ACS Ekstrimitas Asep

7/29/2019 ACS Ekstrimitas Asep

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Acute Compartment Syndrome inExtremities

Diagnostic and Management

Asep Aminudin Aziz


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Introduction

Acute

Compartment

Closed anatomic space bound

by relatively rigid walls of bone

and fascia

Syndrome


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Osseofascial compartment

Thigh 3 Osseofascial compartment

Cruris 4 Osseofascial compartment

Forearm 3 Osseofascial compartment


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Introduction

Acute Compartment

Syndrome (ACS) is apotentially devastating

condition in which the pressure

within an osseofascial

compartment rises to a level

that decreases the perfusion

gradient across tissue capillary

beds, leading to cellular anoxia,muscle ischemia and death


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ACUTE COMPARTMENT SYNDROME

Incidence

45% ACS caused by tibial fx 23% ACS caused by soft tissue injury

16% ACS caused forearm fx

Tibial fx : 110% develop ACS

Close tibial fx : 1,529%

Open tibial fx : 1,2

10,2% Vascular injury : - 1930% develop ACS - other ref. 021%


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Incidence

7.3 per 100.000 in men ( 30 years old) 0.7 per 100.000 in women ( 44 years old)

1,2 % of patients with Closed Tibia fractures

developed CS Mc Quenn et al: studied 164 pts with ACS

69 % was fractured, 36 % Tibial diaphyses; 9,8 % Distalradius

23.2 % Soft tissue injury (fracture - ), 10 % pts takinganticoagulants or bleeding disorder

High or Low energy was equal


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OutcomesACS underwent fasciotomy

Sheridan and Matsen 1)

Clinical outcomes of 44 pts

Before 12 hours 68 % had normal lower extremityfunction

After 12 hours 8 %

Finkelstein et al.2)

Reported 5 pts underwent fasciotomy after 35 hours

One died directly related MOF

Four pts required amputation

1) Sheridan GW, Matsen FA: Fasciotomy in the treatment of the acute compartment

syndrome.JBJS Am, 1976;58:112-115.

2) Finkelstein JA, Hunter GA, Hu RW: Lower limb compartment syndrome: Course

after delayed fasciotomy.J Trauma 1996; 40:342-344


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Pathophysiology of

Ischemia


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Causes of Compartment Syndrome

Fracture Soft-tissue trauma without fracture

Intracompartmental bleeding

Extravasations of intravenous infusion

Venous obstruction Reperfusion injury following prolonged ischemia

Snake envenomation

Penetrating trauma

Tight casts, dressings, or external wrappings Thermal injury, burn eschar


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Diagnostic

Patient history Associated risk factors

The classic clinical diagnosis

Six Ps

1. Pain2. Pressure

3. Pulselessness

4. Paralysis

5. Paresthesia

6. Pallor


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Diagnosis

Direct ICP measurement / objective method

1/. Injection/infusion technique (Whitesides)

equipment in expensive and readily available

in most hospitals, emergency rooms NOT accurate

2/. Wick catheter (Mubarak)

3/. Slit catheter (Rorabeck)

4/. Solid state transducer intracomp catheter (STIC)

1 4 : Fluid filled system

5/. Fiber optic transducer tipped very expensive

6/. Latest device : Electronic Transducer Tipped Catheter

best device


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The measurement devices

P value of 30 mm Hg to

diastolic blood pressure is

an absolute indicator for

fasciotomy


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Interpretation of ICP measurement

Absolute : 30 mm Hg as cut off pointfor fasciotomy

Differential Pressure (Whitesides) :Delta Pressure Diastolic BP minus ICPcut off point < 30 mm Hg

Many UNNECESSARY fasciotomies can beavoided


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Management : Medical therapy

Place the affected limbs at the level of the heart

Elevation is contraindicated because decreasedarterial flow & narrows the arterial venouspressure

Releasing the cast

Correct hypo-perfusion with crystalloid and bloodproducts

In case of snake envenomation, administration ofantivenom


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Management : Surgical therapy

The definitive surgical

therapy is Emergent

Fasciotomy

Within 6 hours

One or two incisions

Subsequent :

Fracture stabilization

Vascular repair if needed


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One incision


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Two incisions


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Complication Volkmann contracture : 110% of all cases

of ACS

Infection : Matsen in late cases surgicaldecomp. 11/24 cases develop infection

5 cases need AMPUTATION Hypesthesia / Painful dysesthesia

Systemic : Acute Renal Failure, sepsis,Acute Resp Distress Syndrome (ARDS)


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Upper extremity


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Post Operative care

Monitor haemodynamic status and maintainadequate blood pressure

If rhabdomyolysis occurs,

continue hydration

monitor urine output and

kidney function

Potassium status closely

Re-dress wound daily

IV lines adequate Antibiotic

Delayed primary suture or STSG within 7 days


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Complication

Volkmann contracture : 1 10% of all casesof ACS

Infection : Matsen in late cases surgicaldecomp. 11/24 cases develop infection

5 cases need AMPUTATION Hypoesthesia / Painful dysesthesia

Systemic : Acute Renal Failure, sepsis,Acute Resp Distress Syndrome (ARDS)


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Conclusions

Acute Compartment Syndrome is true emergency case

Timely diagnose and management

Clinical diagnose quite simple & easy

Surgical treatment within 6-8 hours

Delayed treatment caused high morbidity andmortality

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