc. Not too terribly common.

Sort of rambling, but does that answer your questions??

jc_people said...

Yes that does answer my questions! Thank you. One more though, Does the muscle ever swell back up in the process of being stuffed back in? It would seem to me that having a muscle hanging around outside of your body would put you at a higher risk of infection, and have the added risk of being irritated at being in contact with something more abrasive than it is used to, like bandages. Is that ever an issue with getting the swelling to go down or am I over-complicating it?

jc_people said...

OK, thought some more. If the faciotomy were not done the swelling could increase so that the area from there down loses all circulation and dies and gets gangrene? Hence the amputation thing?

alyca said...

Since it is only a part of the muscle sticking out with the swelling, it is fairly happy to get back inside the leg where it belongs, so therer is minimal extra swelling with the putting it back in process. And yes, no fasciotomy in compartment syndrome causes no blood flow in all or part of the limb below it which leads to cell death and need for amputation if too much dies.

jc_people said...

That is really cool!!!! Never heard of that before! Keep the cool stories coming!!

jc_people said...
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