acute compartment syndrome

Acute compartment Acute compartment syndromesyndrome

Dr.E.Kaizar EnnisDr.E.Kaizar Ennis

DefinitionDefinition

Compartment syndrome is a condition in Compartment syndrome is a condition in which the circulation within a closed which the circulation within a closed compartment is compromised by an increase in compartment is compromised by an increase in pressure within the compartment, causing pressure within the compartment, causing necrosis of muscles and nerves and eventually necrosis of muscles and nerves and eventually of the skin because of excessive swelling. of the skin because of excessive swelling.

HistoryHistory

Volkmann 1881Volkmann 1881 Richard von Volkmann published an article in Richard von Volkmann published an article in

which he attempted to describe the condition which he attempted to describe the condition of irreversible contractures of the flexor of irreversible contractures of the flexor muscles of the hand to ischemic processes muscles of the hand to ischemic processes occurring in the forearm occurring in the forearm

Application of restrictive dressing to an Application of restrictive dressing to an injured limbinjured limb

HistoryHistory

Hildebrand 1906 Hildebrand 1906 First used the term Volkmann ischemic First used the term Volkmann ischemic

contracture to describe the final result of any contracture to describe the final result of any untreated compartment syndrome, and was untreated compartment syndrome, and was the first to suggest that elevated tissue pressure the first to suggest that elevated tissue pressure may be related to ischemic contracture. may be related to ischemic contracture.

HistoryHistory

Thomas 1909Thomas 1909 Reviewed the 112 published cases of Reviewed the 112 published cases of

Volkmann ischemic contracture and found Volkmann ischemic contracture and found fractures to be the predominant cause. Also, fractures to be the predominant cause. Also, noted that tight bandages, an arterial embolus, noted that tight bandages, an arterial embolus, or arterial insufficiency could also lead to the or arterial insufficiency could also lead to the problemproblem

HistoryHistory

Murphy 1914Murphy 1914 First to suggest that fasciotomy might prevent First to suggest that fasciotomy might prevent

the contracture.the contracture.

HistoryHistory

Seddon, Kelly, and Whitesides 1967Seddon, Kelly, and Whitesides 1967 Demonstrated the existence of 4 compartments Demonstrated the existence of 4 compartments

in the leg and to the need to decompress more in the leg and to the need to decompress more than just the anterior compartment. Since then, than just the anterior compartment. Since then, compartment syndrome has been shown to compartment syndrome has been shown to affect many areas of the body, including the affect many areas of the body, including the hand, foot, thigh, and buttocks.hand, foot, thigh, and buttocks.

EtiologyEtiology

Fractures-Fractures-closed closed and openand open Blunt traumaBlunt trauma Cast/dressingCast/dressing Closure of fascial defectsClosure of fascial defects Burns/electricalBurns/electrical Exertional statesExertional states Hemophiliac/coagHemophiliac/coag Snake biteSnake bite Arterial injuryArterial injury IVFIVF

EtiologyEtiology

↓↓ Compartment Size Compartment Size Tight dressing;Tight dressing; Bandage/CastBandage/Cast

localised external pressure.localised external pressure. Closure of fascial defectsClosure of fascial defects

↑↑ Compartment ContentCompartment Content Bleeding; Fx, vas inj, bleeding disordersBleeding; Fx, vas inj, bleeding disorders Capillary Permeability;Capillary Permeability;

Ischemia / Trauma / Burns / Exercise / Snake Bite / Drug InjectionIschemia / Trauma / Burns / Exercise / Snake Bite / Drug Injection

FractureFracture

The most common causeThe most common cause Incidence of accompanying compartment Incidence of accompanying compartment

syndrome of 9.1%syndrome of 9.1% The incidence is directly proportional to the The incidence is directly proportional to the

degree of injury to soft tissue and bonedegree of injury to soft tissue and bone occurred most often in association with a occurred most often in association with a

comminuted, grade-III open injuries.comminuted, grade-III open injuries.

Blick et al JBJS 1986Blick et al JBJS 1986

Blunt TraumaBlunt Trauma

22ndnd most common cause most common cause About 23% of CSAbout 23% of CS 25% due to direct blow25% due to direct blow

McQueen et al; JBJS Br 2000

IncidenceIncidence

McQueen et al; JBJS Br 2000McQueen et al; JBJS Br 2000 164 pts with CS, 149 male, 15 female164 pts with CS, 149 male, 15 female Most pts were usually under 35 Most pts were usually under 35 69% with associated fx, about half were tibial 69% with associated fx, about half were tibial

shaftshaft 23% soft tissue injury without fx23% soft tissue injury without fx

PathophysiologyPathophysiology

Normal tissue pressureNormal tissue pressure 0-4 mm Hg 0-4 mm Hg 8-10 with exertion 8-10 with exertion

Absolute pressure theoryAbsolute pressure theory 30 mm Hg - Mubarak30 mm Hg - Mubarak 45 mm Hg - Matsen45 mm Hg - Matsen

PathophysiologyPathophysiology

Pressure gradient theoryPressure gradient theory < 20 mm Hg of diastolic pressure – Whitesides< 20 mm Hg of diastolic pressure – Whitesides McQueen et al McQueen et al differential pressure (diastolic minus the compartment pressure) of differential pressure (diastolic minus the compartment pressure) of

<30 mm Hg is a criterion for fasciotomy.<30 mm Hg is a criterion for fasciotomy.

The normal mean interstitial tissue pressure is near zero in non-The normal mean interstitial tissue pressure is near zero in non-contracting muscle. If this pressure becomes elevated to 30 mmHg or contracting muscle. If this pressure becomes elevated to 30 mmHg or more, small vessels in the tissue become compressed, which leads to more, small vessels in the tissue become compressed, which leads to reduced nutrient blood flow, ischemia and pain. Of particular reduced nutrient blood flow, ischemia and pain. Of particular importance is the difference between compartment pressure and importance is the difference between compartment pressure and diastolic blood pressure; where diastolic blood pressure exceeds diastolic blood pressure; where diastolic blood pressure exceeds compartment pressure by less than 30 mmHg it is considered an compartment pressure by less than 30 mmHg it is considered an emergency emergency

Tissue SurvivalTissue Survival

MuscleMuscle 3-4 hours - reversible changes3-4 hours - reversible changes 6 hours - variable damage6 hours - variable damage 8 hours - irreversible changes8 hours - irreversible changes

Nerve Nerve 2 hours - looses nerve conduction2 hours - looses nerve conduction 4 hours - neuropraxia4 hours - neuropraxia 8 hours - irreversible changes8 hours - irreversible changes

DiagnosisDiagnosis

Pain out of proportionPain out of proportion Palpably tense compartmentPalpably tense compartment Pain with passive stretchPain with passive stretch Paresthesia/hypoesthesiaParesthesia/hypoesthesia ParalysisParalysis Pulselessness/pallorPulselessness/pallor

Clinical EvaluationClinical Evaluation

““Pain and the aggravation of pain by passive Pain and the aggravation of pain by passive stretching of the muscles in the compartment stretching of the muscles in the compartment

in question are the most sensitive (and in question are the most sensitive (and generally the only) clinical finding before the generally the only) clinical finding before the onset of ischemic dysfunction in the nerves onset of ischemic dysfunction in the nerves

and muscles.”and muscles.” Whitesides AAOS 1996Whitesides AAOS 1996


Pain – most important. Especially pain out of Pain – most important. Especially pain out of proportion to the injury (child becoming more proportion to the injury (child becoming more and more restless /needing more analgesia)and more restless /needing more analgesia)

Most reliable signs are pain on passive Most reliable signs are pain on passive stretching and pain on palpation of the stretching and pain on palpation of the involved compartmentinvolved compartment

Other features like pallor, pulselessness, Other features like pallor, pulselessness, paralysis, paraesthesia etc. appear very late paralysis, paraesthesia etc. appear very late and we should not wait for these things.and we should not wait for these things.


Beware of epidural analgesiaBeware of epidural analgesia

Beware long acting nerve blocksBeware long acting nerve blocks

Beware controlled intravenous opiate Beware controlled intravenous opiate analgesiaanalgesia

Beware of Tourniquet palsy. Beware of Tourniquet palsy.

Differential DiagnosisDifferential Diagnosis

Arterial occlusionArterial occlusion

Peripheral nerve injuryPeripheral nerve injury

Muscle ruptureMuscle rupture

Pressure MeasurementsPressure Measurements

Suspected compartment syndromeSuspected compartment syndrome

Equivocal or unreliable casesEquivocal or unreliable cases

Clinical adjunctClinical adjunct

ContraindicationContraindication

Clinically evident compartment syndromeClinically evident compartment syndrome


InfusionInfusion manometermanometer salinesaline 3-way stopcock3-way stopcock

(Whitesides, CORR 1975)(Whitesides, CORR 1975) CatheterCatheter

wickwick slit wickslit wick

Arterial lineArterial line 16 - 18 ga. Needle 16 - 18 ga. Needle Transducer Transducer Monitor Monitor

Stryker deviceStryker device Side port needleSide port needle


Arterial lineArterial line Zero at the level of the Zero at the level of the

affected limbaffected limb


Simple NeedleSimple Needle 18 gauge18 gauge Least accurateLeast accurate Usually gives falsely Usually gives falsely

higher readinghigher reading

Slit Catheter and Side Slit Catheter and Side ported needleported needle No significant differenceNo significant difference More accurateMore accurate


Measurements must be made in all Measurements must be made in all compartmentscompartments

Anterior and deep posterior are usually highestAnterior and deep posterior are usually highest Measurement made within 5 cm of fxMeasurement made within 5 cm of fx Marginal readings must be followed with Marginal readings must be followed with

repeat physical exam and repeat compartment repeat physical exam and repeat compartment pressure measurementpressure measurement

Heckman, WhitesidesHeckman, Whitesides JBJS 1994JBJS 1994

Algorithm for management of a Algorithm for management of a patient with suspected CS.patient with suspected CS.

ManagementManagement Emergent TreatmentEmergent Treatment

Ensure patient is normotensive ,as hypotension Ensure patient is normotensive ,as hypotension reduces prefusion pressure and facilitates reduces prefusion pressure and facilitates further tissue injury. (IV FLUIDS)further tissue injury. (IV FLUIDS)

Remove cicumferential bandages and castRemove cicumferential bandages and cast Maintain the limb at level of the heart as Maintain the limb at level of the heart as

elevation reduces the arterial inflow and the elevation reduces the arterial inflow and the arterio-venous pressure gradient on which arterio-venous pressure gradient on which perfusion depends. perfusion depends.

Supplemental oxygen administration. Supplemental oxygen administration.

Cast removal Cast removal

Compartmental pressure falls by 30% when cast is Compartmental pressure falls by 30% when cast is split on one sidesplit on one side

Falls by 65% when the cast is spread after splitting. Falls by 65% when the cast is spread after splitting. Splitting the padding reduces it by a further 10% and Splitting the padding reduces it by a further 10% and

complete removal of cast by another 15% complete removal of cast by another 15% Total of 85-90% reduction by just taking off the Total of 85-90% reduction by just taking off the

plaster!plaster!

Garfin, Mubarak JBJS 1981

Surgical TreatmentSurgical Treatment

Fasciotomy- Fasciotomy- prophylactic release of pressure prophylactic release of pressure before permanent damage occurs. Will not before permanent damage occurs. Will not reverse injury from trauma.reverse injury from trauma.

Fracture care – stabilization Fracture care – stabilization Ex-fixEx-fix

Indications for FasciotomyIndications for Fasciotomy

Unequivocal clinical findingsUnequivocal clinical findings Pressure within 30 mm hg of DBPPressure within 30 mm hg of DBP Rising tissue pressureRising tissue pressure Significant tissue injury or high risk ptSignificant tissue injury or high risk pt > 6 hours of total limb ischemia> 6 hours of total limb ischemia As a general rule, when in doubt, the As a general rule, when in doubt, the

compartment should be releasedcompartment should be released. .

CONTRAINDICATION - CONTRAINDICATION - Missed compartment syndrome (>48hrs)Missed compartment syndrome (>48hrs)

Fasciotomy PrinciplesFasciotomy Principles

Make early diagnosisMake early diagnosis LongLong extensile incisions extensile incisions Release all fascial compartmentsRelease all fascial compartments Preserve neurovascular structuresPreserve neurovascular structures Debride necrotic tissuesDebride necrotic tissues Coverage within 7-10 daysCoverage within 7-10 days

CompartmentsCompartments

Most commonMost common ForearmForearm LegOther compartmentsLegOther compartments HandHand FingerFinger Gluteal Gluteal ThighThigh Foot.Foot.

Compartment syndrome Compartment syndrome can develop anywhere can develop anywhere skeletal muscle is skeletal muscle is surrounded by surrounded by substantial fascia, substantial fascia, however, such as in the however, such as in the buttock, thigh, shoulder, buttock, thigh, shoulder, hand, foot, arm, and hand, foot, arm, and lumbar paraspinous lumbar paraspinous muscles. muscles.

ForearmForearm

Four interconnected compartments of the Four interconnected compartments of the forearm are recognized :(1) the superficial forearm are recognized :(1) the superficial volar compartment, (2) the deep volar volar compartment, (2) the deep volar compartment, (3) the dorsal compartment, (4) compartment, (3) the dorsal compartment, (4) and the compartment containing the mobile and the compartment containing the mobile wad of Henry (brachioradialis and extensor wad of Henry (brachioradialis and extensor carpi radialis longus and brevis). carpi radialis longus and brevis).

Forearm Forearm FasciotomyFasciotomy

When performing a volar fasciotomy, a volar When performing a volar fasciotomy, a volar curvilinear incision is used, which allows curvilinear incision is used, which allows release of the lacertus fibrosus proximally and release of the lacertus fibrosus proximally and the carpal tunnel distally. The interval between the carpal tunnel distally. The interval between the flexor carpi ulnaris and the flexor the flexor carpi ulnaris and the flexor digitorum sublimis is used for release of deep digitorum sublimis is used for release of deep and superficial compartments. The dorsal and superficial compartments. The dorsal forearm fascia is released through the interval forearm fascia is released through the interval between the extensor carpi radialis brevis and between the extensor carpi radialis brevis and the extensor digitorum communisthe extensor digitorum communis


Volar-Henry approachVolar-Henry approach Include a carpal tunnel releaseInclude a carpal tunnel release

Release lacertus fibrosus and fasciaRelease lacertus fibrosus and fascia Protect median nerve, brachial artery and Protect median nerve, brachial artery and

tendons after releasetendons after release Consider dorsal releaseConsider dorsal release

Established Volkmann Contracture of Established Volkmann Contracture of the Forearmthe Forearm

If a compartment syndrome is untreated or If a compartment syndrome is untreated or inadequately treated, compartment pressures continue inadequately treated, compartment pressures continue to increase until irreversible tissue ischemia occurs. to increase until irreversible tissue ischemia occurs. Volkmann ischemic contracture is the result of Volkmann ischemic contracture is the result of several different degrees of tissue injury several different degrees of tissue injury

The typical clinical picture of established Volkmann The typical clinical picture of established Volkmann contracture includes elbow flexion, forearm contracture includes elbow flexion, forearm pronation, wrist flexion, thumb adduction, pronation, wrist flexion, thumb adduction, metacarpophalangeal joint extension, and finger metacarpophalangeal joint extension, and finger flexion. flexion.

Contracture of the Forearm Grades & Contracture of the Forearm Grades & TreatmentTreatment

mild contracture -partial ischemia of the profundus mild contracture -partial ischemia of the profundus mass with flexion contractures usually involving only mass with flexion contractures usually involving only two or three fingers. Sensory changes usually are two or three fingers. Sensory changes usually are mild or absent. Intrinsic muscle contractures and joint mild or absent. Intrinsic muscle contractures and joint contractures are absent. During the early stages of a contractures are absent. During the early stages of a mild contracture, dynamic splinting to prevent wrist mild contracture, dynamic splinting to prevent wrist contracture, functional training, and active use of the contracture, functional training, and active use of the muscles may be helpful. After 3 months, the involved muscles may be helpful. After 3 months, the involved muscle-tendon units can be released and lengthened .muscle-tendon units can be released and lengthened .

Cont…Cont…

moderate contracture -involves not only the long moderate contracture -involves not only the long finger flexors, but also the flexor pollicis longus and finger flexors, but also the flexor pollicis longus and possibly the wrist flexors. Median and ulnar nerve possibly the wrist flexors. Median and ulnar nerve sensory changes and intrinsic minus deformities are sensory changes and intrinsic minus deformities are present. In this instance, the muscle sliding operation, present. In this instance, the muscle sliding operation, a careful neurolysis of the median and ulnar nerves a careful neurolysis of the median and ulnar nerves without injuring their branches, and the excision of without injuring their branches, and the excision of any fibrotic muscle mass encountered may be done. any fibrotic muscle mass encountered may be done. When no useful movement of the finger flexors has When no useful movement of the finger flexors has been retained, volar muscle transfers.been retained, volar muscle transfers.

Cont…Cont… severe contracture -involves the flexors and extensors severe contracture -involves the flexors and extensors

of the forearm. Fractures of the forearm bones and of the forearm. Fractures of the forearm bones and scars on the skin also may be present . The preferred scars on the skin also may be present . The preferred treatment in these instances is early excision of all treatment in these instances is early excision of all necrotic muscles, combined with complete median necrotic muscles, combined with complete median and ulnar neurolysis to restore sensibility and and ulnar neurolysis to restore sensibility and possibly intrinsic function. Tendon transfers to possibly intrinsic function. Tendon transfers to restore function should be performed as a secondary restore function should be performed as a secondary procedure (the brachioradialis is transferred to the procedure (the brachioradialis is transferred to the flexor pollicis longus and the extensor carpi radialis flexor pollicis longus and the extensor carpi radialis longus to the flexor digitorum profundus of all four longus to the flexor digitorum profundus of all four fingers.)fingers.)

HandHand

non specific aching of non specific aching of the handthe hand

disproportionate paindisproportionate pain loss of digital motion & loss of digital motion &

continued swellingcontinued swelling MP extension and MP extension and

PIP flexionPIP flexion difficult to measure difficult to measure

tissue pressuretissue pressure

Fasciotomy of HandFasciotomy of Hand

10 separate osteofascial 10 separate osteofascial compartmentscompartments dorsal interossei (4) dorsal interossei (4) palmar interossei (3)palmar interossei (3) thenar and thenar and

hypothenar (2)hypothenar (2) adductor pollicis (1)adductor pollicis (1)

Established Intrinsic Muscle Established Intrinsic Muscle Contractures of the HandContractures of the Hand

mild -the metacarpophalangeal joints can be mild -the metacarpophalangeal joints can be passively extended completely, but while they passively extended completely, but while they are held extended, the proximal are held extended, the proximal interphalangeal joints cannot be flexed interphalangeal joints cannot be flexed (positive intrinsic tightness test); the distal (positive intrinsic tightness test); the distal intrinsic release of Littler may be indicatedintrinsic release of Littler may be indicated

Cont…Cont…

more severe -the interosseous muscles are viable but more severe -the interosseous muscles are viable but contracted, and the intrinsic tightness test is positive. contracted, and the intrinsic tightness test is positive. In these instances, the contracted muscles may be In these instances, the contracted muscles may be released from the metacarpal shafts by a muscle released from the metacarpal shafts by a muscle sliding operation .sliding operation .

most severe contractures -the intrinsic muscles not most severe contractures -the intrinsic muscles not only may be contracted, but also necrotic and only may be contracted, but also necrotic and fibrosed . In these instances, the tendon of each fibrosed . In these instances, the tendon of each muscle must be divided to release the contractures. muscle must be divided to release the contractures. Other procedures, such as capsulotomies and tendon Other procedures, such as capsulotomies and tendon transfers, also may be necessary. transfers, also may be necessary.

FingersFingers

If the fingers are tensely If the fingers are tensely swollen, and capillary refill swollen, and capillary refill is delayed, continue with is delayed, continue with digital fasciotomies digital fasciotomies through midlateral through midlateral incisions along the radial incisions along the radial border of the ring and small border of the ring and small fingers and the ulnar border fingers and the ulnar border of the index and long of the index and long fingers. fingers.

ThighThigh

Lateral to release Lateral to release anterior and posterior anterior and posterior compartmentscompartments

May require medial May require medial incision for adductor incision for adductor compartmentcompartment

LegLeg

4 compartments4 compartments

Lateral: Peroneus longus Lateral: Peroneus longus and brevisand brevis

Anterior: EHL, EDC, Anterior: EHL, EDC, Tibialis anterior, Tibialis anterior, Peroneus tertiusPeroneus tertius

Supeficial posterior-Supeficial posterior-Gastrocnemius, SoleusGastrocnemius, Soleus

Deep posterior-Tibialis Deep posterior-Tibialis posterior, FHL, FDLposterior, FHL, FDL

Surgical optionsSurgical options

FibulectomyFibulectomy Single IncisionSingle Incision Double IncisionDouble Incision

FibulectomyFibulectomy

Kelly & Whiteside in 1967Kelly & Whiteside in 1967 Can be employed if fibula is fracturedCan be employed if fibula is fractured

Single Incision FasciotomySingle Incision Fasciotomy

Davey, Rorabeck, and Davey, Rorabeck, and FowlerFowler

single longitudinal, lateral single longitudinal, lateral incision in line with the incision in line with the fibula, extending from just fibula, extending from just distal to the head of the distal to the head of the fibula to 3 to 4 cm fibula to 3 to 4 cm proximal to the lateral proximal to the lateral malleolus. Avoid injuring malleolus. Avoid injuring the superficial peroneal the superficial peroneal nerve nerve

Look for Superficial Peroneal NerveLook for Superficial Peroneal Nerve

superficial peroneal nerve exits from lateral superficial peroneal nerve exits from lateral compartment about 10 cm above lateral compartment about 10 cm above lateral malleolus and courses into the anterior malleolus and courses into the anterior compartment compartment

Risk of injuryRisk of injury

Double Incision Fasciotomy Double Incision Fasciotomy In most instances it affords better exposure In most instances it affords better exposure

of the four compartmentsof the four compartments 2 vertical incisions separated by minimum 8 cm2 vertical incisions separated by minimum 8 cm One incision over anterior and lateral One incision over anterior and lateral

compartments compartments Superficial peroneal nerveSuperficial peroneal nerve One incision located One incision located

1-2 cm behind posteromedial aspect of Tibia1-2 cm behind posteromedial aspect of Tibia Saphenous Saphenous nerve and veinnerve and vein

Use a Generous IncisionUse a Generous Incision

Lengthening the skin incisions to an average Lengthening the skin incisions to an average of 16 cm decreases intracompartmental of 16 cm decreases intracompartmental pressures significantly. pressures significantly.

The skin envelope is a contributing factor in The skin envelope is a contributing factor in acute compartment syndromes of the leg and acute compartment syndromes of the leg and The use of generous skin incisions is The use of generous skin incisions is supportedsupported

Cohen, Mubarak JBJS Br 1991

FootFoot

9 compartments9 compartments Medial, Superficial, Lateral, CalcanealMedial, Superficial, Lateral, Calcaneal Interossei(4), AdductorInterossei(4), Adductor

Careful exam with any swellingCareful exam with any swelling Clinical suspicion with certain mechanisms of Clinical suspicion with certain mechanisms of

injury injury Lisfranc fracture dislocationLisfranc fracture dislocation Calcaneus fractureCalcaneus fracture

Dorsal incision-to Dorsal incision-to release the interosseous release the interosseous and adductorand adductor

Medial incision-to Medial incision-to release the medial, release the medial, superficial lateral and superficial lateral and calcaneal compartmentscalcaneal compartments

Foot incisionFoot incision

Other AreasOther Areas

Can occur anywhere in the bodyCan occur anywhere in the body Arm-lateral incisionArm-lateral incision Buttock-posterior (Kocher) approachButtock-posterior (Kocher) approach Abdominal- with the Trauma surgeonsAbdominal- with the Trauma surgeons

Delayed FasciotomyDelayed Fasciotomy

Sheridan, Matsen.JBJS 1976 Sheridan, Matsen.JBJS 1976 infection rate of 46% and amputation rate of 21% after a infection rate of 46% and amputation rate of 21% after a

delay of 12 hours delay of 12 hours 4.5 % complications for early fasciotomies and 54% for 4.5 % complications for early fasciotomies and 54% for

delayed ones delayed ones RecommendationsRecommendations

If the CS has existed for more than 8-10 hrs, supportive If the CS has existed for more than 8-10 hrs, supportive treatment of acute renal failure should be considered.treatment of acute renal failure should be considered.

Skin is left intact and late reconstructions maybe planned.Skin is left intact and late reconstructions maybe planned.

Wound ManagementWound Management After the fasciotomy, a bulky compression After the fasciotomy, a bulky compression

dressing and a splint are applied.dressing and a splint are applied. ““VAC” (Vacuum Assisted Closure) can be VAC” (Vacuum Assisted Closure) can be

usedused Foot should be placed in neutral to prevent Foot should be placed in neutral to prevent

equinus contracture. equinus contracture. Incision for the fasciotomy usually can be Incision for the fasciotomy usually can be

closed after three to five daysclosed after three to five days

Wound ManagementWound Management

Wound is not closed at initial surgeryWound is not closed at initial surgery Second look debridement with consideration for Second look debridement with consideration for

coverage after 48-72 hrscoverage after 48-72 hrs Limb should not be at risk for further swellingLimb should not be at risk for further swelling Pt should be adequately stabilized Pt should be adequately stabilized Usually requires skin graftUsually requires skin graft DPC possible if residual swelling is minimalDPC possible if residual swelling is minimal Flap coverage needed if nerves, vessels, or bone exposedFlap coverage needed if nerves, vessels, or bone exposed

Goal is to obtain definitive coverage within 7-10 daysGoal is to obtain definitive coverage within 7-10 days

Wound ClosureWound Closure

STSGSTSG Delayed primary closure Delayed primary closure

with relaxing incisionswith relaxing incisions

Interim Coverage TechniquesInterim Coverage Techniques

Simple absorbent Simple absorbent dressingdressing

Semipermeable skin-Semipermeable skin-like membranelike membrane

Vessel loop “bootlace”Vessel loop “bootlace” ““VAC” (Vacuum VAC” (Vacuum

Assisted Closure)Assisted Closure)

Complications Related to Complications Related to FasciotomiesFasciotomies

Altered sensation within the margins of the wound (77%) Altered sensation within the margins of the wound (77%) Dry, scaly skin (40%) Dry, scaly skin (40%) Pruritus (33%) Pruritus (33%) Discolored wounds (30%) Discolored wounds (30%) Swollen limbs (25%) Swollen limbs (25%) Tethered scars (26%) Tethered scars (26%) Recurrent ulceration (13%) Recurrent ulceration (13%) Muscle herniation (13%) Muscle herniation (13%) Pain related to the wound (10%) Pain related to the wound (10%) Tethered tendons (7%)Tethered tendons (7%)

Fitzgerald, McQueen Br J Plast Surg 2000Fitzgerald, McQueen Br J Plast Surg 2000

Complications related to CSComplications related to CS

Late SequelaeLate Sequelae Volckmann’s Volckmann’s

contracturecontracture Weak dorsiflexorsWeak dorsiflexors Claw toesClaw toes Sensory lossSensory loss Chronic painChronic pain AmputationAmputation

SummarySummary

Keep a high index of suspicionKeep a high index of suspicion Treat as soon as you suspect CSTreat as soon as you suspect CS If clinically evident, do not measure If clinically evident, do not measure Fasciotomy Fasciotomy

Reliable, safe, and effectiveReliable, safe, and effective The only treatment for compartment The only treatment for compartment

syndrome, syndrome, when performed in timewhen performed in time

THANK YOUTHANK YOU

acute compartment syndrome

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