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G04_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

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

• Elevated tissue pressure within a closed
  fascial space
• Reduces tissue perfusion - ischemia
• Results in cell death - necrosis
• True Orthopaedic Emergency
                    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
                   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.
                  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
                  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
                  History
• Ellis 1958
• Reported a 2% incidence of compartment
  syndrome with tibia fractures, and increased
  attention was paid to contractures involving
  the lower extremities
                  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 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
                       Etiology
• Fractures-closed and open   •   Exertional states
• Blunt trauma                •   GSW
• Temp vascular               •   IV/A-lines
  occlusion                   •   Hemophiliac/coag
• Cast/dressing               •   Intraosseous IV(infant)
• Closure of fascial          •   Snake bite
  defects                     •   Arterial injury
• Burns/electrical
                       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
• 2nd most common cause
• About 23% of CS
• 25% due to direct blow




                           McQueen et al; JBJS Br 2000
                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
                  Incidence
Type of Fx % of      Incidence      Incidence
           ACS       all ages       <35
Tibial     36%       4.3%           5.9%(3 fold)
diaphysis
Distal     9.8%      0.25%          1.4%(30 fold)
radius
Forearm    7.9%      3.1%           3.2%
diaphysis

                             McQueen et al; JBJS Br 2000
Patient positioning




             Meyer, Mubarak JBJS 2002
          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
• 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

• 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
•   Pain out of proportion
•   Palpably tense compartment
•   Pain with passive stretch
•   Paresthesia/hypoesthesia
•   Paralysis
•   Pulselessness/pallor
         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 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 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

• Arterial occlusion

• Peripheral nerve injury

• Muscle rupture
Compartment Syndrome
   Pressure Measurements

• Suspected compartment syndrome
• Equivocal or unreliable exam
• Clinical adjunct
• Contraindication
  – Clinically evident compartment
    syndrome
       Compartment Syndrome
             Pressure Measurements
• Infusion              • Arterial line
  – manometer              – 16 - 18 ga. Needle
  – saline                 (5-19 mm Hg higher)
  – 3-way stopcock         – transducer
  (Whitesides, CORR        – monitor
    1975)
                        • Stryker device
• Catheter                 – Side port needle
  – wick
  – slit wick
       Compartment Syndrome
            Pressure Measurements
• Arterial line
   – Zero at the
     level of the
     affected limb
        Compartment Syndrome
              Pressure Measurements

• Simple Needle
   – 18 gauge
   – Least accurate
   – Usually gives falsely higher
     reading
                                    Side port

• Slit Catheter and Side
  ported needle
   – No significant difference
   – More accurate

   Moed et al JBJS 1993
        Compartment Syndrome
            Pressure 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, Whitesides JBJS 1994
  SUSPECTED COMPARTMENT SYNDROME

Unequivocal + Findings   Pt. not alert/polytrauma/inconc.

                         Comp. pressure measurement



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

                                             Serial exams


       FASCIOTOMY        FASCIOTOMY

                                     McQueen JBJSB 1996
           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
•   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 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

• 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

•   Fasciotomy,
    Fasciotomy,
     Fasciotomy,




    –     All compartments !!!
          Compartment Syndrome
                 Surgical 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
•   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
•   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
• 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
• Perifibular Fasciotomy
   – Matsen et al (1980)
   – Single incision just
     posterior to fibula
   – Common peroneal nerve
                 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


                     Gastroc-soleus




                     Flexor digitorum
                     longus
Fasciotomy: Lateral Leg




                      Intermuscular septum




                     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

• 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

• Anatomy-3 compartments
  – Mobile wad-BR,ECRL,ECRB
  – Volar-Superficial and deep
    flexors
  – Dorsal-Extensors
  – Pronator quadratus described
    as a separate compartment
           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 Fasciotomy
• Protect median nerve,
  brachial artery and
  tendons after release
• Consider dorsal
  release
       Compartment Syndrome
                           Foot
• 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
                             Foot
• Dorsal incision-to release the
  interosseous and adductor
• Medial incision-to release the
  medial, superficial lateral and
  calcaneal compartments
       Compartment Syndrome
                       Hand
• 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

• 10 separate osteofascial
  compartments
   – dorsal interossei (4)
   – palmar interossei (3)
   – thenar and hypothenar
     (2)
   – adductor pollicis (1)
       Compartment Syndrome
                       Thigh

• Lateral to release
  anterior and posterior
  compartments
• May require medial
  incision for adductor    Vastus lateralis
  compartment




                           Lateral septum
        Compartment Syndrome
            Other 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?
• 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 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
• 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

• Simple absorbent
  dressing
• Semipermeable skin-
  like membrane
• Vessel loop “bootlace”
• “VAC” (Vacuum
  Assisted Closure)
        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
• STSG
• Delayed primary closure
  with relaxing incisions
          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
• Late Sequelae
     •   Volckmann’s contracture
     •   Weak dorsiflexors
     •   Claw toes
     •   Sensory loss
     •   Chronic pain
     •   Amputation
         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
•   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

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