Compartment syndrome
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Compartment Syndrome. T. Toan Le, MD and Sameh Arebi, MD Original Author: Robert M. Harris, MD; Created March 2004 New Authors: T. Toan Le, MD and Sameh Arebi, MD; Revised December 2005. Compartment Syndrome.

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Compartment syndrome

Compartment Syndrome

T. Toan Le, MD and Sameh Arebi, MD

Original Author: Robert M. Harris, MD; Created March 2004

New Authors: T. Toan Le, MD and Sameh Arebi, MD; Revised December 2005


Compartment syndrome1

Compartment Syndrome

A condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space.


Compartment syndrome definition

Compartment SyndromeDefinition

  • Elevated tissue pressure within a closed fascial space

  • Reduces tissue perfusion - ischemia

  • Results in cell death - necrosis

  • True Orthopaedic Emergency


History

History

  • Volkmann 1881

  • Richard von Volkmann published an article in which he attempted to describe the condition of irreversible contractures of the flexor muscles of the hand to ischemic processes occurring in the forearm

  • Application of restrictive dressing to an injured limb


History1

History

  • Hildebrand 1906

  • First used the term Volkmann ischemic contracture to describe the final result of any untreated compartment syndrome, and was the first to suggest that elevated tissue pressure may be related to ischemic contracture.


History2

History

  • Thomas 1909

  • Reviewed the 112 published cases of Volkmann ischemic contracture and found fractures to be the predominant cause. Also, noted that tight bandages, an arterial embolus, or arterial insufficiency could also lead to the problem


History3

History

  • Murphy 1914

  • First to suggest that fasciotomy might prevent the contracture. Also, suggested that tissue pressure and fasciotomy were related to the development of contracture


History4

History

  • Ellis 1958

  • Reported a 2% incidence of compartment syndrome with tibia fractures, and increased attention was paid to contractures involving the lower extremities


History5

History

  • Seddon, Kelly, and Whitesides 1967

  • Demonstrated the existence of 4 compartments in the leg and to the need to decompress more than just the anterior compartment. Since then, compartment syndrome has been shown to affect many areas of the body, including the hand, foot, thigh, and buttocks


Compartment syndrome etiology

Compartment SyndromeEtiology

Compartment Size

  • tight dressing;Bandage/Cast

  • localised external pressure;lying on limb

  • Closure of fascial defects

    Compartment Content

  • Bleeding; Fx, vas inj, bleeding disorders

  • Capillary Permeability;

    • Ischemia / Trauma / Burns / Exercise / Snake Bite / Drug Injection / IVF


Compartment syndrome etiology1

Fractures-closed and open

Blunt trauma

Temp vascular occlusion

Cast/dressing

Closure of fascial defects

Burns/electrical

Exertional states

GSW

IV/A-lines

Hemophiliac/coag

Intraosseous IV(infant)

Snake bite

Arterial injury

Compartment SyndromeEtiology


Fracture

Fracture

  • The most common cause

  • incidence of accompanying compartment syndrome of 9.1%

  • The incidence is directly proportional to the degree of injury to soft tissue and bone

  • occurred most often in association with a comminuted, grade-III open injury to a pedestrian

Blick et al JBJS 1986


Blunt trauma

Blunt Trauma

  • 2nd most common cause

  • About 23% of CS

  • 25% due to direct blow

McQueen et al; JBJS Br 2000


Incidence

Incidence

  • McQueen et al; JBJS Br 2000

  • 164 pts with CS, 149 male, 15 female

  • Most pts were usually under 35

  • 69% with associated fx, about half were tibial shaft

  • 23% soft tissue injury without fx

  • Ranges of 2-12% have been published


Incidence1

Incidence

McQueen et al; JBJS Br 2000


Patient positioning

Patient positioning

Meyer, Mubarak JBJS 2002


Patient positioning1

Patient Positioning

  • Leaving the calf free when the leg is placed in the hemilithotomy position instead of using a standard well-leg holder

  • Increases the difference between the diastolic blood pressure and the intramuscular pressure

  • May decrease the risk of compartment syndrome

Meyer, Mubarak JBJS 2002


Compartment syndrome pathophysiology

Compartment SyndromePathophysiology

  • Normal tissue pressure

    • 0-4 mm Hg

    • 8-10 with exertion

  • Absolute pressure theory

    • 30 mm Hg - Mubarak

    • 45 mm Hg - Matsen

  • Pressure gradient theory

    • < 20 mm Hg of diastolic pressure – Whitesides

    • McQueen, et al


Compartment syndrome tissue survival

Compartment SyndromeTissue Survival

  • Muscle

    • 3-4 hours - reversible changes

    • 6 hours - variable damage

    • 8 hours - irreversible changes

  • Nerve

    • 2 hours - looses nerve conduction

    • 4 hours - neuropraxia

    • 8 hours - irreversible changes


Compartment syndrome diagnosis

Compartment SyndromeDiagnosis

  • Pain out of proportion

  • Palpably tense compartment

  • Pain with passive stretch

  • Paresthesia/hypoesthesia

  • Paralysis

  • Pulselessness/pallor


Clinical evaluation

Clinical Evaluation

“Pain and the aggravation of pain by passive stretching of the muscles in the compartment in question are the most sensitive (and generally the only) clinical finding before the onset of ischemic dysfunction in the nerves and muscles.”

Whitesides AAOS 1996


Clinical evaluation1

Clinical Evaluation

  • Pain – most important. Especially pain out of proportion to the injury (child becoming more and more restless /needing more analgesia)

  • Most reliable signs are pain on passive stretching and pain on palpation of the involved compartment

  • Other features like pallor, pulselessness, paralysis, paraesthesia etc. appear very late and we should not wait for these things.

Willis &Rorabeck OCNA 1990


Clinical evaluation2

Clinical Evaluation

  • Beware of epidural analgesia

    • Strecker JBJS 1986

    • Morrow J. Trauma 1994

  • Beware long acting nerve blocks

    • Hyder JBJS Br 1995

  • Beware controlled intravenous opiate analgesia


  • Compartment syndrome differential diagnosis

    Compartment SyndromeDifferential Diagnosis

    • Arterial occlusion

    • Peripheral nerve injury

    • Muscle rupture


    Compartment syndrome pressure measurements

    Compartment SyndromePressure Measurements

    • Suspected compartment syndrome

    • Equivocal or unreliable exam

    • Clinical adjunct

    • Contraindication

      • Clinically evident compartment syndrome


    Compartment syndrome pressure measurements1

    Infusion

    manometer

    saline

    3-way stopcock

    (Whitesides, CORR 1975)

    Catheter

    wick

    slit wick

    Arterial line

    16 - 18 ga. Needle

    (5-19 mm Hg higher)

    transducer

    monitor

    Stryker device

    Side port needle

    Compartment SyndromePressure Measurements


    Compartment syndrome pressure measurements2

    Compartment SyndromePressure Measurements

    • Arterial line

      • Zero at the level of the affected limb


    Compartment syndrome pressure measurements3

    Compartment SyndromePressure Measurements

    • Simple Needle

      • 18 gauge

      • Least accurate

      • Usually gives falsely higher reading

    • Slit Catheter and Side ported needle

      • No significant difference

      • More accurate

    Side port

    Moed et al JBJS 1993


    Compartment syndrome pressure measurements4

    Compartment SyndromePressure Measurements

    • Measurements must be made in all compartments

    • Anterior and deep posterior are usually highest

    • Measurement made within 5 cm of fx

    • Marginal readings must be followed with repeat physical exam and repeat compartment pressure measurement

    Heckman, WhitesidesJBJS 1994


    Suspected compartment syndrome

    Unequivocal + Findings

    FASCIOTOMY

    Pt. not alert/polytrauma/inconc.

    Comp. pressure measurement

    w/i 30 mm Hg >30 mm Hg of DBP

    Serial exams

    FASCIOTOMY

    SUSPECTED COMPARTMENT SYNDROME

    McQueen JBJSB 1996


    Threshold for fasciotomy

    Threshold for fasciotomy

    • McQueen, Court-Brown JBJS Br 1996

    • 116 pts with tibial diaphyseal fx had continuous monitoring of anterior compartment pressure for 24 hours

      • 53 pts had ICP over 30 mmHg

      • 30 pts had ICP over 40 mmHg

      • 4 pts had ICP over 50 mmHg

    • Only 3 had delta pr(DBP-ICP) of < 30, they had fasciotomy

    • None of the patients had any sequelae of the compartment syndrome

    • Decompression should be performed if the differential pressure level drops to under 30 mmHg


    Medical management

    Medical Management

    • Ensure patient is normotensive ,as hypotension reduces prefusion pressure and facilitates further tissue injury.

    • Remove cicumferential bandages and cast

    • Maintain the limb at level of the heart as elevation reduces the arterial inflow and the arterio-venous pressure gradient on which perfusion depends.

    • Perfusion pressure = A pr(30-35mmHg) – V pr(10-15mmHg)

    • Supplemental oxygen administration.


    Medical management1

    Medical Management

    • Compartmental pressure falls by 30% when cast is split on one side

    • Falls by 65% when the cast is spread after splitting.

    • Splitting the padding reduces it by a further 10% and complete removal of cast by another 15%

    • Total of 85-90% reduction by just taking off the plaster!

    Garfin, Mubarak JBJS 1981


    Compartment syndrome emergent treatment

    Compartment SyndromeEmergent Treatment

    • Remove cast or dressing

    • Place at level of heart

      (DO NOT ELEVATE to optimize perfusion)

    • Alert OR and Anesthesia

    • Bedside procedure

    • Medical treatment


    Surgical treatment

    Surgical Treatment

    • Fasciotomy, Fasciotomy, Fasciotomy,

      • All compartments !!!


    Compartment syndrome surgical treatment

    Compartment SyndromeSurgical Treatment

    • Fasciotomy - prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma.

    • Fracture care – stabilization

      • Ex-fix

      • IM Nail


    Compartment syndrome indications for fasciotomy

    Compartment SyndromeIndications for Fasciotomy

    • Unequivocal clinical findings

    • Pressure within 15-20 mm hg of DBP

    • Rising tissue pressure

    • Significant tissue injury or high risk pt

    • > 6 hours of total limb ischemia

    • Injury at high risk of compartment syndrome

    • CONTRAINDICATION - Missed compartment syndrome (>24-48 hrs)


    Fasciotomy principles

    Fasciotomy Principles

    • Make early diagnosis

    • Long extensile incisions

    • Release all fascial compartments

    • Preserve neurovascular structures

    • Debride necrotic tissues

    • Coverage within 7-10 days


    Compartment syndrome lower leg

    Compartment SyndromeLower Leg

    • 4 compartments

      • Lateral: Peroneus longus and brevis

      • Anterior: EHL, EDC, Tibialis anterior, Peroneus tertius

      • Supeficial posterior-Gastrocnemius, Soleus

      • Deep posterior-Tibialis posterior, FHL, FDL

    • .


    Single incision

    Single Incision

    • Perifibular Fasciotomy

      • Matsen et al (1980)

      • Single incision just posterior to fibula

      • Common peroneal nerve


    Double incision

    Double Incision

    • In most instances it affords better exposure of the four compartments

    • 2 vertical incisions separated by minimum 8 cm

    • One incision over anterior and lateral compartments

      • Superficial peroneal nerve

  • One incision located 1-2 cm behind postero-medial aspect of tibia

    • Saphenous nerve and vein

  • Mubarak et al JBJS 1977


    Fasciotomy medial leg

    Fasciotomy: Medial Leg

    Gastroc-soleus

    Flexor digitorum

    longus


    Fasciotomy lateral leg

    Fasciotomy: Lateral Leg

    Intermuscular septum

    Superficial peroneal nerve


    Look for superficial peroneal nerve

    Look for Superficial Peroneal Nerve

    • superficial peroneal nerve exits from lateral compartment about 10 cm above lateral malleolus and courses into the anterior compartment

    • Risk of injury


    Use a generous incision

    Use a Generous Incision

    • Lengthening the skin incisions to an average of 16 cm decreases intracompartmental pressures significantly.

    • The skin envelope is a contributing factor in acute compartment syndromes of the leg and The use of generous skin incisions is supported

    Cohen, Mubarak JBJS Br 1991


    Compartment syndrome forearm

    Compartment SyndromeForearm

    • Anatomy-3 compartments

      • Mobile wad-BR,ECRL,ECRB

      • Volar-Superficial and deep flexors

      • Dorsal-Extensors

      • Pronator quadratus described as a separate compartment


    Forearm fasciotomy

    Forearm Fasciotomy

    • Volar-Henry approach

      • Include a carpal tunnel release

    • Release lacertus fibrosus and fascia

    • Protect median nerve, brachial artery and tendons after release


    Forearm fasciotomy1

    Forearm Fasciotomy

    • Protect median nerve, brachial artery and tendons after release

    • Consider dorsal release


    Compartment syndrome foot

    Compartment SyndromeFoot

    • 9 compartments

      • Medial, Superficial, Lateral, Calcaneal

      • Interossei(4), Adductor

    • Careful exam with any swelling

    • Clinical suspicion with certain mechanisms of injury

      • Lisfranc fracture dislocation

      • Calcaneus fracture


    Compartment syndrome foot1

    Compartment SyndromeFoot

    • Dorsal incision-to release the interosseous and adductor

    • Medial incision-to release the medial, superficial lateral and calcaneal compartments


    Compartment syndrome hand

    Compartment SyndromeHand

    • non specific aching of the hand

    • disproportionate pain

    • loss of digital motion & continued swelling

      • MP extension and PIP flexion

    • difficult to measure tissue pressure


    Fasciotomy of hand

    Fasciotomy of Hand

    • 10 separate osteofascial compartments

      • dorsal interossei (4)

      • palmar interossei (3)

      • thenar and hypothenar (2)

      • adductor pollicis (1)


    Compartment syndrome thigh

    Compartment SyndromeThigh

    • Lateral to release anterior and posterior compartments

    • May require medial incision for adductor compartment

    Vastus lateralis

    Lateral septum


    Compartment syndrome other areas

    Compartment SyndromeOther Areas

    • Can occur anywhere in the body

    • Hand-dorsal incisions, thenar, hypothenar

    • Arm-lateral incision

    • Buttock-posterior (Kocher) approach

    • Abdominal- with the Trauma surgeons


    Delayed fasciotomy is it safe

    Delayed FasciotomyIs it Safe?

    • Sheridan, Matsen.JBJS 1976

      • infection rate of 46% and amputation rate of 21% after a delay of 12 hours

      • 4.5 % complications for early fasciotomies and 54% for delayed ones

    • Recommendations

      • If the CS has existed for more than 8-10 hrs, supportive treatment of acute renal failure should be considered.

      • Skin is left intact and late reconstructions maybe planned.


    Delayed fasciotomy is it safe1

    Delayed FasciotomyIs it Safe?

    • Finkelstein et al. J Trauma 1996

      • 5 pts, nine fasciotomies in lower limbs

      • Avg delay 56 h. (35-96 hrs).

      • 1 pt died of septicaemia and multi organ failure, the others required amputations

    • Recommendations:

      • In delayed cases, routine fasciotomy may not be successful


    Wound management

    Wound Management

    • After the fasciotomy, a bulky compression dressing and a splint are applied.

    • “VAC” (Vacuum Assisted Closure) can be used

    • Foot should be placed in neutral to prevent equinus contracture.

    • Incision for the fasciotomy usually can be closed after three to five days


    Interim coverage techniques

    Interim Coverage Techniques

    • Simple absorbent dressing

    • Semipermeable skin-like membrane

    • Vessel loop “bootlace”

    • “VAC” (Vacuum Assisted Closure)


    Wound management1

    Wound Management

    • Wound is not closed at initial surgery

    • Second look debridement with consideration for coverage after 48-72 hrs

      • Limb should not be at risk for further swelling

      • Pt should be adequately stabilized

      • Usually requires skin graft

      • DPC possible if residual swelling is minimal

      • Flap coverage needed if nerves, vessels, or bone exposed

    • Goal is to obtain definitive coverage within 7-10 days


    Wound closure

    Wound Closure

    • STSG

    • Delayed primary closure with relaxing incisions


    Complications related to fasciotomies

    Complications Related to Fasciotomies

    • Altered sensation within the margins of the wound (77%)

    • Dry, scaly skin (40%)

    • Pruritus (33%)

    • Discolored 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 related to cs

    Complications related to CS

    • Late Sequelae

      • Volckmann’s contracture

      • Weak dorsiflexors

      • Claw toes

      • Sensory loss

      • Chronic pain

      • Amputation


    Medical legal pitfalls

    Medical/Legal Pitfalls

    • Most frequent cause of litigation

    • In 1993, Templeman reported an average litigation award of $280,000 for 8 cases of missed CS.

    • In all 8 cases, compartment pressures were never measured.

    • Failure to consider potential errors in compartment pressure measurements

      • Equipment errors occur, and needles are misplaced into tendons, fascia, or a wrong compartment.

      • Interpret all pressure readings within the context of the clinical presentation.


    Summary

    Summary

    • Keep a high index of suspicion

    • Treat as soon as you suspect CS

    • If clinically evident, do not measure

    • Fasciotomy

      • Reliable, safe, and effective

      • The only treatment for compartment syndrome, when performed in time


    Questions

    Questions

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