Transcript Acute Compartment Syndrome

Acute Compartment
Syndrome
Marc Hirner
Demographics
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Incidence:
Men
 Women
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7.3/100,000
0.7/100,000
69% due to trauma
36% fx tibia
 9.8% distal radius
 23% soft tissue injury without fx
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10% on anticoagulants
Case 1
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Patient with ? Trivial knee injury
Seen in ED and admitted
Registrar to ward , pulseless limb
Was in fact a knee dislocation that reduced
spontaneously
End result popliteal artery repair , fasciotomy ,
ligament reconstruction and eventual BKA
Case 2
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Simple fibula fracture
Referred to White Cross several days after injury
with tight swollen calf
Diagnosed acute compartment syndrome 5 days
late
Fasciotomy of no use as muscles necrotic
Case 3
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Child required IV access so the tibia was used
for rapid infusion
Fluid into the calf
Acute compartment syndrome
Orthopaedics notified late
Fasciotomy no use as muscles necrotic
Etiology
Pathophysiology
Increased compartment pressure
Increased venous pressure
Decrease A-V gradient resulting in muscle
and nerve ischemia.
Diagnosis
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History
Clinical exam: the Ps
Compartment pressures
Laboratory tests
CPK
 Urine myoglobin
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Clinical Diagnosis
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The six ‘Ps’:
Pressure
 Pain
 Paresthesia
 Paralysis
 Pallor
 Pulselessness
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Pressure
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Early finding
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Only objective finding
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Refers to palpation of compartment and its
tension or firmness
Pain
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Out of portion to injury
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Exaggerated with passive stretch
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Earliest symptom but inconsistent
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Not available in obtunded patient
Paresthesia
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Early sign
Peripheral nerve tissue is more sensitive than muscle
to ischemia
 Permanent damage may occur in 75 minutes
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Difficult to interpret
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Will progress to anesthesia if pressure not
relieved
Paralysis
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Very late finding
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Irreversible nerve and muscle damage present
Paresis may be present early
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Difficult to evaluate because of pain
Pallor & Pulselessness
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Rarely present
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Indicates direct damage to vessels rather than
compartment syndrome
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Vascular injury more of contributing factor to
syndrome rather than result
Compartment Pressure
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When
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Confirm clinical exam
Obtunded patient with tight compartments
Regional anesthetic
Vascular injury
Technique
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Whiteside infusion
Stic technique: side port needle
Wick catheter
Slit catheter
Stryker Stic System
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Easy to use
Can check multiple compartments
Different areas in one compartment
Distance From Fracture Effects
Pressure
What is Critical Pressure?
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>30 mm Hg as absolute number (Roraback)
Treatment
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Lower leg to level of the heart
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Remove cast
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Split all dressings down to skin
Treatment
If concerned refer these patients early
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Fasciotomy if continued clinical findings and/or
elevated compartment pressure
Treatment
Wound Care
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Soft tissue coverage by 5-7 days
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Delayed closure
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Vascular loop ‘lace technique’
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Split thickness skin graft
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Flaps or free tissue transfer
NO ONE EVER BLAMES US FOR DOING A
FASCIOTOMY BUT MISSING
COMPARTMENT SYDROME IS A
DISASTER