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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
below a level necessary for tissue viability,
That requires urgent surgical release to prevent
muscle necrosis and contractures.
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
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
Acute Compartment Syndrome
Witeside theory easier
60
30
30
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
Myoneural ischemia
Tissue pH falls due to anaerobic metabolism
Irreversible Tissue damage - necrosis
Myoglobin release
Loss of extremity and kidneys insufficiency and loss of life
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
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
Acute Compartment Syndrome
Diagnosis - symptoms
Pain is disproportional and not explainable by the situation
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)
Acute Compartment Syndrome
Differential diagnosis
Cellulitis
Osteomyelitis
DVT
Gas gangrene
Necrotizing fasciitis
Periferal vascular injury
Rhabdomyolysis
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
Acute Compartment Syndrome
Laboratory tests
1. FBC
Hg (anaemia worsens ischemia)
WBC can be elevated
2. U/E
CK Creatinine Kinase normal 10-186 U/l)
Myoglobin
BUN (Blood Urea Nitrogen normal 7-21 mg/dL)
Creatinine
Urea
K
GGT (Gamma Glitamyl transpeptidase)
3. Coagulation profile
4. Blood Culture/sensitivity
Acute Compartment Syndrome
Compartment measurement
•Stryker pressure monitor
•Slit catheter
•Wick catheter
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
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
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
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
Acute Compartment Syndrome
Correction of Associative disorders – bouquet of flowers
Shock
Hypovolemia
Hypercalemia
Dehytradion
Renal Failure
Infection
Coagulopathy
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
Acute Compartment Syndrome
Anatomy of lower leg muscles and Compartments
To learn 4 Compartments Imagine a Tractor on Podium
L
4A
F
T
A
PD
PS
Acute Compartment Syndrome
Anatomy of lower leg muscles
Acute Compartment Syndrome
Anatomy of neurovascular bundles
Acute Compartment Syndrome
Double Incision Fasciotomy defended by Mubarak
Acute Compartment Syndrome
Single Incision Fasciotomy inovated by Matsen
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
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 Plast Surg 2000
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