Abstract
Purpose
Peripheral nerve blockade (PNB) is a useful tool for pain control in the perioperative period. However, there are significant concerns about the use of PNBs following acute orthopaedic trauma due to the theoretical risk of masking acute compartment syndrome (ACS). This study aims to systematically review the effects of PNBs on diagnosis of ACS following long bone fractures.
Methods
A systematic review of the literature was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Results
Six studies, all of which were single-patient case reports, met criteria for inclusion in this review. Two studies reported a delay in diagnosis of ACS in the setting of PNB use, while four studies did not.
Conclusions
Due to the low incidence of ACS, there is a paucity of literature available on ACS following PNB use in the setting of orthopedic trauma. There is no consensus in the literature about the safety of PNB use in the setting of acute long bone fractures, and this review could draw no conclusions from the literature, as the level of evidence is limited to case reports. PNBs should be administered to orthopedic trauma patients only in strictly controlled research environments, and surgeons should be highly cautious about using PNBs for orthopedic long bone fractures, particularly in cases at increased risk for developing ACS.
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References
Minick P, Clark PC, Dalton JA, Horne E, Greene D, Brown M. Long-bone fracture pain management in the emergency department. J Emerg Nurs. 2012;38(3):211–7.
Aguirre JA, Gresch D, Popovici A, Bernhard J, Borgeat A. Case scenario: compartment syndrome of the forearm in patient with an infraclavicular catheter: breakthrough pain as indicator. Anesthesiology. 2013;118(5):1198–205.
Whitesides TE Jr, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop Relat Res. 1975;113:43–51.
Matsen FA, 3rd. Compartmental syndrome. A unified concept. Clin Orthop Relat Res. 1975;(113):8–14.
Duckworth AD, McQueen MM. The diagnosis of acute compartment syndrome: a critical analysis review. JBJS Rev. 2017;5(12):e1.
Schmidt AH. Acute compartment syndrome. Orthopedic Clin. 2016;47(3):517–25.
Rorabeck CH. The treatment of compartment syndromes of the leg. J Bone Joint Surg Br. 1984;66(1):93–7.
Lagerstrom CF, Reed RL 2nd, Rowlands BJ, Fischer RP. Early fasciotomy for acute clinically evident posttraumatic compartment syndrome. Am J Surg. 1989;158(1):36–9.
Hayakawa H, Aldington DJ, Moore RA. Acute traumatic compartment syndrome: a systematic review of results of fasciotomy. Trauma. 2009;11(1):5–35.
Bhattacharyya T, Vrahas MS. The medical-legal aspects of compartment syndrome. J Bone Joint Surg Am. 2004;86(4):864–8.
Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003;85(5):625–32.
Cascio BM, Wilckens JH, Ain MC, Toulson C, Frassica FJ. Documentation of acute compartment syndrome at an academic health-care center. J Bone Joint Surg Am. 2005;87(2):346–50.
Mannion S, Capdevila X. Acute compartment syndrome and the role of regional anesthesia. Int Anesthesiol Clin. 2010;48(4):85–105.
McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br. 1996;78(1):99–104.
McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br. 1996;78(1):95–8.
White TO, Howell GE, Will EM, Court-Brown CM, McQueen MM. Elevated intramuscular compartment pressures do not influence outcome after tibial fracture. J Trauma. 2003;55(6):1133–8.
Clark L, Robinson M, Varbanova M. Role of regional anesthesia in orthopedic trauma. Anesthesiol Clin. 2014;32(4):789–808.
Paul JE, et al. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology. 2010;113(5):1144–62.
Pagnotto MR, Pagnano MW. Multimodal pain management with peripheral nerve blocks for total knee arthroplasty. Instr Course Lect. 2012;61:389–95.
Wiederhold BD, Garmon EH, O'Rourke MC. Nerve Block Anesthesia. [Updated 2019 Jun 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431109/
Vadhanan P, Tripaty DK, Adinarayanan S. Physiollogical and pharmacologic aspects of peripheral nerve blocks. J Anaesthesiol Clin Pharmacol. 2015;31(3):384–93.
Klucka J, Stourac P, Stouracova A, Masek M, Repko M. Compartment syndrome and regional anaesthesia: Critical review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2017;161(3):242–51.
O’Sullivan MJ, Rice J, McGuinness AJ. Compartment syndrome without pain! Ir Med J. 2002;95(1):22.
Harrington P, Bunola J, Jennings AJ, Bush DJ, Smith RM. Acute compartment syndrome masked by intravenous morphine from a patient-controlled analgesia pump. Injury. 2000;31(5):387–9.
Richards H, Langston A, Kulkarni R, Downes EM. Does patient controlled analgesia delay the diagnosis of compartment syndrome following intramedullary nailing of the tibia? Injury. 2004;35(3):296–8.
Yang J, Cooper MG. Compartment syndrome and patient-controlled analgesia in children—analgesic complication or early warning system? Anaesth Intensive Care. 2010;38(2):359–63.
Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. 2003;85(1):1–3.
Ganeshan RM, Mamoowala N, Ward M, Sochart D. Acute compartment syndrome risk in fracture fixation with regional blocks. BMJ Case Rep. 2015;pii: bcr2015210499.
Hyder N, Kessler S, Jennings AG, De Boer PG. Compartment syndrome in tibial shaft fracture missed because of a local nerve block. J Bone Joint Surg Br. 1996;78(3):499–500.
Rauf J, Iohom G, O’Donnell B. Acute compartment syndrome and regional anaesthesia—a case report. Rom J Anaesth Intensive Care. 2015;22(1):51–4.
Uzel AP, Steinmann G. Thigh compartment syndrome after intramedullary femoral nailing: possible femoral nerve block influence on diagnosis timing. Orthop Traumatol Surg Res. 2009;95(4):309–13.
Munk-Andersen H, Laustrup TK. Compartment syndrome diagnosed in due time by breakthrough pain despite continuous peripheral nerve block. Acta Anaesthesiol Scand. 2013;57(10):1328–30.
Via AG, Oliva F, Spoliti M, Maffulli N. Acute compartment syndrome. Muscles Ligaments Tendons J. 2015;5(1):18–22.
Branco BC, Inaba K, Barmparas G, Schnuriger B, Lustenberger T, Talving P, Lam L, Demetraides D. Injury. 2011;42(10):1157–63.
Lenart MJ, Wong K, Gupta RK, Mercaldo ND, Schildcrout JS, Michaels D, Malchow RJ. The impact of peripheral nerve techniques on hospital stay following major orthopedic surgery. Pain Med. 2012;13(6):828–34.
Kalyani BS, Fisher BE, Roberts CS, Giannoudis PV. Compartment syndrome of the forearm: a systematic review. J Hand Surg Am. 2011;36(3):535–43.
Gadsden J, Warlick A. Regional anesthesia for the trauma patient: improving patient outcomes. Local Reg Anesth. 2015;8:45–55.
Kontrobarsky Y, Love J. Gluteal compartment syndrome following epidural analgesic infusion with motor blockage. Anaesth Intensive Care. 1997;25(6):696–8.
Patillo D, Della Rocca GJ, Murtha YM, Crist BD. Pilon fracture complicated by compartment syndrome: a case report. J Orthop Trauma. 2010;25(6):e54–e5757.
Morrow BC, Mawhinney IN, Elliott JR. Tibial compartment syndrome complicating closed femoral nailing: diagnosis delayed by an epidural analgesic technique—case report. J Trauma. 1994;37(5):867–8.
Haggis P, Yates P, Blakeway C, Fick D, Morgan DA, Holt M, Wood D. Compartment syndrome following total knee arthroplasty: a report of seven cases. J Bone Joint Surg Br. 2006;88(3):331–4.
Kumar V, Saeeed K, Panagopoulous A, Parker PJ. Gluteal compartment syndrome following joint arthroplasty under epidural anaesthesia: a report of 4 cases. J Orthop Surg (Hong Kong). 2007;15(1):113–7.
Pachecho RJ, Buckley S, Oxborrow NJ, Weeber AC, Allerton K. Gluteal compartment syndrome after total knee arthroplasty with epidural postoperative analgesia. J Bone Joint Surg Br. 2001;83(5):739–40.
Mannion S, Lee P, Taylor C. Cold Case Files: 15 years on, did patient controlled analgesia mask acute compartment syndrome? Ir Med J. 2017;110(7):625.
McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. 2000;82(2):200–3.
McCulloch P, Altman DG, Campbell WB, et al. No surgical innovation without evaluation: the IDEAL recommendations. Lancet. 2009;374(9695):1105–12.
Hatz BA, Frima H, Sommer C. Selective fasciotomy for acute traumatic lower leg compartment syndrome: is it feasible? Arch Orthop Trauma Surg. 2019;139(12):1755–62.
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The authors Andrew Tran, Danny Lee, Safa Fassihi, Evan Smith, Ryan Lee, and Gautam Siram have no conflicts of interest.
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Tran, A.A., Lee, D., Fassihi, S.C. et al. A systematic review of the effect of regional anesthesia on diagnosis and management of acute compartment syndrome in long bone fractures. Eur J Trauma Emerg Surg 46, 1281–1290 (2020). https://doi.org/10.1007/s00068-020-01320-5
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DOI: https://doi.org/10.1007/s00068-020-01320-5