Acute compartment syndrome

ACUTE COMPARTMENT SYNDROME

HISTORY Raised pressure in a closed space Richard von Volkmann

Hilderbrand Rowlands Murphy

PATHOPHYSIOLOGY

Raised pressure within a confined space Increased volume of compartment

Ischemia reperfusion injury MAJOR VESSEL RARELY OBSTRUCTED Difference between compartment and

diastolic pressure Crush syndrome Anesthetized / sedated / intubated patient Prolonged surgery Tight cast / constrictive dressing /

pneumatic anti shock garment

ETIOLOGY Decreased compartment size

   Constrictive dressings and casts   Closure of fascial defects   Thermal injuries and frostbite   Localized external pressure   Pneumatic tourniquetIncreased compartment contents   Primary edema accumulation       Postischemic swelling         Arterial injuries         Arterial thrombosis or embolism         Reconstructive vascular and bypass surgery         Replantation         Prolonged tourniquet time         Arterial spasm         Cardiac catheterization and angiography         Ergotamine ingestion      Prolonged immobilization with limb compression         Drug overdose with limb compression         General anesthesia with limb compression     

 Increased capillary pressure or permeability         Exercise         Venous obstruction         Thermal injuries and frostbite         Exertion, seizures, and eclampsia         Venous disease         Intraarterial injection         Venomous snake bite         Infection

Primarily hemorrhage accumulation      Hereditary bleeding disorders (e.g., hemophilia)      Anticoagulant therapy      Vessel laceration   Combination of edema and hemorrhage accumulation      Fractures         Supracondylar elbow         Both-bone forearm         Distal radius      Soft tissue injury         Crush         Severe muscle tear, contusion         Gunshot wounds         Iatrogenic (i.e., postoperative bleeding, inflammation)   Miscellaneous      Intravenous infiltration (e.g., blood, saline)      High-pressure injection

DIAGNOSIS : CLINICAL ASSESSMENT Symptoms may be masked by other injuries ?? Open fracture Disproportionate pain In regional/epidural anesthesia Numbness / tingling Signs Compartment Stretch pain Sensory deficit Paresis

Pulse / capillary refill Differential – artery occlusion, nerve injury,

crush syndrome ?? Delay in diagnosis of major arterial

injury Arterial pressure index Nerve injury – diagnosis of exclusion Crush syndrome

TISSUE PRESSURE MEASUREMENT Incipient vs. fulminant Ideally after every fracture Polytrauma patient Chemical overdose / head injury + long

bone fracture Arterial repair

MEASUREMENT TECHNIQUES

1. Needle manometer• Landerer• 18 gauge needle, 20ml syringe, column

of saline and air, mercury manometer

2. Wick catheter• Scholander• Polyglycolic acid suture, polyethylene

tubing• Disadvantage

3. Slit catheter• Rorabeck• Polyethylene tubing

with 5 3mm slits in end

4. STIC catheter• Hand held device

5. Micro capillary infusion

6. Arterial transducer measurement

7. Tc 99m-methoxyisobutylisonitrile

8. Doppler flow measurement

9. Near infrared spectroscopy

PRESSURE THRESHOLD FOR FASCIOTOMY

Within 10-30 mm Hg of diastolic pressure (Whitesides)

Above 45mm Hg (Matsen) 30mm Hg difference between

compartment and diastolic pressure (Mc Queen)

40mm Hg difference between mean arterial pressure and compartment pressure (Heppenstall)

TREATMENT OF INCIPIENT COMPARTMENT SYNDROME

Incipient compartment syndrome Remove tight dressings and casts Limb position at the level of heart Oxygen support Hydration

ESTABLISHED COMPARTMENT SYNDROME

Surgical decompression

HAND Clinical feature Crush injury /

carpal fracture Longitudinal

dorsal incisions

FOREARM Fracture / soft tissue fluid infiltration / gun

shot injury / deep infection / iv drug abuse 3 compartments Volar Henry / volar ulnar / Thompson Both superficial and deep compartment

should be released

Henry approach

Volar ulnar approach

Dorsal approach

LEG Fibulectomy – Patman / radical surgery Perifibular fasciotomy – Matsen

Single incision technique

Double incision technique - Mubarak

THIGH 3 compartments

FOOT Claw toe deformity Calcaneal fractures /

Lisfranc injury / blunt trauma

Difficult to diagnose

AFTERCARE Collagen / Cuticell Splintage Antibiotics Wound inspection after

48 hrs Opsite roller Vessel loop bootlace Plastic surgery

COMPLICATIONS1. COMPARTMENT SYNDROME2. FASCIOTOMY

MEDICAL MANAGEMENT Mannitol Hyperbaric oxygen

SKELETAL INJURIES Fracture must be stabilized Location, character of fracture / skill of

surgeon Plating / nailing / ex fix Soft tissue coverage

MUST AVOID CONTRACTURE SENSORY DEFICIT PARALYSIS INFECTION NON UNION AMPUTATION