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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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ACUTE COMPARTMENT SYNDROME
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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ACUTE COMPARTMENT SYNDROME
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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ACUTE COMPARTMENT SYNDROME
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