Acute Compartment Syndrome - Medical Job Interviewmedicaljobinterview.org.uk/orthopaediceducation/books/images/pdf... · FRCSOrth.co.uk Mr Dipak Raj, Consultant Orthopaedic Surgeon,

FRCSOrth.co.uk Mr Dipak Raj, Consultant Orthopaedic Surgeon, Boston UKFRCSOrth.co.uk Mr Dipak Raj, Consultant Orthopaedic Surgeon, Boston UK

Acute Compartment Acute Compartment SyndromeSyndrome

Dipak RajDipak Raj

Consultant Orthopaedic SurgeonConsultant Orthopaedic Surgeon

Pilgrim Hospital, BostonPilgrim Hospital, Boston


Definition:An increased pressure within enclosed

osteofascial space that reduces capillary perfusion below level necessary for tissue viability; the underlying mechanism is:

increased volume within space decreased space for contents combination of both


HistoryHistory

1881-Volkman 1881-Volkman described contracted state described contracted state believed due to ischemic musclebelieved due to ischemic muscle

1884-Lesser 1884-Lesser developed clinical modeldeveloped clinical model 1888-Peterson 1888-Peterson felt due to nerve compromisefelt due to nerve compromise 1906-Hildebrand 1906-Hildebrand coined “Volkman’s ischemic coined “Volkman’s ischemic

contracture”contracture” 1914-Murphy 1914-Murphy recommended fasciotomy to recommended fasciotomy to

prevent contractureprevent contracture 1940-Griffiths 1940-Griffiths ‘4 Ps’‘4 Ps’ 1966-Seddon 1966-Seddon emphasized lower extremityemphasized lower extremity 1967-Whiteside 1967-Whiteside stressed 4 compartment stressed 4 compartment

fasciotomyfasciotomy


DemographicsDemographics

Incidence:Incidence:Men Men 7.3/100,0007.3/100,000WomenWomen 0.7/100,0000.7/100,000

69% due to trauma69% due to trauma36% fx tibia36% fx tibia9.8% distal radius9.8% distal radius23% soft tissue injury without fx23% soft tissue injury without fx

10% on anticoagulants10% on anticoagulantsHigh energy = low energy incidenceHigh energy = low energy incidence


EtiologyEtiology

Trauma with bleeding/swellingTrauma with bleeding/swellingBleeding disordersBleeding disordersBurnsBurnsTight wrapsTight wrapsTractionTractionSurgical positioningSurgical positioningPneumatic antishock garmentPneumatic antishock garmentReprefusion swellingReprefusion swelling


Casting & WrapsCasting & Wraps

Casting increases pressure 3-7 timesCasting increases pressure 3-7 timesPositioning may effect pressurePositioning may effect pressure

Leg best position 0-37° plantar flexionLeg best position 0-37° plantar flexion

Elevation of extremity changes A-V Elevation of extremity changes A-V gradientgradient


TractionTraction

Pressure increases linear with increasing Pressure increases linear with increasing weightweightPosterior compartment of leg most effectedPosterior compartment of leg most effected1 kg added weight1 kg added weight

5% increase in posterior compartment5% increase in posterior compartment<2% increase in anterior compartment<2% increase in anterior compartment

Calcaneal traction increases dorsiflexionCalcaneal traction increases dorsiflexion


PositioningPositioning

Lithotomy positionLithotomy positionElevation of legElevation of legPressure on posterior compartmentPressure on posterior compartmentCircumferential inflated devicesCircumferential inflated devicesWraps Wraps


Tibial FracturesTibial Fractures

Don’t use tractionDon’t use tractionBoth reamed & unreamed nails increase Both reamed & unreamed nails increase

pressurepressureLow threshold for prophylactic Low threshold for prophylactic

fasciotomiesfasciotomiesRevascularizationRevascularizationLong procedureLong procedureUnresponsive patientUnresponsive patient


Pathophysiology:Increased compartment pressure

leadsto increased venous pressure which decreases AV gradient resulting in muscle and nerve ischemia.


Variables to ConsiderVariables to Consider

Vascular toneVascular toneBlood pressureBlood pressureDuration of elevated pressureDuration of elevated pressureMetabolic demand of tissueMetabolic demand of tissueLowered ischemic threshold of damaged Lowered ischemic threshold of damaged

musclemuscle


MyoglobinemiaMyoglobinemia

Released in high levels at reperfusionReleased in high levels at reperfusionToxic to glomeruliToxic to glomeruliMetabolic acidosis & hperkalemiaMetabolic acidosis & hperkalemiaTogether lead to:Together lead to:

Renal failureRenal failureCardiac arrhythmia & failureCardiac arrhythmia & failureHypothermiaHypothermiaShockShock


DiagnosisDiagnosis

HistoryHistoryClinical exam:Clinical exam: the Psthe PsCompartment pressuresCompartment pressuresLaboratory testsLaboratory tests

CPKCPKUrine myoglobinUrine myoglobin


Clinical DiagnosisClinical Diagnosis

The six ‘Ps’:The six ‘Ps’:PressurePressurePainPainParesthesiaParesthesiaParalysisParalysisPallorPallorPulselessnessPulselessness


PressurePressure

Early findingEarly findingOnly objective findingOnly objective findingRefers to palpation of compartment and its Refers to palpation of compartment and its

tension or firmness tension or firmness


PainPain

Classically out of portion to injuryClassically out of portion to injuryExaggerated with passive stretch of the Exaggerated with passive stretch of the

involved muscles in compartmentinvolved muscles in compartmentEarliest symptom but inconsistentEarliest symptom but inconsistentNot available in obtunded patientNot available in obtunded patient


ParesthesiaParesthesia

Also early signAlso early signPeripheral nerve tissue is more sensitive than Peripheral nerve tissue is more sensitive than

muscle to ischemiamuscle to ischemiaPermanent damage may occur in 75 minutesPermanent damage may occur in 75 minutes

Difficult to interpretDifficult to interpretWill progress to anesthesia if pressure not Will progress to anesthesia if pressure not

relievedrelieved


ParalysisParalysis

Very late findingVery late finding Irreversible nerve and muscle damage presentIrreversible nerve and muscle damage present

Paresis may be present earlyParesis may be present earlyDifficult to evaluate because of painDifficult to evaluate because of pain


Pallor & PulselessnessPallor & Pulselessness

Rarely presentRarely present Indicates direct damage to vessels rather Indicates direct damage to vessels rather

than compartment syndromethan compartment syndromeVascular injury may be more of Vascular injury may be more of

contributing factor to syndrome rather than contributing factor to syndrome rather than resultresult


Compartment PressureCompartment Pressure

When?When? Confirm clinical examConfirm clinical exam Obtunded patient with tight compartmentsObtunded patient with tight compartments Regional anestheticRegional anesthetic Vascular injuryVascular injury

TechniqueTechnique Whiteside infusionWhiteside infusion Stic technique: side port needleStic technique: side port needle Wick catheterWick catheter Slit catheterSlit catheter

*most common technique?*most common technique?


Whiteside TechniqueWhiteside Technique

Simple techniqueSimple techniqueReadily available suppliesReadily available suppliesWith 18 gauge needle least accurateWith 18 gauge needle least accurateMore accurate if use side port needleMore accurate if use side port needle


Slit CatheterSlit Catheter

Developed by RorabeckDeveloped by RorabeckConsidered ‘gold standard’Considered ‘gold standard’Need the catheterNeed the catheterCan use the measuring unit for Stic Can use the measuring unit for Stic

systemsystemCan leave indwelling for continuous Can leave indwelling for continuous

monitoringmonitoring


Stryker Stic SystemStryker Stic System

Easy to useEasy to useCan check multiple compartmentsCan check multiple compartmentsDifferent areas in one compartmentDifferent areas in one compartment


Distance From Fracture Effects Distance From Fracture Effects PressurePressure


What is Critical Pressure?What is Critical Pressure?

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

>45 mm Hg as absolute number (Matsen)>45 mm Hg as absolute number (Matsen)<30 mm Hg for ∆p (where ∆p =diastolic <30 mm Hg for ∆p (where ∆p =diastolic

pressure – compartment pressure, pressure – compartment pressure, McQueen)McQueen)

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

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


Decision MakingDecision Making

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


TreatmentTreatment

Lower leg to level of the heartLower leg to level of the heartRemove castRemove castSplit all dressings down to skinSplit all dressings down to skinFasciotomy if continued clinical findings Fasciotomy if continued clinical findings

and/or elevated compartment pressureand/or elevated compartment pressure


CompartmentsCompartments

Most commonMost commonForearmForearmLegLeg

Other compartmentsOther compartmentsHandHandFingerFingerGluteal Gluteal ThighThighFootFoot


ForearmForearm


Leg AnatomyLeg Anatomy


Leg AnatomyLeg Anatomy


Leg Single Incision TechniqueLeg Single Incision Technique


Leg Two Incision TechniqueLeg Two Incision Technique


Hand CompartmentsHand Compartments


Hand CompartmentsHand Compartments


Foot CompartmentsFoot Compartments


Foot CompartmentsFoot Compartments


Wound CareWound Care

Soft tissue coverage by 5-7 daysSoft tissue coverage by 5-7 daysDelayed closureDelayed closure

Vascular loop ‘lace technique’Vascular loop ‘lace technique’

Split thickness skin graftSplit thickness skin graftFlaps or free tissue transferFlaps or free tissue transfer

Although specific clinical parameters reflect an early increased rate of functional recovery in association with computer-assisted minimally invasive total knee arthroplasty within the first postoperative month, the main advantage of this technique over conventional total knee arthroplasty is improved postoperative radiographic alignment without increased short-term complications.


ReferencesReferences Acute compartment syndrome WHO IS AT RISK? M. M. McQueen, P. Gaston, C. M. Court-Brown From the Royal Infirmary of Edinburgh, Scotland J Bone J Surg. VOL. 82-B, NO. 2, MARCH 2000.

ACUTE COMPARTMENT SYNDROME IN TIBIAL DIAPHYSEAL FRACTURES. M. M. MCQUEEN, J. CHRISTIE, C. M. COURT-BROWN. J Bone J Surg. VOL. 78-B, NO. 1, JANUARY 1996 95.

COMPARTMENT MONITORING IN TIBIAL FRACTURES. THE PRESSURE THRESHOLD FOR DECOMPRESSION. M. M. MCQUEEN, C. M. COURT-BROWN. J Bone J Surg. .VOL. 78-B, NO. 1, JANUARY 1996


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Acute Compartment Syndrome - Medical Job Interviewmedicaljobinterview.org.uk/orthopaediceducation/books/images/pdf... · FRCSOrth.co.uk Mr Dipak Raj, Consultant Orthopaedic Surgeon,