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Acute compartment syndrome DR SANDEEP BHADOO
- 1. Acute Compartment Syndrome Frederick C. Schreiber, D.O. Orthopedic Residency Director Genesys Regional Medical Center
- 2. Definition: An increased pressure within enclosed osteofascial space that reduces capillary per- fusion below level necessary for tissue viability; the underlying mechanism is: - increased volume within space - decreased space for contents - combination of both
- 3. History 1881-Volkman described contracted state believed due to ischemic muscle 1884-Lesser developed clinical model 1888-Peterson felt due to nerve compromise 1906-Hildebrand coined “Volkman’s ischemic contracture” 1914-Murphy recommended fasciotomy to prevent contracture 1940-Griffiths ‘4 Ps’ 1966-Seddon emphasized lower extremity 1967-Whiteside stressed 4 compartment fasciotomy
- 4. Demographics 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 High energy = low energy incidence
- 5. Etiology Trauma with bleeding/swelling Bleeding disorders Burns Tight wraps Traction Surgical positioning Pneumatic antishock garment Reprefusion swelling
- 6. Casting & Wraps Casting increases pressure 3-7 times Positioning may effect pressure Leg best position 0-37° plantar flexion Elevation of extremity changes A-V gradient
- 7. Traction Pressure increases linear with increasing weight Posterior compartment of leg most effected 1 kg added weight 5% increase in posterior compartment <2% increase in anterior compartment Calcaneal traction increases dorsiflexion
- 8. Positioning Lithotomy position Elevation of leg Pressure on posterior compartment Circumferential inflated devices Wraps
- 9. Tibial Fractures Don’t use traction Both reamed & unreamed nails increase pressure Low threshold for prophylactic fasciotomies Revascularization Long procedure Unresponsive patient
- 10. Pathophysiology: Increased compartment pressure leads to increased venous pressure which decreases A-V gradient resulting in muscle and nerve ischemia.
- 11. Variables to Consider Vascular tone Blood pressure Duration of elevated pressure Metabolic demand of tissue Lowered ischemic threshold of damaged muscle
- 12. Myoglobinemia Released in high levels at reperfusion Toxic to glomeruli Metabolic acidosis & hperkalemia Together lead to: Renal failure Cardiac arrhythmia & failure Hypothermia Shock
- 13. Diagnosis History Clinical exam: the Ps Compartment pressures Laboratory tests CPK Urine myoglobin
- 14. Clinical Diagnosis The six ‘Ps’: Pressure Pain Paresthesia Paralysis Pallor Pulselessness
- 15. Pressure Early finding Only objective finding Refers to palpation of compartment and its tension or firmness
- 16. Pain Classically out of portion to injury Exaggerated with passive stretch of the involved muscles in compartment Earliest symptom but inconsistent Not available in obtunded patient
- 17. Paresthesia 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
- 18. Paralysis Very late finding Irreversible nerve and muscle damage present Paresis may be present early Difficult to evaluate because of pain
- 19. Pallor & Pulselessness Rarely present Indicates direct damage to vessels rather than compartment syndrome Vascular injury may be more of contributing factor to syndrome rather than result
- 20. Compartment Pressure 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?
- 21. Whiteside Technique Simple technique Readily available supplies With 18 gauge needle least accurate More accurate if use side port needle
- 22. Slit Catheter Developed by Rorabeck Considered ‘gold standard’ Need the catheter Can use the measuring unit for Stic system Can leave indwelling for continuous monitoring
- 23. Stryker Stic System Easy to use Can check multiple compartments Different areas in one compartment
- 24. Distance From Fracture Effects Pressure
- 25. What is Critical Pressure? >30 mm Hg as absolute number (Roraback) >45 mm Hg as absolute number (Matsen) <30 mm Hg for ∆p (where ∆p =diastolic pressure – compartment pressure, McQueen) <40 mm Hg for ∆P (where ∆P mean arterial pressure* – compartment pressure, Heppenstall) *mean arterial pressure is diastolic pressure plus 1/3 of pulse pressure
- 26. Decision Making Fractures in Adults, 5th edition Skeletal Trauma, 3rd edition
- 27. Treatment Lower leg to level of the heart Remove cast Split all dressings down to skin Fasciotomy if continued clinical findings and/or elevated compartment pressure
- 28. Compartments Most common Forearm Leg Other compartments Hand Finger Gluteal Thigh Foot
- 29. Forearm
- 30. Leg Anatomy
- 31. Leg Single Incision Technique
- 32. Leg Two Incision Technique
- 35. Wound Care Soft tissue coverage by 5-7 days Delayed closure Vascular loop ‘lace technique’ Split thickness skin graft Flaps or free tissue transfer