Compartment syndrome

Compartment syndromesDr. Situ OladeleRegistrar in Trauma, Department of Surgery, National Hospital, Abuja. Sep. 2015

OutlineINTRODUCTIONCAUSESLOCATIONS OF COMPARTMENT SYNDROMES (COMMON & LESS COMMON)EXTREMITY COMPARTMENT SYNDROMEPathophysiology of compartment syndromesManagement : General clinical presentationDiagnosis and general investigationsGeneral treatment principlesPrinciples of fasciotomy

COMMON ACUTE EXTRIMITY COMPARTMENT SYNDROMES:Compartment syndrome of the leg: applied anatomy and fascitomy for leg ACSCompartment syndrome of the forearm and fasciotomy for ACS of the forearmUNCOMMON UNCOMMON EXTREMITY COMPARTMENT SYNDROMESCompartments of the arm and fasciotomy for ACS the armThe hand compartments and ACS of the handThigh compartment syndrome and managementThe compartments and ACS of the footWhat to do after fasciotomyDifferential diagnosis of ACSPrevention

Complications and prognosis of extremity compartment syndromeABDOMINAL COMPARTMENT SYNDROMEDefinitionCauses and classificationsRisk factors and grading systemClinical effects and clinical recognitionTreatment Effects of difficult abdominal wall closure in Abdominal compartment syndromeOptions of abdominal wall closure in abdominal compartment syndromePreventionPrognosis

Outline OTHER COMPARTMENT SYNDROMESThoracic compartment syndromeCranial compartment syndromeAcute orbital compartment syndromeCardiac compartment syndromeCONCLUSIONREFERENCES

Introduction Rapid elevation of interstitial pressure in an enclosed myofascial or osseofascial space that results in microvascular compromise (Also known as Volkmanns ischaemia)Can occur in any closed fascial spaceIs a clinical emergency and requires rapid recognition, diagnosis and intervention to achieve a successful clinical outcomeCan be acute or chronic (long distance runners)

Mubaraks definition6

Causes (according to Matson):compartment size1o closure of fascial defectsTight dressingsLocalised external pressurecompartment contentbleeding (post traumatic or dyscrasias)Extravasation of I.V.FMuscle hypertrophycapillary pressure & permeabilityBurnsTraumaExercisesVenous obstructionSeizureIntra-arterial drugsNephrotic syndromeSnake bites

CausesTraumatic Crush injuries and Muscle contusionsOpen or closed fracturesGunshot woundsVascular (combined Arterial & venous) injuriesExtravasation at arterial and venous access sitesBurns Osteotomy of tibia and forearm bonesNon- traumaticSnake bitesTourniquetsConstrictive dressingsTight casts

locationsCommonForearm (volar aspect is commoner)LegAbdomen*ThoracicCranial

Less Commonupper armthigh FootPalmar spacesPulp spacesShoulderButtocks Ocular

Extremity compartment syndrome

PathophysiologyMuscle oedemaPrevention of venous outflow = congestion = muscle ischemia = more muscle edemaHealing by fribrosis (Volkmanns contracture)Bleeding and space occupying hematomaExternal restrictive or compressive cast, bandagePeripheral nerves & muscles can survive as long as 4 hours under ischemia without irreversible damage, 6hrs= variable damage, >8hours irreversible damage and muscle injury

Nerve is capable of regeneration but muscle, once infarcted, can never recover and is replaced by inelastic fibrous tissue (Volkmanns ischaemic contracture).In compartment syndrome the ischaemia occurs at the capillary level, so pulses may still be felt and the skin may not be pale!

General Clinical PresentationIschemic muscle pain (earliest and most reliable)pressureparesthesiaPallorParalysisPulselessness (late sign)

Diagnosis and General Investigations High index of suspicion (If three or more clinical signs are present, the diagnosis is almost certain). REPEATED CLINICAL SURVEILLANCE OF THE LIMB!Invasive and non-invasive monitoringContinuous or serialDoppler studiesFBC % HgUrinalysis for myoglobiuriaEUCrCreatinine phosphokinase

Diagnosis and Investigations Mubarak and Hargens: says absolute tissue pressure of 30mmHg = fasciotomyWhitesides and Heckman: change in intra compartmental Pressure approaches 20 mmHg in the presence of documented rising pressure, tissue injury or history of 6hrs of total ischemia time of extremityMcQueen and Court-Brown: sustained intra compartmental pressure change of 30mmHg relative to diastolic pressure = no problemMost Doctors = P 30mmHg (30mmHg normal BP or >15-20 in Patient with low BP

Management of Hand Compartment SyndromeHigh index of suspicion and vigilanceRemoval of jewelleries and tight castsElevate and rest limbAnalgesicsFasciotomies within 6hrs of diagnosis: HAND: dorsal incisions over D2 and D4 metacarpals, Thenar release incision, Hypothenar release incision, digital mid axial

Finger/hand compartment release

Finger/hand compartment release

The thigh compartmentsThe thigh is an uncommon site for an acute compartment syndrome due to the high volume of fascial space, andblending of the thighs facial space with the hip (allowing extravasation of content outside the compartment)The thigh has three compartmentsAnterior (quadriceps)Medial (adductors)Posterior (hamstrings)

Risk factors for thigh compartment syndromeExternal compression of the thigh (eg cast or bandage)CoagulopathySevere blunt traumaCercumferencial burnsOverlenghtening with skeletal traction (reducing compartment volumes)Systemic hypotension (reduced pefusion pressure)Vascuar injury (reducing muscle lood flow)

Release of thigh compartment syndromeLongitudinal incision over the lateral aspect of the thigh from the greater trochanter to thelateral epicondyle of femurTo release the anterior compartment, the iliotibial tract is incised and the vastus lateralis is reflected off the intermuscular septum bluntly To release the posterior compartment, the intermuscular septum is then incised along its length (not to close to the femur to avoid the perforating arteries passing through the septum)The medial adductor compartment is released through a separate anteromedial incision

The compartments and compartment syndrome of the footThe foot has five compartments:The lateral compartment: bounded dorsally by the 5th metatarsal shaft, laterally by plantar aponeurosis, and medially by intermuscular septumThe medial compartment: bounded dorsally by the inferior surface of the 1st metatarsal, medially by plantar aponeurosis extension & laterally by intermuscular septumCentral compartment: bounded laterally and medially by intermuscular septum, dorsally by interosseous fascia and plantarly by plantar aponeurosis

4.The interosseous compartment: bounded medially by the lateral 1st metatarsal, dorsally by metatarsals and dorsal interosseous fascia, and plantarly by planter interosseous fascia

5.The calcaneal compartment: quadratus plantae muscle

Caution: A compartment syndrome of the foot (e.g. following metatarsal fractures) is easily missed if one fails to test specifically for plantar nerve function.

Fasciotomy for the foot compartment syndrome

Compartment syndrome of the buttocks

Aetiology: can occur after gunshot wounds, abscesses, cellulitis, prolonged immobilization (surgery, coma), vascular injuries (superior gluteal aretery), hip dislocation, bone marrow biopsy, i.m injections, iliac bone grafting, robotic assisted prostatectomy, Ehler-Danlos

Clinical: tense, erythema, tenderness, palsy of sciatic nerve, myoglobinuria

What to do after fasciotomyThe wounds should be left open and inspected 2 days later: if there is muscle necrosis, debridement can be carried outAntibiotics and anti-tetanus may be given as indicated

OPTIONS OF WOUND CLOSURE:If the tissues are healthy, the wounds can be sutured by delayed primary closure (without tension)Be Allowed to heal by Secondary intensionBe Skin-grafted or covered with flapsBe closed using Negative pressure wound therapy (Vacuum Assisted Closure) could be used

Differential diagnosis DVTSepsis: cellulitis, myositis, abscessFatigue fracture may be mistaken for a chronic compartment syndromeSnake biteGas gangrenePeripheral vascular injury

Prevention High index of suspicionProphylactic fasciotomies after osteotomiesFasciotomies and escarotomies in circumferential full thickness burns patientsAvoid limb nerve blocks in patients with risk of compartment syndromesRemoval of devitalised tissues and muscles during debridementAvoid casts in patients in early hours of fractureAvoid tight constrictive dressings

Prevention If the clinical signs are soft, the limb should be examined at 30-minute intervals and if there is no improvement within 2 hours of splitting the dressings, fasciotomy should be performed

Complications and PrognosisLimb dysfunction Limb amputationDeathVolkmann (Ischemic) Contracture in acute compartment syndromesPes cavus (high-arched feet)

Volkmanns ischemic contractureconstant length phenomenon

Claw foot rom calf Compartment syndrome

Abdominal compartment syndrome

Abdominal compartment syndromeDefinition:Abdominal compartment syndrome (AbCS) can be defined as increased intra-abdominal pressure(IAP) associated with adverse physiological consequences/organ dysfunctionAbdominal wall and diaphragm have good compliance and abdominal cavity behaves like a good hydraulic system.

Normal Intra-abdominal pressureNormal IAP 5-7mmHg or less. It is about 9-14mm in obese Patients. IAP is 4mmHg at 30O head up IAP is 9mmHg at 45O head up. IAP >12mmHg = intra-abdominal hypertensionAbdominal perfusion pressure (APP) = Mean arterial Pressure (MAP) Intra-abdominal pressure (IAP)Aim is to achieve APP >60 mmHg

Causes and ClassificationClassification:Primary: abdominal or pelvic pathology present (eg, abdominal distension)Secondary: nil abdominal or pelvic pathology (oedema from capillary leak or decreased oncotic pressure, ascites following shock aggressive fluid resuscitation in irreversible shock, severe haemoperitoneum)

causes(1) Retroperitoneal:Retroperitoneal oedema or haemorrhage(e.g AAA rupture)Pancreatitis, large abscesses(2) IntraperitonealMassive abdominal haemorrhageMassive pelvic haemorrhageBowel distension: ileus, mechanical obstruction, bowel oedemaascites, pneumoperitoneum, Abdominal packingReduction of a large ventral hernia(3) Abdominal wallCircumferential torso burn injuryMilitary anti-shock garments

Chronic abdominal compartment syndromeCentral obesityPregnancyAscitesLarge intra-abdominal tumors

Risk factorsMultiply injured patient requiring emergency laparotomy with abdominal packing for staged/abbreviated laparotomyPatients with coagulopathy caused by core hypothermia or cirrhosisAcute resuscitation from shock (who require vassopressors, large volume of crystalloids and blood products)

Grading system for AbCSGRADEIAP (mmHg)I10 14II15 24III25 35IV>35

Effects of ACS from IAP (abdominal and extra-abdominal)CVS:vascular resistance, venous return & CO, afterload, cardiac work, tissue perfusionRenal: renal dysfuntion from direct parenchymal compression and renal hypoperfusion and shunting of renal plasma flow, oligouria/anuria, ATNPulmonary:splinting of diaphragm, pulmonary compliance, tidal volume, respiratory acidosis

Effects of ACS from IAP (abdominal and extra-abdominal)Intestine:Bowel ishaemia and necrosis = bowel edemaGut anastomotic breakdownHepatic dysfunctionIncreased translocation of gut bacteriaDifficulties with abdominal wall closureCNSAggravated Intracranial hypertension from impaired SVC draining by intra-thoracic pressureCerebral edema, cerebral hypoxia

Effects of AbCS from IAP (abdominal and extra-abdominal)Pooling of blood in the extremities and pelvisPoor wound healingCoagulopathyDVT and PE riskAcidosis from tissue anaerobic respiration

Clinical recognitionHigh index of suspicionTensely distended abdomenProgressive oligouria inspite of adequate cardiac outputHypoxia with increased airway pressures

Measurement of intra-abdominal pressureNB: IAP at which a Patient develops AbCS is patient-specific hence recognition and treatment are based on patient physiologic response to AbCSPEEP ventilation and prone position affect IAPBladder pressure measurement:50ml H2O instilled aseptically by foleys catheterConnected to tubing elevated 50-60cm0 point is level of pubic symphysis, midline.

Measuring intra-abdominal pressure

1mmHg = 1.36cmH20Normal bladder pressure: 0-5mmHgNormal Post laparotomy bladder pressures: 10-15mmHg>20 mmHg (27 cmH2O): urgent decompression surgery2. Gastric pressure measurement:50ml via NG tube0 point is mid-axillary lineTreshhold is 2.5cm that of bladder pressure

Treatment options for AbCSGrading system for ACSGRADEIAP (mmHg)TREATMENTI10 14Normovolemic resuscitationII15 24Hypovolaemic resuscitationIII25 35Watch PO2, SaO2, urine output, Decompression laparotomy likelyIV>35Emergency re-exploration/decompression

I.V.F Resuscitation, INO2, ventilation, urethral catheter, work up for surgery as neededPercutaneous drainage of ascites

Difficult abdominal wall closure in AbCSSutures cut through fasciaRisk of burst abdomenIncreased risk of incisional herniaIncreased risk of catching a bowel loop in a suture during abdominal wall closure

Methods of improving abdominal wall closure Restricted fluidMannitolDiureticsAnalgesia, sedationNG and rectal tube decompressionBogota bagpolyglycolic acid or polypropylene mesh sewn to the fascia, split-thickness skin grafts placed directly on the bowel, Staged delayed primary closureSuture sterile 3L urobagmusculocutaneous flapsSecondary wound closure

Prevention options for AbCSVacuum assisted closureTemporary abdominal wall closure using haemostats, 3L urologic irrigation bags, bagotta bagsPercutaneous drainage of ascitesAbsorbable meshes for ventral herniaSkin grafts

PrognosisUntreated ACS leads to mortality on 50%

Thoracic compartment syndromeSimilar phenomenon as with abdominal compartment syndromeCauses: acute diaphragmatic hernia, massive haemothorax, tension pneumothorax, massive hydrothorax, pulmonary edema, tumors,Effects: hypotension, distended neck veins, shift or widening of midiastinum, respiratorry embarasmments, chest pains

Cranial compartment syndromeMonro-kelly doctrine [Scottish Surgeon Alexander Monro (1733-1817) and his student George Kellie (1758-1829) during the late 18th century] Normal ICP in supine position = 10-15mmHgCerebral prerfusion pressure (CPP) = Mean artrial pressure (MAP) intracranial pressure (ICP)Goal of CPP >60 70mmHgICP in standing adult = -10 15mmHgCauses: intracranial hemorrhage, cerebral edema, hydrocephalus, tumors, abscesses, CSF flow

Pathophysiology elevated ICP reduces cerebral perfusion pressure (CPP) = cerebral hypoxia and neuronal dysfunction and deathElevated ICP causes brain shifts = brain tissue compression and/or herniation of the brainstem or other vital structures. When the MAP is less than 65 mm Hg or greater than 150 mm Hg, the arterioles are unable to autoregulate, and blood flow becomes entirely dependent on the blood pressure, a situation defined as "pressure-passive flow."

Clinical signs: cushion triad, ipsilateral dilated pupils, vomiting, seizure, loss of consciousness, lateralising sings, Diagnosis: clinical, intracranial pressure transducerICP monitoring may be discontinued when the ICP remains in the normal range within 48-72 hours of withdrawal of ICP therapy or if the patients neurological condition improves to the point where he or she is following commands

Cranial compartment syndromeRx:Medical: elevation of HOB, O2, mannitol, frusemide, hypothermia, hyperentilationSurgical: Craniotomy and evacuation of epidural or subdural haematomaCraniectomy & storage of bone flapVentricular drainage of CSF (internal/external)

Cardiac compartment syndromeCardiac tamponade: becks triadCauses: haemopericardium, hydropericardium, TB pericarditis, bacterial pericarditisDiagnosis: Clinical and USSRx: pericardiocentesis, pericardiectomy

Acute orbital compartment syndromeRare complication of facial traumaAcute elevation of pressure within the confined orbital spaceAetiology: depressed orbital fracture, retrobulbar haematoma or edema, post Op complication, subperiosteal hematoma, orbital emphysema, intraocular hematoma, abscess, tumor, I.V.FSources of bleed include infraorbital artery, peralaminar capillariesGlaucoma: Timolol

Clinical featuresProptosisEcchymosis of eyelidsChemosisOpthalmoplegiaPapilledemaDecreased visual acuity Decreased visual fieldPale optic disc (late sign)

Acute orbital compartment syndromePathophysiology: when intraorbital pressure exceeds central retinal artery pressure = pressure ischemia = blindness. Also vasospasm from blood product decompositionTreatment :High dose steroids, mannitol, ? Beta blockersPressure decompression through orbital fractures Surgery Lateral cathotomyInferior cantholysisPROGNOSISIrreversible visual loss after 2 hours of acute orbital compartment syndrome

Conclusion Compartment syndrome can occur in any of the bodys non-expansible or minimally expansible compartment or spaceHave various aetiologies and can be acute or chronicAcute compartment syndromes and sometimes chronic compartment syndromes are surgical emergenciesCompartment syndromes are often associated with increased patients morbidity and mortality of not decompressed quickly

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De Keulenaer BL1, De Waele JJ, Powell B, Malbrain ML: What is normal intra-abdominal pressure and how is it affected by positioning, body mass and positive end-expiratory pressure? Pubmed.govhttp://emedicine.medscape.com/article/1829950-overview#a6War Surgery