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Acute Compartment Syndrome

Acute Compartment Syndrome. Viktoras Kubaitis 10/09/2012. Acute Compartment Syndrome. Definition A compartment syndrome is a pathological condition in which high pressure within a closed fascio - osseus space reduces capillary blood perfusion

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Acute Compartment Syndrome

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  1. Acute Compartment Syndrome • ViktorasKubaitis 10/09/2012

  2. Acute Compartment Syndrome Definition A compartment syndrome is a pathological condition in which high pressure within a closed fascio - osseus space reduces capillary blood perfusion below a level necessary for tissue viability, That requires urgent surgical release to prevent muscle necrosis and contractures.

  3. Acute Compartment Syndrome Compartment can develop anywhere • Deltoid 1 Compartment • Iliacus 1 • Upper Arm 2 • Gluteal 3 • Thigh 3 Forearm 4 Hand 4 Leg 4 Foot 9 comp 4 groups

  4. Acute Compartment Syndrome Pathophysyology - Witeside theory DBP - TIP = MPP Diastolic blood pressure 60 - 70 mmHg Tissue intramuscular = Interstitial pressure 4 – 10 mmHg Muscle perfusion MPP = Capillary perfusion pressure SPP 25 – 30 mmHg

  5. Acute Compartment Syndrome Witeside theory easier 60 30 30

  6. Acute Compartment Syndrome Pathophysiology - Mechanizm Injury causes bleeding or oedema, Increase in intracompartmental pressure or Decrease in compartmental size When interstitial pressure raises higher then 30 mmHg, Outgoing to venous system capillaries collapses Blood flow through the capillaries stops, Oxygen delivery to organ stops Cells sustain Hypoxic Injury Cells release vasoactive substances Histamine Serotonine Increase in permeability of endothelium Capillaries allow continued fluid loss Increase in interstitial pressure Nerve conduction and blood flow slows Myoneuralischemia Tissue pH falls due to anaerobic metabolism Irreversible Tissue damage - necrosis Myoglobin release Loss of extremity and kidneys insufficiency and loss of life

  7. Acute Compartment Syndrome Aetiology • 1. Increased fluid content Fracture Big vessel injury Inflammation • 2. Decreased Compartment size Cast Burn Lying on a limb long time Prolonged tourniquet time Malpositioning during traction procedure

  8. Acute Compartment Syndrome • Aetiology – Demographics 36-45 % tibial shaft (open/closed) 23% soft tissue injury without fracture 19% isolated vascular injury 10% on anticoagulants High energy = low energy European journal of trauma & emergency surgery. 2007, MC queen & al. 2007 www.emedicine.com/Acute Compartment Syndrome

  9. Acute Compartment Syndrome Diagnosis - symptoms Pain is disproportional and not explainable by the situation

  10. Acute Compartment Syndrome Diagnosis – the 7 P • Pain out to proportion to the injury • Pain on passive movement • Palpably tight compartment • Paraesthesia • Palor • Paralysis • Pulseless (a pulse is not issue)

  11. Acute Compartment Syndrome Differential diagnosis Cellulitis Osteomyelitis DVT Gas gangrene Necrotizing fasciitis Periferal vascular injury Rhabdomyolysis

  12. Acute Compartment Syndrome • Possible Delayed diagnosis due to • children are unable to verbalize feelings • Patients with multiple injuries • Unconscious patients • Drug abuse • Continuous epidural/spinal anaesthesia • Altered neurological function in a past • Vascular injuries in a past

  13. Acute Compartment Syndrome • Laboratory tests 1. FBC Hg (anaemia worsens ischemia) WBC can be elevated 2. U/E CK CreatinineKinase normal 10-186 U/l) Myoglobin BUN (Blood Urea Nitrogen normal 7-21 mg/dL) Creatinine Urea K GGT (Gamma Glitamyltranspeptidase) 3. Coagulation profile 4. Blood Culture/sensitivity

  14. Acute Compartment Syndrome • Compartment measurement • Stryker pressure monitor • Slit catheter • Wick catheter

  15. Acute Compartment Syndrome • Measurement technique • Should be taken on maximal swelling site • Patient in a comfortable position • Assemble the system • Zero the system • 45 degrees angle • Subfascial catheter needle tip insertion • Get the reading in mmHg

  16. Acute Compartment Syndrome • Complications of Compartment without treatment Muscle longstanding weakness Ulceration Acidosis Hypercalemia Rhabdomyolysis Disabling joint contractures DIC disseminated Intravascular Coagulation Sepsis Myoglobinuric renal Failure ARDS Acute Respiratory Distress Syndrome Loss of limb Multiple Organ Failure MOF Death

  17. Acute Compartment Syndrome Delayed diagnosis consequences. Is it safe? Infection rate of 46% and Amputation rate of 21% after a delay of 12 hours 4.5% complications for early fasciotomies and 54% for delayed ones. Sheridan, Matsen. JBJS 1976

  18. Acute Compartment Syndrome • Concervative treatment • Circular Cast and dressings down • Treat systemic hypotension/shock • Do not elevate the affected extremity. • Additional oxygen should be administered • Hyperbaric oxygen • Vascular surgeon review • Correction of Coagulopathy • Antivenin • Mannitol Mannitol treatment for acute compartment syndrome. Nephron. Aug. 1998; 79(4):4923

  19. Acute Compartment Syndrome • Correction of Associative disorders – bouquet of flowers Shock Hypovolemia Hypercalemia Dehytradion Renal Failure Infection Coagulopathy

  20. Acute Compartment Syndrome Indications for fasciotomy 1. When tissue pressure rises more than 30 mm Hg 2. When a difference between diastolic pressure and measured tissue pressure is 30 mm Hg or less 3. Clinically confirmed ACS

  21. Acute Compartment Syndrome Anatomy of lower leg muscles and Compartments To learn 4 Compartments Imagine a Tractor on Podium 4 A A T L F PD PS

  22. Acute Compartment Syndrome Anatomy of lower leg muscles

  23. Acute Compartment Syndrome Anatomy of neurovascular bundles

  24. Acute Compartment Syndrome • Double Incision Fasciotomy defended by Mubarak

  25. Acute Compartment Syndrome • Single Incision Fasciotomyinovated by Matsen

  26. Acute Compartment Syndrome • Postoperative care after fasciotomy Bulky dressings to promote oedema reduction Extremity elevation Skin graft when oedema resolved if needed STSG Split Thickness Skin Graft Delayed Primary Closure with relaxing incisions Active movements of joints to prevent stiffness

  27. Acute Compartment Syndrome • Complications after Fasciotomies Altered sensation within the margins of the wound 77% Dry, scaly skin 40% Pruritus 33% Discoloured wounds 30% Swollen limbs 25% Tethered scars 26% Recurrent ulceration 13% Muscle herniation 13% Pain related to the wound 10% Tethered tendons 7% Fitzgerald, McQueen Br J PlastSurg 2000

  28. Acute Compartment Syndrome • Summary High index of suspicion remains the cornerstone of diagnosis ACS Treat as soon as you suspect ACS ICP measurement gives additional information ACS is a clinical diagnosis If ACS is clinically evident, do not measure pressures In doubt, cut! Avoid delays in management Fasciotomy is reliable, safe and effective the only treatment for compartment syndrome when performed in time

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