acute compartment syndrome dr sandeep bhadoo
TRANSCRIPT
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Acute Compartment
Syndrome
Frederick C. Schreiber, D.O.
Orthopedic Residency Director
Genesys Regional Medical Center
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Definition:An increased pressure within enclosed
osteofascial space that reduces capillary per-
fusion below level necessary for tissue
viability; the underlying mechanism is:
- increased volume within space
- decreased space for contents
- combination of both
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History
1881-Volkman described contracted state believed due to ischemic muscle
1884-Lesser developed clinical model
1888-Peterson felt due to nerve compromise
1906-Hildebrand coined “Volkman’s ischemic contracture”
1914-Murphy recommended fasciotomy to prevent contracture
1940-Griffiths ‘4 Ps’
1966-Seddon emphasized lower extremity
1967-Whiteside stressed 4 compartment fasciotomy
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Demographics
Incidence:
Men 7.3/100,000
Women 0.7/100,000
69% due to trauma
36% fx tibia
9.8% distal radius
23% soft tissue injury without fx
10% on anticoagulants
High energy = low energy incidence
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Etiology
Trauma with bleeding/swelling
Bleeding disorders
Burns
Tight wraps
Traction
Surgical positioning
Pneumatic antishock garment
Reprefusion swelling
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Casting & Wraps
Casting increases pressure 3-7 times
Positioning may effect pressure
Leg best position 0-37° plantar flexion
Elevation of extremity changes A-V gradient
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Traction
Pressure increases linear with increasing weight
Posterior compartment of leg most effected
1 kg added weight
5% increase in posterior compartment
<2% increase in anterior compartment
Calcaneal traction increases dorsiflexion
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Positioning
Lithotomy position
Elevation of leg
Pressure on posterior compartment
Circumferential inflated devices
Wraps
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Tibial Fractures
Don’t use traction
Both reamed & unreamed nails increase pressure
Low threshold for prophylactic fasciotomies
Revascularization
Long procedure
Unresponsive patient
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Pathophysiology:
Increased compartment pressure leads
to increased venous pressure which
decreases A-V gradient resulting in muscle
and nerve ischemia.
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Variables to Consider
Vascular tone
Blood pressure
Duration of elevated pressure
Metabolic demand of tissue
Lowered ischemic threshold of damaged muscle
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Myoglobinemia
Released in high levels at reperfusion
Toxic to glomeruli
Metabolic acidosis & hperkalemia
Together lead to:
Renal failure
Cardiac arrhythmia & failure
Hypothermia
Shock
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Diagnosis
History
Clinical exam: the Ps
Compartment pressures
Laboratory tests
CPK
Urine myoglobin
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Clinical Diagnosis
The six ‘Ps’:
Pressure
Pain
Paresthesia
Paralysis
Pallor
Pulselessness
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Pressure
Early finding
Only objective finding
Refers to palpation of compartment and its
tension or firmness
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Pain
Classically out of portion to injury
Exaggerated with passive stretch of the involved
muscles in compartment
Earliest symptom but inconsistent
Not available in obtunded patient
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Paresthesia
Also early sign
Peripheral nerve tissue is more sensitive than muscle
to ischemia
Permanent damage may occur in 75 minutes
Difficult to interpret
Will progress to anesthesia if pressure not
relieved
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Paralysis
Very late finding
Irreversible nerve and muscle damage present
Paresis may be present early
Difficult to evaluate because of pain
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Pallor & Pulselessness
Rarely present
Indicates direct damage to vessels rather than
compartment syndrome
Vascular injury may be more of contributing
factor to syndrome rather than result
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Compartment Pressure
When? Confirm clinical exam
Obtunded patient with tight compartments
Regional anesthetic
Vascular injury
Technique Whiteside infusion
Stic technique: side port needle
Wick catheter
Slit catheter
*most common technique?
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Whiteside Technique
Simple technique
Readily available supplies
With 18 gauge needle least accurate
More accurate if use side port needle
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Slit Catheter
Developed by Rorabeck
Considered ‘gold standard’
Need the catheter
Can use the measuring unit for Stic system
Can leave indwelling for continuous monitoring
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Stryker Stic System
Easy to use
Can check multiple compartments
Different areas in one compartment
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Distance From Fracture Effects
Pressure
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What is Critical Pressure?
>30 mm Hg as absolute number (Roraback)
>45 mm Hg as absolute number (Matsen)
<30 mm Hg for ∆p (where ∆p =diastolic pressure – compartment pressure, McQueen)
<40 mm Hg for ∆P (where ∆P mean arterial pressure* – compartment pressure, Heppenstall)
*mean arterial pressure is diastolic pressure plus 1/3 of pulse pressure
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Decision Making
Fractures in Adults, 5th edition Skeletal Trauma, 3rd edition
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Treatment
Lower leg to level of the heart
Remove cast
Split all dressings down to skin
Fasciotomy if continued clinical findings and/or
elevated compartment pressure
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Compartments
Most common
Forearm
Leg
Other compartments
Hand
Finger
Gluteal
Thigh
Foot
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Forearm
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Leg Anatomy
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Leg Single Incision Technique
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Leg Two Incision Technique
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Hand Compartments
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Foot Compartments
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Wound Care
Soft tissue coverage by 5-7 days
Delayed closure
Vascular loop ‘lace technique’
Split thickness skin graft
Flaps or free tissue transfer