Acute Compartment Syndrome-Apichat Kaewdech

8/2/2019 Acute Compartment Syndrome-Apichat Kaewdech

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APICHAT KAEWDECH

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Rockwood And Green's Fractures In Adults, 7thEdition ,2010

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An increased pressure within enclosed

osteofascial space that reduces capillary perfusionbelow level necessary for tissue viability;

the underlying mechanism is : increased volume within space

decreased space for contents

combination of both

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Exertional compartment syndrome

An elevation of intercompartment

pressure during exercise, causing ischemia, pain,

and rarely neurological symptoms and signs. Volkmanns ischemic contracture

The end stage of neglected ACS withirreversible muscle necrosis leading to ischemic

contractures.


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Crush syndromeThe systemic result of muscle necrosis

commonly caused by prolonged externalcompression of an extremity.


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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

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The annual age- and gender-specific incidence

of acute compartment syndrome. 7


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The annual age specific incidence of all distal radius fractures compared with the

annual age specific incidence of acute compartment syndrome in distal radialfractures.


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Conditions Associated with Injury Causing Acute Compartment SyndromePresenting to an Orthopaedic Trauma Unit 9


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Critical closing pressure theory TM = TC r

AV gradient theory

the increases in local tissue pressure reduce thelocal arteriovenous pressure gradient and thusreduce blood flow.

LBF = Pa - Pv R

Microvascular occlusion theory


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Skeletal muscle is the tissue in the extremities mostvulnerable to ischemia and is therefore the mostimportant tissue to be considered in acutecompartment syndrome.

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The mechanism of damage to nerve is as yet uncertainand could result from ischemia, ischemia pluscompression, toxic effects, or the effects of acidosis.

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Nonunion

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The reperfusion syndrome is a group of complicationsfollowing reestablishment of blood flow to ischemictissues and can occur after fasciotomy and restorationof muscle blood flow in the acute compartment

syndrome.

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History

Clinical exam: the Ps

Compartment pressures

Laboratory tests CPK

Urine myoglobin

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The six Ps: Pressure

Pain

Paresthesia

Paralysis

Pallor

Pulselessness

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Early finding

Only objective finding

Refers to palpation of compartment and its tension or

firmness

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Classically out of portion to injury

Exaggerated with passive stretch of the involvedmuscles in compartment

Earliest symptom but inconsistent Not available in obtunded patient

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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

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Very late finding Irreversible nerve and muscle damage present

Paresis may be present early Difficult to evaluate because of pain

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Rarely present

Indicates direct damage to vessels rather thancompartment syndrome

Vascular injury may be more of contributing factor tosyndrome rather than result

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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?

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Simple technique

Readily available supplies

With 18 gauge needle least accurate

More accurate if use side port needle

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Developed by Rorabeck

Considered gold standard

Need the catheter

Can use the measuring unit for Stic system Can leave indwelling for continuous monitoring

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Easy to use

Can check multiple compartments

Different areas in one compartment

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>30 mm Hg as absolute number (Roraback) >45 mm Hg as absolute number (Matsen)


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Most common Forearm Leg

Other compartments Hand Finger Gluteal Thigh

Foot

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Fasciotomy of the forearm in a case of crush syndrome.There is necrosis of the forearm flexors proximally. The

carpal tunnel has been decompressed. 32


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Fasciotomy of the anterior and lateral compartments of theleg. Note that the incision extends the whole length of themuscle compartment, allowing inspection of all muscle

groups. 36


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Decompression of the medial side of the leg. Thesuperficial posterior compartment is being retracted todisplay the deep compartment. The scissors are deep to

the fascia overlying the deep posterior compartment. 37


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Fasciotomy of the thigh through a single lateral incision43


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Lower leg to level of the heart Remove cast

Split all dressings down to skin

Fasciotomy if continued clinical findings and/orelevated compartment pressure

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The basic principle of fasciotomy of any compartmentis full and adequate decompression.

Skin incisions must be made along the full length ofthe affected compartment.

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The wounds should be left open and dressed, and atapproximately 48 hours after fasciotomya secondlook procedure should be undertaken to ensureviability of all muscle groups.

The recent introduction of vacuum assisted closure(VAC) systems is likely to be a significant advantage inthis area and may reduce the need for split skingrafting, with a low complication rate

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Delay to fasciotomy of more than 6 hours is likely tocause significant sequelae, including musclecontractures, muscle weakness, sensory loss, infection,and nonunion of fractures

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Early diagnosis of acute compartment syndrome isessential, and it is important to be aware of thepatients at risk for acute compartment syndrome.

Good clinical examination techniques in the alertpatient will help to identify the compartments at risk.

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Acute Compartment Syndrome-Apichat Kaewdech