Acute Compartment syndrome David Agolley department of orthopaedics David Agolley department of...

Acute Compartment

syndrome

Acute Compartment

syndromeDavid Agolley

department of orthopaedicsDavid Agolley

department of orthopaedics

DefinitionDefinition

Acute Compartment Syndrome occurs when there is elevated pressure in a closed fascial (osteofascial) space, resulting in a critical reduction of blood flow to the tissues contained within.

Acute Compartment Syndrome


VariationsVariations


Exertional Compartment syndrome

Crush Syndrome



Historical ReviewHistorical ReviewLate complications of ischaemic contracture

Volkman, 1881

Paralysis and ischaemia, too-tight bandaging of the forearm and hand,arterial blockage and irreversible contracture.

Leser 1884 - animal studies

Brooks 1922 - venous obstruction

Griffiths 1940 - Pain with.. , Painful onset, Pallor, Puffiness

Bardenheuer 1911 - fasciotomy forearm

Whitesides, Hargens and Mubarak, and Matsen 1970’s - tissue pressure measurement techniques.

Current - sustained microcirculatory impairment,

Still occurs. Not uncommon



EpidemiologyEpidemiology

3.1 per 100,000

Young Male 10 fold increase

MVA

sports

muscle volume



PathophysiologyPathophysiology



PathophysiologyAetiology

PathophysiologyAetiology

Fracture (69%)

Soft tissue injury

Crush syndrome (2)

arterial injury / revascularisation

High pressure injection

exercise

fluid infusion

arterial puncture

ruptured ganglia / cysts

Osteotomy

Snake bite

nephrotic syndrome

leukaemic infiltration

viral myosis

acute haematogenous osteomyelitis

coagulopathy (1)

cast / dressings

repair fascia, hernia

burns



PathophysiologyPathophysiology



PathophysiologyPathophysiologyNormal tissue pressure

0-4 mm Hg

8 - 10 mm Hg with exertion

Absolute compartment pressure theory

30mmHg - Mubarak and Hargens

45 mmHg - Matsen

AV gradient theory

LBF = Pa - Pv / R

<30mmHg diastolic pressure

‘do not elevate arm’

Microvascular occlusion theory



Tissue SurvivalTissue SurvivalMuscle

3 - 4 hrs = reversible damage

6 hrs = variable damage

8 hrs = irreversible damage

Nerve

2 hrs = loose nerve conduction

4 hrs = Neuropraxia

8 hrs = irreversible damageAcute Compartment

SyndromeAcute Compartment

Syndrome

Night intern, Call from Paeds“Dr, I think little Jimmy has compartment syndrome”

Night intern, Call from Paeds“Dr, I think little Jimmy has compartment syndrome”

Assessment of Compartment

Syndrome

Assessment of Compartment

Syndrome



AssessmentAssessmentPrioritise

History

mechanism injury

intervention

analgesic requirements

Examination

InvestigationsAcute Compartment


Syndrome

Diagnosisthe 6 Ps

Hargens and Mubarak

Diagnosisthe 6 Ps

Hargens and Mubarak

Pain out of proportion / Passive stretch

Palpably tense compartment

Parasthesia

Paresis

Pink skin colour

Pulse presentAcute Compartment


Syndrome

DiagnosisDifferentialsDiagnosis

Differentials

Arterial Occlusion

Peripheral nerve injury

Muscle rupture



Emergent TreatmentEmergent TreatmentPlace at level of heart

Cut dressing or cast - MUST SEE SKIN

Alert senior Dr, OR, Anaesthetist and fast patient

ReviewAcute Compartment


Syndrome

InvestigationsInvestigationsRadiographs

MRI USS not routine

Arterial doppler flow

Pulse Oximetry

Pressure measurements

Suspected CS

Equivocal or unreliable exam

Clinical adjunct



At risk PatientsAt risk PatientsDemographic

Youth

Male

Tibia fracture

High energy

Bleeding diathesis /anticoagulants

Altered Pain Perception

Altered consciousness

Regional anaesthesia

Patient-Controlled Analgesia

Central or peripheral neurological injury

Children

Associated nerve injury



Pressure MonitoringPressure Monitoring



Surgical TreatmentIndications for fasciotomy

Surgical TreatmentIndications for fasciotomy

Clinical findings

Pressure absolute above 30mmHg, or within 20mmHg Diastolic

Rising tissue pressure

>6hours of total limb ischaemia

High risk injury

CONTRAINDICATION - Missed CS 24-48hrs



Surgical treatmentPrinciples

Surgical treatmentPrinciples

Early diagnosis

Long extensile incision

Release all fascial compartments

Preserve neurovascular structures

Rigid fracture stabilisation

Debride necrotic tissues

Cover 7-10 daysAcute Compartment


Syndrome

Forearm FasciotomyForearm Fasciotomy



Leg FasciotomyLeg Fasciotomy



Thigh FasciotomyThigh Fasciotomy



Foot FasciotomyFoot Fasciotomy



Other Compartments

Other Compartments

Hand, forearm, arm, deltoid

Abdomen

Buttock



Temporary CoverageTemporary Coverage

Simple dressing

Progressive suturing

Vessel loop “Bootlace”

Vacuum Assisted Closure



Definitive CoverageDefinitive CoverageSecond look

Cover 7-10 days after risk of necrotic tissue passed

Split skin graft

Local flap

Free flapAcute Compartment


Syndrome

SummarySummary


High Index of suspicion

Early diagnosis

Early intervention

Expedite time to surgery

Questions?Questions?

Acute Compartment syndrome David Agolley department of orthopaedics David Agolley department of...

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