key: cord-0834732-60mnq021
authors: Scollan, Joseph P.; Bertsch, Morgan L.; Flanagan, Christopher D.; Chughtai, Morad; Chepla, Kyle J.; Hoyen, Harry A.; Bafus, Blaine T.
title: Acute compartment syndrome of the deltoid: a case report and systematic review of the literature
date: 2020-09-07
journal: JSES Int
DOI: 10.1016/j.jseint.2020.07.016
sha: 43f939530737b98ddf555455e5d2491882adc6b1
doc_id: 834732
cord_uid: 60mnq021

BACKGROUND: Deltoid compartment syndrome is a rare entity. The purpose of this study was to report a recent case and perform a systematic literature review. METHODS: Patient data were gathered from chart review and clinical encounters. For the review, the MEDLINE, Embase, and Ovid databases were queried for deltoid compartment syndrome cases. Seventeen articles reporting on 18 patients with deltoid compartment syndrome were included. RESULTS: Including our patient, 9 of 19 patients (47.4%) presented with compartment syndrome limited to the deltoid. Most patients presented with additional affected compartments, most commonly in the ipsilateral arm (7 of 19, 37%). Isolated deltoid involvement often resulted from iatrogenic injury; of 10 iatrogenic reports, 8 involved only the deltoid. Of 19 cases, 5 (26%) occurred in powerlifters, climbers, or anabolic steroid or testosterone injectors. In 13 of 19 cases (68%), the patients were men aged 18-36 years, and only 1 female case (5%) was reported. Prolonged recumbence owing to substance abuse was documented in 6 of 19 cases (32%). CONCLUSION: Deltoid compartment syndrome is rare, with only 19 reported cases, including our patient. Men are more commonly affected, and isolated deltoid compartment syndrome occurs in about 50% of reported cases. More than half of cases are iatrogenic, secondary to prolonged lateral decubitus positioning, injections, and surgical interventions about the shoulder. Prolonged recumbence from intoxication is also a common etiology. Providers should be aware of and recognize deltoid compartment syndrome to facilitate urgent surgical management.

Acute compartment syndrome is an orthopedic emergency, with potentially devastating morbidity and death. Without quick recognition and appropriate decompression, the patient is likely to have severe long-term sequelae. 1 Compartment syndromes of the lower legs and forearms are well documented and are presentations with which most orthopedic surgeons and emergency providers are familiar. 19 However, compartment syndrome of the deltoid is rare and has been infrequently reported. 2 Currently, there are 18 reported cases in the literature, with only 8 having isolated deltoid involvement. 1,2,4e9,11e18,20 We recently encountered the case of a patient who had isolated compartment syndrome of the right deltoid after being found lying down for an unknown period. The purpose of this study was to (1) present the encountered case and (2) perform a systematic literature review of deltoid compartment syndrome.

For the case report, we longitudinally gathered data from chart review and clinical encounters. For the systematic review, the MEDLINE, Embase, and Ovid databases were queried from database inception to May 14, 2020, using the following search terms: (deltoid OR shoulder OR (upper arm)) AND (compartment Institutional review board approval was not required for this case report. * Corresponding author: Joseph P. Scollan, MD, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, 9500 Euclid Ave, Bldg A40, Cleveland, OH 44195, USA.

E-mail address: scollaj@ccf.org (J.P. Scollan).

j o u rn a l h o m e p a g e : w w w . j s e s i n t e r n a t i o n a l . o r g were also excluded. Finally, articles reporting on compartment syndromes of the rotator cuff muscles without deltoid involvement were excluded. Ultimately, 17 articles reporting on 18 patients with deltoid compartment syndrome were reviewed for this report by 2 authors (J.P.S. and M.C.). 1,2,4e9,11e18,20 The study-selection flow diagram is depicted in Figure 1 . chronic obstructive pulmonary disease, and bipolar disorder was brought to the emergency department by police after an extended period of lying on his right side. The patient was disoriented and was unable to provide a consistent or reliable history; therefore, it was unclear how long he had been immobilized. Chart review showed multiple admissions in previous months for alcohol, marijuana, and cocaine use, as well as suicidal ideation.

In the emergency department, the patient had hypertension (183/90 mm Hg), had tachycardia (112 beats/min), was febrile (38.3 C), and had tachypnea (34 breaths/min). Because of his hemodynamic status and confusion, a septic workup was initially undertaken by emergency physicians. This showed a normal white cell count of 10,200/mL, erythrocyte sedimentation rate of 14 mm/h, C-reactive protein level of 3.8 mg/dL, and lactate level of 1.9 mmol/ L. The test result for severe acute respiratory syndrome coronavirus 2 (obtained because of the current pandemic) was negative, and blood cultures were obtained (with no growth on final culture). Laboratory values indicated rhabdomyolysis and myoglobinuria, with a creatine kinase level of 15,131 U/L. There was no detectable serum ethanol. A shoulder radiograph demonstrated normal osseous anatomy with soft-tissue swelling (Fig. 2) . A computed tomography scan of the shoulder showed extensive soft-tissue edema of the deltoid without any focal fluid collections (Fig. 3) . The patient was determined to be in alcohol withdrawal with a score of 15 on the Clinical Institute Withdrawal Assessment of Alcohol, Revised (CIWA-Ar) scale.

The patient's orthopedic examination findings were notable for diffuse firmness in the right shoulder with a tense deltoid and tenderness to palpation. He had no pain with small arcs of motion and had equivocal pain with shoulder abduction. He had full sensation and motor function in the extremity, as well as a palpable radial pulse. Given the high index of suspicion and ambiguous examination findings owing to mental status, compartment pressures were measured using a Stryker Intra-Compartmental Pressure Monitor System (Stryker, Kalamazoo, MI, USA). This recorded absolute pressures of 45 mm Hg in the middle compartment and 45 mm Hg in the anterior compartment of the deltoid (d pressures of 50 mm Hg and 45 mm Hg, respectively). The extremity distal to the deltoid was soft and compressible. The patient was then brought to the operating room for deltoid fasciotomy.

The patient was positioned supine with a bump under the right shoulder. A 1-incision, lateral approach was performed superficially from the acromion toward the deltoid insertion on the humerus; this was approximately 15 cm in length. The subcutaneous tissue was edematous, and the underlying muscle belly was firm. The deltoid fascia was divided above the axillary nerve. The raphe and the superficial deltoid fasciae of the anterior and posterior compartments were divided. The muscle was noticeably decompressed. The wound was copiously irrigated. The muscle bellies were all able to be stimulated with electrocautery, although the inferior aspect of the deltoid appeared slightly dusky. The incision was intermittently covered with a negative-pressure wound vacuum and was reassessed in the operating room 48 hours later. The posterior compartment of the deltoid was found to be necrotic and was d ebrided, with a repeated negative-pressure wound vacuum application. The patient was again taken to the operating room 4 days later and was found to have healthy remaining muscle tissue throughout the deltoid (Fig. 4) . The incision was closed primarily at that time, and the patient was discharged home.

Deltoid compartment syndrome is a rare entity. The anatomy of the shoulder girdle decreases the risk of clinically significant swelling in the deltoid compartments. Anteromedially, the deep deltoid fascia is contiguous with the pectoralis fascia. The deltoid fascia also communicates with the infraspinatus fascia posteriorly and with the brachial fascia inferiorly. 2,3 Moreover, the fascia of the deltoid is more compliant than that of the leg and forearm and is able to tolerate more muscular swelling without compartmental pressure changes. 2,10 As such, amassing sufficient edema to cause intracompartmental pressures to reach the threshold of syndromic levels requires a severe insult. This report presents a case of isolated deltoid compartment syndrome in an obese male patient with polysubstance use who was found lying down for an unknown period and was ultimately treated with surgical intervention. His case required 3 operations, with the first to release the compartments, the second to d ebride a nonviable posterior compartment, and the third to obtain a final look and achieve primary wound closure.

In the systematic review, the selected studies demonstrated that the etiologies of deltoid compartment syndrome are varied and that patients often have multiple risk factors. Including our patient, fewer than half of reported patients presented with compartment syndrome limited to the deltoid muscle (9 of 19 patients, 47.4%). 1,4e6,11,13,17,20 In the majority of cases, patients presented with additional affected compartments, most commonly in the ipsilateral arm (7 of 19 patients, 37%) and pectoralis (2 of 19 patients, 11%) ( Table I) . This finding likely demonstrates the ability of the upperextremity fascial planes to distribute tensile forces. 3 Cases of isolated deltoid involvement were often the result of iatrogenic injury; of 10 reports with iatrogenic causes, 8 involved only the deltoid compartment. 1, 4, 6, 11, 13, 15, 17, 20 These cases included antegrade humeral intramedullary nailing, humeral intraosseous access, and multiple instances of insufficient padding in the lateral decubitus position. Previous reports have also noted that a large muscle massdespecially a rapidly expanding muscle mass owing to anabolic steroid usedis a likely risk factor for deltoid compartment syndrome. 1, 8 Our review supports this finding, as 5 cases occurred in powerlifters, professional climbers, or persons selfadministering anabolic steroid or testosterone injections. 2, 11, 14, 16, 20 In 13 of 19 cases (68%), the patients were men aged 18-36 years, and only 1 case (5%) has been reported in a female patient. 1,2,4,8,9,11e13,15,16,18,20 Her case was notable as it was caused by an expanding hematoma rather than solely muscular edema. 17 Prolonged recumbence owing to substance abuse was documented in 6 of 19 cases (32%), including our case report. 5, 8, 12, 18 As extended periods of pressure lead to tissue edema, positional dependence on the deltoid will lead to increased compartmental pressure. 12 Although the acutely treating orthopedist is incapable of preventing presentations from substance abuse, 3 included reports concerned deltoid compartment syndrome from prolonged intraoperative lateral decubitus positioning (3 of 19, 16%). 1, 5, 13 Therefore, it is imperative to properly position and pad potential pressure points during orthopedic procedures, as well as to be cognizant of operative time.

Accurately identifying deltoid compartment syndrome is crucial to timely fasciotomy. Although direct compartment pressure measurement is not necessary to diagnose compartment syndrome, in patients who are in an altered state and unable to fully participate in an examination, we recommend obtaining quantitative compartmental pressures. Absolute compartment pressures > 30 mm Hg or within 30 mm Hg of diastolic pressure are appropriate thresholds to confirm suspected compartment syndrome. 8 In patients in whom neighboring muscle compartments are also afflicted, opting for easily extensile approaches is recommended,

Middle compartment

Posterior compartment such as an anterior incision for combined deltoid and pectoralis compartment syndrome. For isolated deltoid compartment syndrome, 3 reports described 2-incision approaches. 1,4,17 A 2-incision approach may allow for easier visualization of both the deltoid raphes and the axillary nerve branches; this may facilitate avoidance of denervation of the teres minor if posterior deltoid d ebridement is required. 18 Five author groups reported a 1-incision approach, including us. 6, 11, 13, 20 With a single incision, there is no concern about the viability of a skin bridge under tension and there is a smaller defect if grafting is ultimately required. One author group used a transverse, saber-type 1-incision approach. 13 Although their patient achieved a full recovery at 1 year, a transverse incision may place the supraclavicular nerves at higher risk of transection during the approach. Ultimately, the surgeon should use the approach with which he or she is most confident of successful deltoid decompression, as this is the major determinant of patient outcomes.

This study does have limitations. It is a case report and literature review of a rare entity. As such, it is difficult to draw generalizable conclusions from only 19 reported cases. Because the cases discussed are all from small case series or reports, there are no comparison groups. The included studies all provide level IV evidence, and the treatment strategies documented are reliant on the treating surgeon's individual practice. We are unable to calculate the statistical significance of any of the proposed trends and etiologies of deltoid compartment syndrome and are unable to perform a meta-analytical assessment.

The documentation of an additional case and a review of this rare entity will provide surgeons with further treatment information if they were to encounter deltoid compartment syndrome in their practices. Further study of deltoid compartment syndrome will be reliant on future documentation of cases. The rarity of this syndrome may make it challenging to design any comparative study of outcomes based on etiologies or incision choices.

Deltoid compartment syndrome is a rare entity, with only 19 reported cases, including our patient. It most commonly presents in men, and isolated deltoid compartment syndrome occurs in about 50% of reported cases. The other half of cases appear to be varied but essentially occur after prolonged recumbence in patients who are intoxicated. Providers should be aware of and recognize deltoid compartment syndrome to facilitate urgent surgical management.

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Deltoid compartment syndrome after prolonged lateral decubitus positioning

Acute compartment syndrome of the triceps and deltoid

Anatomy of the upper extremity muscle compartments

Deltoid compartment syndrome after antegrade humeral nailing

Compartment syndrome of the deltoid: a case report of a common presentation in a rare location

Hyperperfusion syndrome of the deltoid muscle after subclavian artery angioplasty and stenting

Posterior arm and deltoid compartment syndrome after vitamin B12 injection

Ipsilateral deltoid and hand compartment syndrome: a case report and review of the literature

Compartment syndrome: effect of limb position on pressure measurement

Compartment syndrome of the upper arm

Compartment syndrome of the shoulder girdle

Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter

Deltoid compartment syndrome: a result of operative positioning

A swollen shoulder after repair of acute dissection of the aorta: an unusual presentation of a compartment syndrome

Compartment syndrome of the deltoid and pectoralis major in a young man following quetiapine use

Exercise induced compartment syndrome of the pectoralis major/deltoid in a professional tree climber

Deltoid compartment syndrome

Deltoid compartment syndrome is a surgical emergency

Diagnosis and treatment of acute extremity compartment syndrome

Deltoid compartment syndrome as a complication of lateral decubitus positioning for contralateral elbow surgery in an anabolic steroid abuser