COMPARTMENT SYNDROME

ORTHOPEDICS UNIT PRESENTATION

DR. BASHIR YUNUS

4/3/14

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OUTLINE

• INTRODUCTION• AETIOLOGY• RELEVANT ANATOMY• CLASSIFICATION• PATHOPHYSIOLOGY• CLINICAL FEATURES• DIAGNOSIS• TREATMENT• PREVENTION• PROGNOSIS

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INTRODUCTION

An elevation of interstitial pressure in a closed osteofascial compartment that would lead to microvascular compromise with resultant ischemia and necrosis

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INTRODUCTION

Normal intra compartmental pressure is 0-10mmHg. Acute compartment syndrome occurs if pressure increase to 25-30mmHg or about 30mmHg below diastolic

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INTRODUCTION

• Usually occurs in younger patients(usu males under 35years)

• Site: any where skeletal muscle is surrounded by an unyielding fascial compartment; legs, forearm, thigh, arm, abdomen, buttocks, hand, feet of DM patient, lumber paraspinalmuscles

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AETIOLOGY

The causes results from either increase in content of the compartment or a reduction in its volume from external compression.

Common causesTRAUMA :- About 40% accompany tibia fracture(ant> lat>post)

– 23% accompany soft tissue trauma

– 18% complicate fore-arm fracture

– In the US 2-12% anterior distal LL injuries result in CS

– 30% of Limbs devp CS fol vascular injury

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AETIOLOGY

• Constrictive dressings/ Tight casts• TBS Splinting• Ischaemic reperfusion injuries following

vascular injuries• Burns esp circumferential• Prolonged limb compression• Poor prolonged positioning during surgery &

in drug users• Envenomations e.g Snake bites

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RELEVANT ANATOMY

• LEG : muscle compartments

– Lat compart.

– Ant. Compart.

– Post. Compart. -superficial -deep

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• FOREARM: - superficial flexor

deep flexor

extensor

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RELEVANT ANATOMY

• These compartment are separated and enclosed by tight fascial separation.

• Running through these areas are blood vessels and nerves.

• The functions of all the above mentioned structures are affected if ICP rises above Capillary pressure.

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CLASSIFICATION

• ACUTE:

is a surgical emergency which if not

recognised and treated early can lead to

devastating disabilities, amputation and even

death in some situations

• CHRONIC:

Seen in long standing runners

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CLASSIFICATION

CHRONIC

• Transient rise in compartmental pressure following activity

• Symptoms

• Pain

• Weakness

• Neurologic deficits.

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PATHOPHYSIOLOGY

• Local blood flow= arteriovenous pressure gradient(Pₐ -Pᵥ)

local vascular resistance• Injury to tissue leads to oedema with increase

tissue pressure and increase Pᵥ. There is deminished arteriovenous pressure gradient with resultant deminished or absent local blood flow.(Pᵥ >30mmHg for a prolong period)

• Arterial blood flow however continued until late stages.

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Pathophysiology

• Increased compartment pressure

Increased venous

pressureDecreased blood

flow

Decreases

perfusion

Increased muscle

swelling

Increased

permeability

Increased compartment

pressure

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CLINICAL FEATURES

• Pain• Paraesthesia• Pallor• Pulselesness• Paralysis – loss of vibration sense is early.• ‘Perishing cold’–• Patients prone to compartment syndrome;• Hypotension• External compression• Coagulopathy• Vascular injury or repair

Less prone if well resuscitated

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CLINICAL FEATURES

• PAIN

– Earliest symptom & most important

– Severe & out of proportion, rest pain and pain on passive stretch

– Occasionally not reliable eg. Unconscious anaesthesized, children and in nerve injury

– It is 19% sensitive and 97% specific

– There is false negative or missed cases

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CLINICAL FEATURES

• PARASTHESIA/HYPOESTHESIA

– Occur in the territory of the Nerve within the compartment.

– It is the first sign of Nerve ischaemia

– It can be due to N. injury

– 13% sensitive and 98% specific

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CLINICAL FEATURES

• PARALYSIS

– It affects the muscle within the compartment

– It is a late sign

– Can be due to inhibition by pain, muscle injury or N injury

– It has a low sensitivity

– ACS with muscle deficit, complete recovery is rare

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CLINICAL FEATURES

• PERISHING COLD– The part of the body affected feels cold due to

decreased blood flow

• PULSELESSNESS– It is a very late features,it follows onset of gangrene– It can be as a result of major vascular injury

• SWELLING– The affected compartment is usually swollen – It may be difficult to assess b/cos of cast ,dressing or

the location of the compartment– Skin changes are late features ACS

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DIAGNOSIS

• Mainly clinical

• There should be high index of suspicion.

Passive stretching of fingers or toes (muscle stretch)will lead to severe pain (diagnostic sign)

Never wait for signs of ischemia (5Ps): irreversible damage

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Objective method of diagnosing ACS

Involves dynamic measurement of ICP which was introduced in 1970 following Matson unified concept of identifying increase ICP irrespective of aetiology.

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Indications include:(i) Unconscious patient(ii) Uncooperative patient(iii) Children(iv) Equivocal features(v) Multiply injured patients(vi) Assessment of adequacy of decompressive

fasciotomy.Current Concept is that ICP should be measured in

all cases of suspected

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Devices adopted for measurement include:

(i) Hand-held needle manometer

(ii) The wick – catheter

(iii) The Slit – catheter

(iv) Solid – state transducer intra-compartment catheter (STIC)- stryker

(v) Transducer – tipped – probe

(vi) Whiteside manuever

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Stryker STIC Monitor

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Wick hand held instrument

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Whiteside maneuver

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Interpretations of measurement of intra-compartmental pressure

I. Absolute intracompartment pressure

level of >30mmHg

(ii) Differential pressure: the concept is that the level of ICP at which ischaemic of tissue occurs is related to the perfusion pressure.

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(iii) Delta pressureDiastolic – ICPrange 10-35mmHg< 30mmHg

Time factor - The intracompartmentalpressure should however not be treated in isolation rather the trend of ICP over time or Delta Pressure should be observed.

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Other supportive inx

Lab studies:

• FBC,Creatine, phosphokinase & Urine myoglobin,Serum

• myoglobin,Urinalysis,PT & APTT, Urine

• toxicology screen,

X-RAY of affected extremity

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DIFFERENTIAL DIAGNOSIS

• Cellulitis

• Coelenterate and Jellyfish Envenomations

• DVT and Thrombophlebitis

• Gas Gangrene

• Necrotizing Fasciitis

• Peripheral Vascular injuries

• Rhabdomyolytis

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Treatment

• Don’t wait so long

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Treatment

GENERAL: ABCD OF RESUSCITATION Since ACS is often due to trauma,follow the ATLS

protocol to stabilize the patient

SPECIFIC:(i) Remove all the circumferential dressing down

to the skin eg bandage, casts(ii) Do not elevate the limb above heart level(iii) fasciotomy.

This must be prompt and adequate.

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Treatment

catastrophic clinical results were inevitable iffasciotomy were delayed for over 12hrs butfull recovery was achieved if decompressionwas performed within six hours of makingdiagnosis.

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INDICATIONS FOR FASCIOTOMY

1. Clinical features highly suggestive of ACS

2. Absolute compartment pressure >30-40 mmHg

3. Mean arterial pressure – ICP >40mmHg

4. Diastolic BP – ICP (delta p) <30mmHg

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COMPLICTIONS OF FASCIOTOMY

• Complications are real >25%

– Chronic swelling

– Chronic pain

– Muscle weakness

– Iatrogenic NV injury

– Cosmetic concerns

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Early complicatios of CS

• Myoglobinemia

• Hypercalemia

• Acidosis

• Infection

• Acute renal injury

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Prevention

• High index of suspicion on complaint of extremity pain esp post high velocity injury & px on cast

• Health education of px in cast on recognition of symptoms & early re-presentation in the hospital

• Waiting for swellings to resolve b4 application of cast

• Splitting of cast

• Routine measurement of ICP

• Prompt tx on diagnosis

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prognosis

1. Nerve dysfxn maybe reversible with time but infarcted muscle is damaged permanently.

2. Early surgery gives good fxnal outcome but delay results in muscle ischaemia & necrosis

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Role of TBS

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Conclusion

• Compartment syndrome is a serious syndrome, Which needs

• to be diagnosed early.• Palpable pulse doesn’t exclude compartment

syndrome• If diagnosis and fasciotomy were done within 24 hrs,

the • prognosis is good.• If delayed, complications will develop.

• The earlier you diagnose, the safer you are

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1.Apley’s system of orthopedics and fractures; Louis et al, 9th edition

2.Principles Of Surgery; Schwartz.7th edition.1999.

3. A.H.CrenshawCampbell,s Operative Orthopedics;

8th Edition,20024.E-medicine;5.Ronald Mcrae, Max Esser;Practical Fracture Treatment, 4th ed. Churchill

Livingstone,200

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