henrik grønborg, co-director rigshospitalet trauma center copenhagen · 2016-04-14 · compartment...
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Compartment syndromeDiagnostic difficulties & future developments
Henrik Grønborg, co-directorRigshospitalet Trauma Center
Copenhagen
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• The past
• The present (difficulties)– Symptoms– Diagnosis
• The future ?
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History
• Volkmann's ischaemic contracture
• Permanent flexion contracture• Claw-like deformity of the
hand and fingers
1830 - 1889
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Development of acute CSIn an enclosed muscle (osteofascial) compartment:
Increase in volume of contentsand/or
Reduction in size of compartment
↓increased pressure within the compartment
↓compression of muscles, nerves & vessels
↓impaired blood flow
↓ischemia & necrosis
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• Fracture (also open #’s)• Blunt trauma• Cast/dressing• Arterial injury• Post-ischemic
hyperperfusion• Burns/electrical injuries• Distorsion (ankle)• Tumour• Lithotomy position
• IM nailing (reaming)• Exertional states• Closure of fascial
defects• GSW / stabbings• IV & A-lines• Hemophil./coag.disorder• Intraosseous infusion• Snake bite
Numerous etiologies
……….and more
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Symptoms
• Pain out of proportion• Pain on passive stretch• Paraesthesia• Paresis• Pulses present • Palpatory pain
• ACS is a surgical emergency !
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20042008
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Patient characteristics
JBJS1996
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Patient characteristics
CJEM 2003
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• 17% of consultant anaesthetists• 9% of nonconsultant anaesthetistshad seen CS masked by regional anaesthesia !
Injury2006
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Diagnostic delay
CJEM 2003
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JOT2002
The clinical findings
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• Bayes’ theorem– Estimating the probability of a diagnosis based
on a series of clinical findings
– The likelihood ratio that compartmentsyndrome exists in a patient with a tibial shaft #
• based on pain, paresthesia, PPS, paresis:
JOT2002
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JOT2002
Clinical features of ACS of the lower leg are:
• more useful by their absence in excluding ACS• than they are when present in confirming ACS
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JOT2002
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Measurement ofintracompartmental
pressure
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Pressure monitoring
Kodiag
Stryker
Whitesidetechnique
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AJEM2003
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JBJS2005
SP
S
SL
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• A-line manometer with:– side-port needle
or– slit catheter
• Available at ICU’s !
JBJS2005
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Pressure measurementsshould be performed in:
1. both the anterior and the deepposterior compartments
2. at the level of the fracture+
3. at locations proximal and distalto the fracture zone
HeckmanJBJS-A, 1994
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• A pressure threshold of 30 mmHg seemsto give an unacceptably high rate offasciotomies– ”Even if the absolute pressure limit had been
increased to 40 or 50 mmHg, we would have 19% or 14%, respectively”
Arch OrthopTrauma Surg
1998
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– 116 patients with tibial #’s– Continuous monitoring of anterior tibial
compartment for 24 hrs– P=30 mmHg threshold for fasciotomy
• 3 patients (2.6%) fasc.• no missed cases
– If P=30mmHg• 50 patients (43%) fasc.
– If P=40mmHg• 27 patients (23%) fasc.
JBJS1996
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95 patients with 97 tibial #’s• ICP > 30mmHg
or• PP = P = (DBP – ICP) <30 mmHg
– acceptable sensitivitybut
– poor specificity too many fasciotomies
• PP = P = (MAP – ICP) <30 mmHg, used in combinationwith clinical symptoms or a second measurement after 1hr– excellent specificity
but– low sensitivity too many missed CS’s
Injury2001
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• ↑ fracture complexity => ↓ P• ↑ delay to diagnosis => ↓ P
• Open vs. closed # => ns diff. in P
• IM nail vs. Ex-Fix => ns diff. in P
JBJS1996
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• CCPM is– invasive– requires hourly nursing attention– regular in-service training of nursing staff
• not cost effective
• CCPM is not indicated in alert patients who are adequately observed
JBJS1996
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Management of acute compartmentsyndrome - how do we do it ?
Injury1998
ANZ J.Surg2007
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• 100 questionaires to consultants at different centres
• 78 answers– 36/78 had equipment for pressure monitoring
• 12/36 used equipmet routinely• 24/36 used it selectively or not at all
Injury1998
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Injury1998
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• 264 valid responses– (29% of all eligible respondents).
• 78% of respondents regularly measuredcompartment pressure– 33% used an absolute P threshold– 28% used a P threshold– 39% took both into consideration
ANZ J.Surg2007
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ANZ J.Surg2007
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ANZ J.Surg2007
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ANZ J.Surg2007
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Immediate actions• Limb elevation =>↓ compartment pressure
BUT• BP ↓ in elevated limb• 53% ↓ in perfusion pressure
NO
Wiger & Styf, J Orthop Trauma. 1998
• Cut & spread plaster• Cut webril• Remove cast
YES
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• Fasciotomy most efficacious when performed early• However, when performed late
– similar rates of limb salvage as compared to early fasc– but increased risk of infection
• Results support aggressive use of fasciotomyregardless of time of diagnosis
Surgery1997
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• 5 patients• Average delay 56 hrs (35-96 hrs)• 9 fasciotomies in lower limbs
– 1 death of septicaemia and MOF– 4 required amputations
• If CP in a closed lower limb injury > 8 to 10 hours:– ICP recordings after an 8-hour period is not useful– Treatment of potential acute renal failure must be considered– Viable skin left intact; no exposure of necrotic muscle to infection– Late reconstructive procedures to correct muscle contractures
JOT1996
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The future ?
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JBJS 1999
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Physiol Meas2004
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J OrthopTrauma
2006
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Identifying the patient at risk
• Unconsciousness• Intoxication• Concomitant nerve injury• Multiple injuries• Young children• Individual patients with equivocal
symptoms and signs • Epidural anaesthesia
”seek, and ye shall find”Matthew (ch. VII, v. 7-8)
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Trauma 2007
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Take home message• ACS is a surgical emergency• High level of suspicion (”seek, and ye shall find”)
• Classic clinical symptoms have:– low sensitivity & pos+ predictive value– high specificity & neg- predictive value
• ICP easily measured with A-line manometer• P=30 mmHg useful threshold for fasciotomy• Screening protocols for patients at risk• Non-invasive pressure monitoring is coming
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This lecture is available at:
www.flims.dk