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Old 03-04-2011, 02:20 PM   #1
mikem9 OP
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Compartment Syndrome after a Motorcycle Crash

This is something we should probably all be aware of since it's pretty common in motorcycle injuries. I had it once when my foot was crushed on a rock while riding. Thankfully, didn't have to get the surgery. But, came close. Emergency rooms don't always tell you about this either - some just cast you up and send you home. That's what happened to me. Then a friend who is a surgeon said I should go see a specialist. Saved my foot.

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by Steve Natt

The only thing I don't like about riding motorcycles is when my ride comes to an abrupt and unexpected end. In a word: crashing.We all, by definition, consider this an assumable risk, as unpleasant as it is. Sure there are many among us who are far more skilled than others at the art of denial (visions of riders in shorts and sneakers come to mind), but I'd argue that most of us ride with proper gear on and blinders off.

I've always tried to do just that. I have more than two decades of motorcycling behind me. I've been in more emergency rooms than I care to think about (mostly for friends) and I have some now-dusty certificates in CPR and emergency first aid. Because of all this, I thought I was better versed than most in how to handle crash-related injuries. The fact is that I knew just enough to be dangerousto myself.

It took a terrible but hardly rare combination of bad luck, bravado and ignorance for a seemingly benign bruise I sustained in a 10 mph get-off to grow into a limb-threatening injury in a matter of hours. Here's what happened: I was shooting a story for the "Bike Week" series on the new SpeedVision TV network about how much better a Harley will stop with high-end aftermarket brakes. We set up the camera on a semi-private side street to shoot me riding somebody else's $15,000 DynaGlide with the Wide-Glide front end. With an aftermarket 21" front wheel and skinny chopper-style tire, this thing had a contact patch only slightly larger than my contact lens. I had a total of two minutes of seat time on this bike when we began to roll tape. There were lots of people standing around and the thought of a national TV audience never left my awareness.

I was able to bring the Dyna to a stop from 25 mph using the stock front brake in 34'. The front wheel never locked up. In the
interest of serving our viewers, I then videotaped the aftermarket brake company's mechanic changing out the single-piston,
single-action stock caliper for one of their potent 4-pot jobs.

Thirty minutes later I was back out on the street to see how much better the Dyna would stop. I managed to lock the front wheel in the last 10' of braking, and the bike came to a stop in only 27'. Since I skidded the front tire and didn't crash the motorcycle, I felt quite good about my riding skills. In fact, we decide to do it again and go for a record (and prove once and for all that I'm an idiot). So this time I grabbed a big, dumb right handful of brake lever. The 21" front wheel locked and turned right, and the portly cruiser flopped over on my right leg. We got it all on videoit looks like the bike was moving at about 10 mph as it impaled me against the macadam.

Only a few of the many ostentatious chrome pieces were scratched. This was largely because all 600 lbs. of motorcycle came
down where the lower exhaust pipe met the bottom of my right calf. Massive internal bleeding ensued over the next few hours,
including two where I "John-Wayned-it" and joined my wife and another couple for a pleasant Italian dinner.

I knew nothing was broken, and therefore assumed that with a standard application of R-I-C-E (rest, ice, compression, elevation), I'd be fine in a day or two. Unfortunately, the bleeding was so deep in my leg that I couldn't see any discoloration and I thought that at worst I'd be sore for a while.

Well, along came my old friend serendipity. The people at the dinner table included my toddler's pediatrician, Robert Hamilton, who politely offered to check my leg when I hobbled into the restaurant on some crutches I had left over from a previous mishap (don't ask). I declined his offer, charmingly suggested that he was "off-the-clock," and that I was just a tad too old to be examined by a baby doctor. By the time we were into the Decaf and Tiramisu, my right lower leg was feeling hot, much thicker than usual and rock hard. My discomfort must have been obvious because the Doctor reached under the table and put his hand on my calf (This was done for purely medical reasons, I assure you). He blanched and said, "we're going to the emergency room." Like James Bond, he simultaneously whipped out his cellular phone and the valet parking ticket. In a flash I was sprawled across the back seat of his 300e and on the way to the E.R.

Walking in off the street into any emergency room immediately teaches you the meaning of "oxymoron." It doesn't matter if you're bleeding, choking or have a javelin sticking out of your head, you are the only person who sees it as an emergency, and there's never enough room to get comfortable. But coming in with a Doctorespecially one who regularly works at that hospitalis a whole different story. Faster than the service JFK got at Dallas General, I went straight to a gurney and the attending resident was at my side in two minutes flat.

No triage, no interminable interview where I'm forced to teach them how to spell as they struggle through the forms. It took less than a minute for me to get the diagnosiscompartment syndrome (which is not a kind of claustrophobia) as a result of a traumatic crush injury.

Ten more minutes and a call from our friendly pediatrician's cell phone brought one
of the best orthopedic trauma surgeons in Southern California to my side: Thomas
Knapp, MD. He has treated hundreds of people with compartment syndrome, and
here's why this should matter to you: the vast majority of them are motorcyclists.
"This is one of the very few true orthopedic emergencies," he wryly remarked when
I spoke with him at his Santa Monica office. "We see it a lot in motorcyclists
because even what may seem like a relatively innocuous motorcycle accident can
cause a crush injury that could trigger compartment syndrome. Of course it's more
commonly associated with a fracture."

He told me it was a very good thing that I wasn't left in the waiting room with the
useless panacea of a bag of ice while my leg killed itself.

"If you get thrown over the handlebars, you're probably not going to develop
compartment syndrome unless you break a bone," he later said. "It's when you get
pinned, or a car sideswipes you and pins your leg against your bike, or if you fall and
your leg hits a curb. It's the isolated crush that happens very quickly in a concentrated small area that you have to watch out for.
That said, there is also the possibility that a larger more widespread bruisingnot an arterial injurycan develop into compartment
syndrome, but this would be of a more insidious onset taking 12-24 hours to set in. It would go from a generalized ache to 'Wow,
this REALLY HURTS!' to 'My foot is numb and it feels cold.'"

That was exactly how I was feeling, and it had only been six hours since my crash. When he met me that night at the emergency room, he brought with him a rare and wonderful gadget for measuring the internal pressure of the various compartments in my leg. Here's fair warning: those of you with weak stomachs should now leave the room. Since the human leg is not equipped with a schrader valve, Dr. Knapp's device uses a needle big enough to sink the USS Enterprise. Normal internal pressures range from 2mm of mercury to 10mm. When he inserted the "horse-killer" into my calf you could practically hear the weight shoot up to ring the bell and the carny guy scream, "Step right up and win a cupie doll!" My poor crunched leg had pumped up to an internal pressure of just over 60mm of mercury. The surgeon blithely said, "Steve, if I don't cut you open and relieve the pressure right now, you will lose your leg from the knee down." Apparently the unseen internal bleeding and swelling was literally killing the muscles and nerves in my lower legI was getting gangrene. Never having been interested in having my moniker become "Stumpy," I quickly agreed.

They made me a nice cocktail consisting of a potent narcotic injection and an anesthetic spinal block that cut off all feeling from my waist down. They then broke out the Ginsu kit and in less than 30 seconds, I realized why the entire surgery team was wearing plastic splash guard masks. Simply put, it was a gushing mess.

A nine-inch incision on one side of my leg was followed by a six-incher on the other side. I must have dozed through the part
where he tied off the blown artery and massaged out about a pint of black, deoxygenated blood. I came to just as he began
snapping as many as 50 staples across the gaping wound. (It was a strangely funny experience, leaning up on my elbows and see him quickly ka-chunk, ka-chunk the stainless fasteners into my new seam. When the stapler jammed, I wryly asked, "What are we going to try next, twine? Mucilage? Is Office Depot still open?" Everyone had a good laugh and he immediately ordered the anesthesiologist to knock me out again.) He later told me what he found during the surgery. "What the crash did was it slammed the post-tibial artery, which is deep in your leg, against the tibia bone. That weakened the blood vessel, and as it continued to pump blood it began to pouch out like a hose getting ready to rupture. So what happened was over the first couple hours the pain probably wasn't too bad, but when the artery ruptured, the pressure went up and the veins collapsed. At this point there is no turning back. The pressure around the vein compresses the veins and there is no way to get the blood back out of the leg. And there is nothing you can do to stop the cycle of the pressure getting higher and taking off very quickly. Besides a lot of pain in the area, you begin to have decreased sensation in the foot, in the area controlled by the nerve going through the pressurized compartment. Also, the blood supply to the muscle is compromised so that the muscle begins to die. Muscle can survive about six hours without blood supply before the damage is irreversible. And obviously, the higher the pressure the faster the muscle dies, because what can happen in elevated cases is that even the artery is unable to pump more blood and what you get is a tense, almost solid mass. That's what I found with youyou didn't have a pulse in your foot."

When I went in for my final follow-up exam, I asked him how any of us non-medical professionals are supposed to know if it's just a bruise or something far more serious. Dr. Knapp suggests the best rule of thumb (or leg, or arm) is this: "Pain normally starts off high and gets better. If it's a bruise, local first aid measures should make it feel better relatively quickly. If the pain starts to escalate after half an hour to an hour, that's when you should start thinking about seeing a physician."

But what would happen if this kind of injury happened in some remote place, like a dual sport trip through Baja? He smiled wanly and said, "That would beuhbad. Just remember that this is a time where elevation is actually worse than not elevating it, because if you elevate it the veins will collapse prematurely. So if you suspect this, you want to keep the leg nice and level. My suggestion would be get to a hospital just as quickly as possible. This is not the kind of thing you can tough out. You can't put a tourniquet on it, you can't take a couple of aspirinthe only thing to do is get to a hospital for emergency surgery because once the pain escalates, you've got about six hours or you'll lose the limb."

All told I spent a couple of days in the hospital, had about 20 physical therapy sessions and, except for the scars, am completely healed. I am very lucky and will forever be grateful to the pediatrician who diagnosed my condition and the surgeon who relieved it. As a motorcyclist, I've learned a couple of important things: don't take any crash lightly, carry good health insurance and always, always squeeze (never grab) the brake lever.

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Old 03-04-2011, 02:37 PM   #2
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Interesting stuff, I've heard of Compartment Syndrome but never knew what it was. Now that i know I think I shall avoid it!
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Old 03-04-2011, 04:55 PM   #3
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Great informative read, thanks for sharing, now I am paranoid about yet another thing that could happen to me ....
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Old 03-04-2011, 05:59 PM   #4
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Very good to know. I was especially grateful to the author to put in the section where he asked the doctor how to tell the difference between a bruise or compartment syndrome.

Lots of pain right away that goes away over time -- good(as far as injuries go! )

Not so much pain that starts to get worse after an hour. --bad!
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Old 03-05-2011, 03:42 PM   #5
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Its also called 3rd spacing. I had it, after a bad accident, my stomach was shut down. My testicles swelled like grape fruit.
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Old 03-05-2011, 06:01 PM   #6
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Emergency rooms don't always tell you about compartment syndrome, but good ones do.
The pressure meter is not rare..again all good ER's have one.

Just to restate, the first symptom of compartment syndrome is severe pain that does not go away when you take pain medicine or raise the affected area. In more severe cases, symptoms may/usually include: Decreased sensation, Pale/shiny skin, pain that gets worse, weakness, taught extremity. Usually crush injuries are usually (my experience) on the lower extremity and the lower leg will experience severe pain when moving the toes up and down.

Third spacing can happen after a crush injury or compartment syndrome, but is totally different. It is also referred to as edema. It is fluid going out into the tissues, not within muscles. People with congestive heart failure get the big swollen ankles, etc., people with liver cirrhosis/failure get ascites, people with low albumin levels can have this happen, and a lot of times after surgery it can happen. Many ways it can happen, but not the same as compartment syndrome.
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Old 03-05-2011, 09:02 PM   #7
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I had this condition post op from my total hip replacement.
The doc nicked an artery and kept telling me it would heal itself.
Two days later my thigh was the size of a basket ball and my primary doctor came to see me and how I was doing. She took one look and lost it on the hip surgeon. Took another trip upstairs to get rid of all the dead blood, they kneaded it out and to fix the leak and they added a couple of units I lost during the surgeon's lack of giving a sh**. I never experianced pain like that before ever. It literly took my breath away. Thank god for morphine. Come to find out a month later he cut some nerves as well that will never grow back together. Needless to say, he is on my permenant sh** list.
At least I still have my leg and can walk and ride. Way better than the alternatives. Live for today, tomorrow might not come.
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Old 03-07-2011, 06:07 AM   #8
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Thanks for the information. Very interesting and informative. So many of us have the "tough it out" mindset and don't think about residual damage we may be causing.
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Old 03-07-2011, 01:23 PM   #9
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This is indeed an excellent topic that is something everyone who rides should be aware of. Just to clarify a few points though. While post op hematoma can lead to compartment syndrome it is not the same thing. Nor is third spacing. Compartment syndrome denotes a specific issue when the pressure within a specific compartment exceeds the incoming blood pressure. This effectively stops the flow of blood to this space and results in ischemia to the tissue / nerves / vessels etc within this space. For this to occur you need a space that doesn't stretch well. The calf accounts for the majority of compartment syndrome because it is divided into distinct compartments enclosed in connective tissue that doesn't stretch well so it can only accommodate so much bleeding before the pressure begins to rise. Compartment syndrome can occur in other locations as well (forearm, hand, foot) but this is uncommon. Spaces that can accommodate large amounts of blood such as the abdomen don't usually compartment because by the time you get that much blood in this space, you have other problems (hemorrhagic shock). Enclosing a leg in a rigid cast functionally creates a compartment that cannot accommodate stretch and can increase the risk of compartment syndrome. This is one reason I usually prefer a non circumferential splint that will allow for some stretch as the initial immobilization device.
From a diagnostic standpoint, intra-compartment pressures are nice but often the diagnosis is based on simpler things. Think of the letter "P". Pain: this should pretty much be uniformly present unless you are insensate. the pain should be significant, out of proportion, increasing and unremitting. Paralysis: If nerves are involved you may get weakness of the muscle groups supplied by those nerves. Paresthesia: similarly you may have a loss of sensation also caused by nerve compromise. Palor: pale skin color caused by lack of blood flow. Similarly, a cold foot (or other downstream appendage) is not good.
Any blunt trauma can cause bruising or even hematoma (blood collections) of various sizes, but the above signs, particularly in the calf, require immediate attention. Ice would also be a typically good first aid step. I have never heard that elevation would be bad. In a brief informal poll of my collegues no one else had either. (Addendum : I talked with an ortho friend of mine tonight and he said his training was to leave the limb gravity neutral as elevation might decrease incoming blood flow. Again, these are all considerations in the hospital setting of compartment syndrome. In the field if I was trying to prevent increased swelling, I would still elevate my leg.)

(In the interest of disclosure, I'm a MD, board certified in Emergency Medicine and have been in full time practice since 1996)
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Old 03-07-2011, 07:25 PM   #10
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Quote:
Originally Posted by WW Ronin View Post
T
(In the interest of disclosure, I'm a MD, board certified in Emergency Medicine and have been in full time practice since 1996)
And you still own and ride motorcycles?!?!? Good to know. Thanks for the helpful explanation on Compartment Syndrome.
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Old 03-07-2011, 10:02 PM   #11
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another reason for body armor. We have lots of options for chest, and back, arms and neck, but not too much for legs, other than knee braces and shin guards. What would help in this case, where a heavy bike drops on your leg?
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Old 03-07-2011, 10:25 PM   #12
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BMW Boxer motor might have helped in this situation. Kind of leaves a space for your leg to not be as crushed.
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Old 03-08-2011, 05:56 AM   #13
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Quote:
Originally Posted by peterman View Post
another reason for body armor. We have lots of options for chest, and back, arms and neck, but not too much for legs, other than knee braces and shin guards. What would help in this case, where a heavy bike drops on your leg?

Good boots would surely help dissipate some of the energy. Even then, there is a chance you get really unlucky and something really hard comes down on your knee/thigh/etc.
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Old 02-27-2014, 10:02 AM   #14
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bump.

http://www.washingtonpost.com/lifest...y.html?hpid=z5
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Old 02-27-2014, 05:12 PM   #15
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Good bumb.
Would have missed this otherwise.
I'd love to see this item added to the first aid lessons.

Illustrates a real hazard for riders. Especially on heavier mounts.
Wisely chosen crash bars can make a difference. At least I'd prefer those over the bmw barrels.
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