Lesson of the Week: Crush syndrome following unconsciousness: need for urgent orthopaedic referral

Abstract

The acute compartment syndrome occurs when increased pressure within osteofascial compartments results in local muscle ischaemia. If left untreated it may lead to muscle necrosis and contractures. The systemic manifestations of this - the crush syndrome - are the results of haemodynamic and metabolic disburbances and acute renal failure.1 Failure to appreciate the importance of muscle necrosis as the underlying problem in the crush syndrome may have disastrous consequences. The crush syndrome was originally described during the London Blitz in civilians who had been buried beneath the debris of destroyed houses.2 Nowadays, victims are typically encountered in war zones, in mining disasters, after earthquakes, and in industrial or road traffic accidents.3 The syndrome may also develop after isolated compression of arms or legs by the victim's own body - for example, during unconsciousness after a drug overdose.1 Such patients often delay seeking medical attention or have other more apparent complications that need urgent attention. The local signs of muscle compression and necrosis may therefore initially be overlooked. We describe 11 such cases referred to our unit over 51 months. During April 1989 to July 1993, 11 patients were admitted to this infirmary with the crush syndrome secondary to a drug overdose. They were all referred for orthopaedic assessment after a considerable delay - mean 35 hours (table). Nine patients were men. The mean age was 31 years (range 20-54 years). As all the patients had been unconscious for an unknown length of time before presentation, the delay from time of injury until medical attention was given could not always be assessed. Four patients were unconscious on admission. Ten patients had taken an overdose of sedatives or painkillers, and one patient had carbon monoxide poisoning. During the period of unconsciousness their torso had compressed one or more …