Acute Compartment Syndrome Marc Hirner. Demographics Incidence: Incidence: Men 7.3/100,000 Men 7.3/100,000 Women0.7/100,000 Women0.7/100,000 69% due to.

Acute Acute Compartment Compartment

SyndromeSyndromeMarc HirnerMarc Hirner

DemographicsDemographics

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

69% due to trauma69% due to trauma 36% fx tibia36% fx tibia 9.8% distal radius9.8% distal radius 23% soft tissue injury without fx23% soft tissue injury without fx

10% on anticoagulants10% on anticoagulants

Case 1Case 1

Patient with ? Trivial knee injury Patient with ? Trivial knee injury Seen in ED and admittedSeen in ED and admittedRegistrar to ward , pulseless limbRegistrar to ward , pulseless limbWas in fact a knee dislocation that Was in fact a knee dislocation that reduced spontaneouslyreduced spontaneously

End result popliteal artery repair , End result popliteal artery repair , fasciotomy , ligament reconstruction fasciotomy , ligament reconstruction and eventual BKAand eventual BKA

Case 2Case 2

Simple fibula fracture Simple fibula fracture Referred to White Cross several days Referred to White Cross several days after injury with tight swollen calfafter injury with tight swollen calf

Diagnosed acute compartment Diagnosed acute compartment syndrome 5 days latesyndrome 5 days late

Fasciotomy of no use as muscles Fasciotomy of no use as muscles necroticnecrotic

Case 3Case 3

Child required IV access so the tibia Child required IV access so the tibia was used for rapid infusionwas used for rapid infusion

Fluid into the calf Fluid into the calf

Acute compartment syndrome Acute compartment syndrome

Orthopaedics notified late Orthopaedics notified late Fasciotomy no use as muscles necroticFasciotomy no use as muscles necrotic

EtiologyEtiology

Pathophysiology

Increased compartment pressure

Increased venous pressure

Decrease A-V gradient resulting in muscle and nerve ischemia.

DiagnosisDiagnosis

HistoryHistory Clinical exam:Clinical exam: the Psthe Ps Compartment pressuresCompartment pressures Laboratory testsLaboratory tests

CPKCPK Urine myoglobinUrine myoglobin

Clinical DiagnosisClinical Diagnosis

The six ‘Ps’:The six ‘Ps’: PressurePressure PainPain ParesthesiaParesthesia ParalysisParalysis PallorPallor PulselessnessPulselessness

PressurePressure

Early findingEarly finding

Only objective findingOnly objective finding

Refers to palpation of compartment Refers to palpation of compartment and its tension or firmness and its tension or firmness

PainPain

Out of portion to injuryOut of portion to injury

Exaggerated with passive stretchExaggerated with passive stretch

Earliest symptom but inconsistentEarliest symptom but inconsistent

Not available in obtunded patientNot available in obtunded patient

ParesthesiaParesthesia

Early signEarly sign Peripheral nerve tissue is more sensitive Peripheral nerve tissue is more sensitive

than muscle to ischemiathan muscle to ischemia Permanent damage may occur in 75 minutesPermanent damage may occur in 75 minutes

Difficult to interpretDifficult to interpret

Will progress to anesthesia if pressure Will progress to anesthesia if pressure not relievednot relieved

ParalysisParalysis

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

presentpresent

Paresis may be present earlyParesis may be present early Difficult to evaluate because of painDifficult to evaluate because of pain

Pallor & PulselessnessPallor & Pulselessness

Rarely presentRarely present

Indicates direct damage to vessels Indicates direct damage to vessels rather than compartment syndromerather than compartment syndrome

Vascular injury more of contributing Vascular injury more of contributing factor to syndrome rather than factor to syndrome rather than resultresult

Compartment PressureCompartment Pressure WhenWhen

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

Stryker Stic SystemStryker Stic System

Easy to useEasy to use Can check multiple compartmentsCan check multiple compartments Different areas in one compartmentDifferent areas in one compartment

Distance From Fracture Distance From Fracture Effects PressureEffects Pressure

What is Critical What is Critical Pressure?Pressure?

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

TreatmentTreatment

Lower leg to level of the heartLower leg to level of the heart

Remove castRemove cast

Split all dressings down to skinSplit all dressings down to skin

TreatmentTreatment

If concerned refer these patients earlyIf concerned refer these patients early

Fasciotomy if continued clinical Fasciotomy if continued clinical findings and/or elevated findings and/or elevated compartment pressurecompartment pressure

TreatmentTreatment

Wound CareWound Care

Soft tissue coverage by 5-7 daysSoft tissue coverage by 5-7 days

Delayed closureDelayed closure Vascular loop ‘lace technique’Vascular loop ‘lace technique’

Split thickness skin graftSplit thickness skin graft

Flaps or free tissue transferFlaps or free tissue transfer

NO ONE EVER BLAMES US FOR NO ONE EVER BLAMES US FOR DOING A FASCIOTOMY BUT DOING A FASCIOTOMY BUT MISSING COMPARTMENT MISSING COMPARTMENT SYDROME IS A DISASTER SYDROME IS A DISASTER