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Acute Compartment Syndrome. Viktoras Kubaitis 10/09/2012. Acute Compartment Syndrome. Definition A compartment syndrome is a pathological condition in which high pressure within a closed fascio - osseus space reduces capillary blood perfusion

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Acute Compartment Syndrome
  • ViktorasKubaitis 10/09/2012
slide2
Acute Compartment Syndrome

Definition

A 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.

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Acute Compartment Syndrome

Compartment can develop anywhere

  • Deltoid 1 Compartment
  • Iliacus 1
  • Upper Arm 2
  • Gluteal 3
  • Thigh 3

Forearm 4

Hand 4

Leg 4

Foot 9 comp 4 groups

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Acute Compartment Syndrome

Pathophysyology - Witeside theory

DBP - TIP = MPP

Diastolic blood pressure 60 - 70 mmHg

Tissue intramuscular = Interstitial pressure 4 – 10 mmHg

Muscle perfusion MPP = Capillary perfusion pressure SPP 25 – 30 mmHg

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Acute Compartment Syndrome

Witeside theory easier

60

30

30

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Acute Compartment Syndrome

Pathophysiology - Mechanizm

Injury causes bleeding or oedema,

Increase in intracompartmental pressure or

Decrease in compartmental size

When interstitial pressure raises higher then 30 mmHg,

Outgoing to venous system capillaries collapses

Blood flow through the capillaries stops,

Oxygen delivery to organ stops

Cells sustain Hypoxic Injury

Cells release vasoactive substances

Histamine Serotonine

Increase in permeability of endothelium

Capillaries allow continued fluid loss

Increase in interstitial pressure

Nerve conduction and blood flow slows

Myoneuralischemia

Tissue pH falls due to anaerobic metabolism

Irreversible Tissue damage - necrosis

Myoglobin release

Loss of extremity and kidneys insufficiency and loss of life

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Acute Compartment Syndrome

Aetiology

  • 1. Increased fluid content

Fracture

Big vessel injury

Inflammation

  • 2. Decreased Compartment size

Cast

Burn

Lying on a limb long time

Prolonged tourniquet time

Malpositioning during traction procedure

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Acute Compartment Syndrome
  • Aetiology – 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. 2007

www.emedicine.com/Acute Compartment Syndrome

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Acute Compartment Syndrome

Diagnosis - symptoms

Pain is disproportional and not explainable by the situation

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Acute Compartment Syndrome

Diagnosis – 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)
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Acute Compartment Syndrome

Differential diagnosis

Cellulitis

Osteomyelitis

DVT

Gas gangrene

Necrotizing fasciitis

Periferal vascular injury

Rhabdomyolysis

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Acute Compartment Syndrome
  • Possible Delayed diagnosis due to
  • 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
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Acute Compartment Syndrome
  • Laboratory tests

1. FBC

Hg (anaemia worsens ischemia)

WBC can be elevated

2. U/E

CK CreatinineKinase normal 10-186 U/l)

Myoglobin

BUN (Blood Urea Nitrogen normal 7-21 mg/dL)

Creatinine

Urea

K

GGT (Gamma Glitamyltranspeptidase)

3. Coagulation profile

4. Blood Culture/sensitivity

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Acute Compartment Syndrome
  • Compartment measurement
  • Stryker pressure monitor
  • Slit catheter
  • Wick catheter
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Acute Compartment Syndrome
  • Measurement technique
  • 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
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Acute Compartment Syndrome
  • Complications of Compartment without treatment

Muscle longstanding weakness

Ulceration

Acidosis

Hypercalemia

Rhabdomyolysis

Disabling joint contractures

DIC disseminated Intravascular Coagulation

Sepsis

Myoglobinuric renal Failure

ARDS Acute Respiratory Distress Syndrome

Loss of limb

Multiple Organ Failure MOF

Death

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Acute Compartment Syndrome

Delayed diagnosis consequences. Is it safe?

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.

Sheridan, Matsen. JBJS 1976

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Acute Compartment Syndrome
  • Concervative treatment
  • 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

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Acute Compartment Syndrome
  • Correction of Associative disorders – bouquet of flowers

Shock

Hypovolemia

Hypercalemia

Dehytradion

Renal Failure

Infection

Coagulopathy

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Acute Compartment Syndrome

Indications 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

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Acute Compartment Syndrome

Anatomy of lower leg muscles and Compartments

To learn 4 Compartments Imagine a Tractor on Podium

4

A

A

T

L

F

PD

PS

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Acute Compartment Syndrome

Anatomy of lower leg muscles

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Acute Compartment Syndrome

Anatomy of neurovascular bundles

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Acute Compartment Syndrome
  • Double Incision Fasciotomy defended by Mubarak
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Acute Compartment Syndrome
  • Single Incision Fasciotomyinovated by Matsen
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Acute Compartment Syndrome
  • Postoperative care after fasciotomy

Bulky dressings to promote oedema reduction

Extremity elevation

Skin graft when oedema resolved if needed

STSG Split Thickness Skin Graft

Delayed Primary Closure with relaxing incisions

Active movements of joints to prevent stiffness

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Acute Compartment Syndrome
  • Complications after Fasciotomies

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 PlastSurg 2000

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Acute Compartment Syndrome
  • Summary

High index of suspicion remains the cornerstone of diagnosis ACS

Treat as soon as you suspect ACS

ICP measurement gives additional information

ACS is a clinical diagnosis

If ACS is clinically evident, do not measure pressures

In doubt, cut!

Avoid delays in management

Fasciotomy is

reliable, safe and effective

the only treatment for compartment syndrome

when performed in time

ad