Acute Compartment Syndrome

Viktoras Kubaitis 10/09/2012

Acute Compartment SyndromeDefinitionA compartment syndrome is a pathological condition in which high pressure within a closed fascio - osseus space reduces capillary blood perfusion below a level necessary for tissue viability,That requires urgent surgical release to prevent muscle necrosis and contractures.

Acute Compartment Syndrome

Deltoid 1 CompartmentIliacus 1

Upper Arm 2

Gluteal 3 Thigh 3 Forearm 4Hand 4Leg 4

Foot 9 comp 4 groups

Compartment can develop anywhere

Acute Compartment SyndromePathophysyology - Witeside theory

DBP - TIP = MPP

Diastolic blood pressure 60 - 70 mmHgTissue intramuscular = Interstitial pressure 4 – 10 mmHgMuscle perfusion MPP = Capillary perfusion pressure SPP 25 – 30 mmHg

Acute Compartment SyndromeWiteside theory easier

60

30 30

Acute Compartment SyndromePathophysiology - Mechanizm

Injury causes bleeding or oedema,Increase in intracompartmental pressure orDecrease in compartmental sizeWhen interstitial pressure raises higher then 30 mmHg, Outgoing to venous system capillaries collapsesBlood flow through the capillaries stops,Oxygen delivery to organ stopsCells sustain Hypoxic InjuryCells release vasoactive substancesHistamine SerotonineIncrease in permeability of endotheliumCapillaries allow continued fluid lossIncrease in interstitial pressureNerve conduction and blood flow slowsMyoneural ischemiaTissue pH falls due to anaerobic metabolismIrreversible Tissue damage - necrosisMyoglobin releaseLoss of extremity and kidneys insufficiency and loss of life

Acute Compartment SyndromeAetiology

1. Increased fluid contentFractureBig vessel injuryInflammation

2. Decreased Compartment sizeCastBurnLying on a limb long timeProlonged tourniquet timeMalpositioning during traction procedure

Acute Compartment SyndromeAetiology – Demographics

36-45 % tibial shaft (open/closed)

23% soft tissue injury without fracture

19% isolated vascular injury

10% on anticoagulants

High energy = low energy

European journal of trauma & emergency surgery. 2007, MC queen & al. 2007www.emedicine.com/Acute Compartment Syndrome

Acute Compartment Syndrome

Pain is disproportional and not explainable by the situation

Diagnosis - symptoms

Acute Compartment SyndromeDiagnosis – the 7 P

•Pain out to proportion to the injury•Pain on passive movement•Palpably tight compartment•Paraesthesia•Palor•Paralysis•Pulseless (a pulse is not issue)

Acute Compartment SyndromeDifferential diagnosis

CellulitisOsteomyelitisDVTGas gangreneNecrotizing fasciitisPeriferal vascular injuryRhabdomyolysis

Acute Compartment Syndrome

•children are unable to verbalize feelings •Patients with multiple injuries•Unconscious patients•Drug abuse•Continuous epidural/spinal anaesthesia•Altered neurological function in a past•Vascular injuries in a past

Possible Delayed diagnosis due to

Acute Compartment Syndrome

1. FBCHg (anaemia worsens ischemia)WBC can be elevated

2. U/E CK Creatinine Kinase normal 10-186 U/l)MyoglobinBUN (Blood Urea Nitrogen normal 7-21

mg/dL) Creatinine

UreaKGGT (Gamma Glitamyl transpeptidase)

3. Coagulation profile4. Blood Culture/sensitivity

Laboratory tests

Acute Compartment Syndrome

•Stryker pressure monitor

•Slit catheter

•Wick catheter

Compartment measurement

Acute Compartment Syndrome

•Should be taken on maximal swelling site•Patient in a comfortable position•Assemble the system•Zero the system•45 degrees angle•Subfascial catheter needle tip insertion•Get the reading in mmHg

Measurement technique

Acute Compartment Syndrome

Muscle longstanding weaknessUlcerationAcidosisHypercalemiaRhabdomyolysisDisabling joint contracturesDIC disseminated Intravascular Coagulation SepsisMyoglobinuric renal FailureARDS Acute Respiratory Distress SyndromeLoss of limbMultiple Organ Failure MOFDeath

Complications of Compartment without treatment

Acute Compartment SyndromeDelayed diagnosis consequences. Is it safe?

Infection rate of 46% andAmputation rate of 21% after a delay of 12 hours

4.5% complications for early fasciotomies and54% for delayed ones.

Sheridan, Matsen. JBJS 1976

Acute Compartment Syndrome

•Circular Cast and dressings down•Treat systemic hypotension/shock•Do not elevate the affected extremity.•Additional oxygen should be administered•Hyperbaric oxygen•Vascular surgeon review•Correction of Coagulopathy•Antivenin•Mannitol

Mannitol treatment for acute compartment syndrome. Nephron. Aug. 1998; 79(4):4923

Concervative treatment

Acute Compartment Syndrome

ShockHypovolemiaHypercalemiaDehytradionRenal FailureInfectionCoagulopathy

Correction of Associative disorders – bouquet of flowers

Acute Compartment SyndromeIndications for fasciotomy

1. When tissue pressure rises more than 30 mm Hg

2. When a difference between diastolic pressure and measured tissue pressure is 30 mm Hg or less

3. Clinically confirmed ACS

Acute Compartment SyndromeAnatomy of lower leg muscles and Compartments

ATF

To learn 4 Compartments Imagine a Tractor on Podium

A

PDL

PS

4

Acute Compartment SyndromeAnatomy of lower leg muscles

Acute Compartment SyndromeAnatomy of neurovascular bundles

Acute Compartment SyndromeDouble Incision Fasciotomy defended by Mubarak

Acute Compartment SyndromeSingle Incision Fasciotomy inovated by Matsen

Acute Compartment Syndrome

Bulky dressings to promote oedema reductionExtremity elevationSkin graft when oedema resolved if neededSTSG Split Thickness Skin GraftDelayed Primary Closure with relaxing incisionsActive movements of joints to prevent stiffness

Postoperative care after fasciotomy

Acute Compartment Syndrome

Altered sensation within the margins of the wound 77%Dry, scaly skin 40%Pruritus 33%Discoloured wounds 30%Swollen limbs 25%Tethered scars 26%Recurrent ulceration 13%Muscle herniation 13%Pain related to the wound 10%Tethered tendons 7%Fitzgerald, McQueen Br J Plast Surg 2000

Complications after Fasciotomies

Acute Compartment Syndrome

High index of suspicion remains the cornerstone of diagnosis ACSTreat as soon as you suspect ACSICP measurement gives additional informationACS is a clinical diagnosisIf ACS is clinically evident, do not measure pressuresIn doubt, cut!Avoid delays in management

Fasciotomy is reliable, safe and effective the only treatment for compartment syndrome when performed in time

Summary