Acute Compartment Syndrome

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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 Volkmans 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
• lt2 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

• Dont 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?

• gt30 mm Hg as absolute number (Roraback)
• gt45 mm Hg as absolute number (Matsen)
• lt30 mm Hg for ?p (where ?p diastolic pressure
  compartment pressure, McQueen)
• lt40 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
Skeletal Trauma, 3rd edition
Fractures in Adults, 5th 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