acute compartment syndrome dr sandeep bhadoo

Acute Compartment

Syndrome

Frederick C. Schreiber, D.O.

Orthopedic Residency Director

Genesys Regional Medical Center

Definition:An increased pressure within enclosed

osteofascial space that reduces capillary per-

fusion below level necessary for tissue

viability; the underlying mechanism is:

- increased volume within space

- decreased space for contents

- combination of both

History

1881-Volkman described contracted state believed due to ischemic muscle

1884-Lesser developed clinical model

1888-Peterson felt due to nerve compromise

1906-Hildebrand coined “Volkman’s ischemic contracture”

1914-Murphy recommended fasciotomy to prevent contracture

1940-Griffiths ‘4 Ps’

1966-Seddon emphasized lower extremity

1967-Whiteside stressed 4 compartment fasciotomy

Demographics

Incidence:

Men 7.3/100,000

Women 0.7/100,000

69% due to trauma

36% fx tibia

9.8% distal radius

23% soft tissue injury without fx

10% on anticoagulants

High energy = low energy incidence

Etiology

Trauma with bleeding/swelling

Bleeding disorders

Burns

Tight wraps

Traction

Surgical positioning

Pneumatic antishock garment

Reprefusion swelling

Casting & Wraps

Casting increases pressure 3-7 times

Positioning may effect pressure

Leg best position 0-37° plantar flexion

Elevation of extremity changes A-V gradient

Traction

Pressure increases linear with increasing weight

Posterior compartment of leg most effected

1 kg added weight

5% increase in posterior compartment

<2% increase in anterior compartment

Calcaneal traction increases dorsiflexion

Positioning

Lithotomy position

Elevation of leg

Pressure on posterior compartment

Circumferential inflated devices

Wraps

Tibial Fractures

Don’t use traction

Both reamed & unreamed nails increase pressure

Low threshold for prophylactic fasciotomies

Revascularization

Long procedure

Unresponsive patient

Pathophysiology:

Increased compartment pressure leads

to increased venous pressure which

decreases A-V gradient resulting in muscle

and nerve ischemia.

Variables to Consider

Vascular tone

Blood pressure

Duration of elevated pressure

Metabolic demand of tissue

Lowered ischemic threshold of damaged muscle

Myoglobinemia

Released in high levels at reperfusion

Toxic to glomeruli

Metabolic acidosis & hperkalemia

Together lead to:

Renal failure

Cardiac arrhythmia & failure

Hypothermia

Shock

Diagnosis

History

Clinical exam: the Ps

Compartment pressures

Laboratory tests

CPK

Urine myoglobin

Clinical Diagnosis

The six ‘Ps’:

Pressure

Pain

Paresthesia

Paralysis

Pallor

Pulselessness

Pressure

Early finding

Only objective finding

Refers to palpation of compartment and its

tension or firmness

Pain

Classically out of portion to injury

Exaggerated with passive stretch of the involved

muscles in compartment

Earliest symptom but inconsistent

Not available in obtunded patient

Paresthesia

Also early sign

Peripheral nerve tissue is more sensitive than muscle

to ischemia

Permanent damage may occur in 75 minutes

Difficult to interpret

Will progress to anesthesia if pressure not

relieved

Paralysis

Very late finding

Irreversible nerve and muscle damage present

Paresis may be present early

Difficult to evaluate because of pain

Pallor & Pulselessness

Rarely present

Indicates direct damage to vessels rather than

compartment syndrome

Vascular injury may be more of contributing

factor to syndrome rather than result

Compartment Pressure

When? Confirm clinical exam

Obtunded patient with tight compartments

Regional anesthetic

Vascular injury

Technique Whiteside infusion

Stic technique: side port needle

Wick catheter

Slit catheter

*most common technique?

Whiteside Technique

Simple technique

Readily available supplies

With 18 gauge needle least accurate

More accurate if use side port needle

Slit Catheter

Developed by Rorabeck

Considered ‘gold standard’

Need the catheter

Can use the measuring unit for Stic system

Can leave indwelling for continuous monitoring

Stryker Stic System

Easy to use

Can check multiple compartments

Different areas in one compartment

Distance From Fracture Effects

Pressure

What is Critical Pressure?

>30 mm Hg as absolute number (Roraback)

>45 mm Hg as absolute number (Matsen)

<30 mm Hg for ∆p (where ∆p =diastolic pressure – compartment pressure, McQueen)

<40 mm Hg for ∆P (where ∆P mean arterial pressure* – compartment pressure, Heppenstall)

*mean arterial pressure is diastolic pressure plus 1/3 of pulse pressure

Decision Making

Fractures in Adults, 5th edition Skeletal Trauma, 3rd edition

Treatment

Lower leg to level of the heart

Remove cast

Split all dressings down to skin

Fasciotomy if continued clinical findings and/or

elevated compartment pressure

Compartments

Most common

Forearm

Leg

Other compartments

Hand

Finger

Gluteal

Thigh

Foot

Forearm

Leg Anatomy

Leg Single Incision Technique

Leg Two Incision Technique

Hand Compartments

Foot Compartments

Wound Care

Soft tissue coverage by 5-7 days

Delayed closure

Vascular loop ‘lace technique’

Split thickness skin graft

Flaps or free tissue transfer