Compartment syndromes 3

Acute Compartment Syndrome (ACS) of lower extremities : 

Acute Compartment Syndrome (ACS) of lower extremities 2nd Surgery Journal club presentation By A. Mbuyi Tshimpanga

Presentation outline : 

Presentation outline Objectives Definition Pathophysiology Clinical evaluation Diagnosis Management Complications Summary References 2

Objectives : 

Objectives 3 To recognise the importance of ACS To identify and manage ACS To know how to measure and monitor ICP To Prevent the occurrence of ACS To possibly develop a guideline for BPH

Definition : 

Definition Clinical manif. due to sudden and severe microvascular compromise caused by raised interstitial pressure in a closed osteofascial compartment >> neuromuscular malfunction >> irreversible tissue damage. 4

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HISTORY 1872- R.V. Volkmann described contracted state believed due to ischemic muscle 1906-Hildebrand :“Volkmann’s ischemic contracture” 1914 - Murphy recommended fasciotomy to prevent contracture 5

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HISTORY 1940-Griffiths ‘4 Ps’ 1941- Bywaters made researches during World war II 1968: wick catheter introduced, made popular by Mubarak in 1976 6

Demographics : 

Demographics 36-45% # tibial shaft (open/closed) 23% soft tissue injury without # 19% with isolated vascular injury require fasciotomy 10% on anticoagulants High energy = low energy incidence 7 European journal of trauma & emergency surgery, 2007, MC Queen & al. 2007 www.emedicine.com/ Acute Compartment Syndrome

Sites of ACS : 

Sites of ACS Can develop anywhere a skeletal muscle is surrounded by a fascia. ACS may occur in foot, leg, thigh, buttocks, lumbar paraspinous muscles, hand, forearm, arm and shoulder. 8

Compartments : 

Compartments Foot 9: separated into 4gps: (- central/calcaneal - intrinsic/interosseous – medial and – lateral) Leg: 4 (anterior, lateral, sup & deep posterior) Thigh 3 (anterior, posterior, medial) Gluteal region: 3. maximus, tensor, and medius/minimus. 9

Aetiology : 

Aetiology Externally applied pressure: - tight closed casts/dressing/bandage - lying on limb for long period* - MAST / PASG - malfunctioning pneumatic boot - circular burn eschar* - prolonged tourniquet - crash injury - Excessive trans-osseous traction in # 10

During surgery : 

During surgery Limb malposition during traction / procedure 11

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Aetiology (2) Expanding IC volume tissue oedema: - contusion (e.g. crush injury) - fracture/osteotomy (tibial #) - post-op, closing fascial gap - post-ischemic swelling - snakebite Myositis, Intra-compartmental fluid infusion, etc. 12

Pathophysiology : 

Pathophysiology ICP → vascular compromise → local/distal tissue ischaemia Muscle metabolism: 5-7 mmHg O2 tension, which can readily be obtained with a CPP of 25 mmHg and an interstitial tissue pressure of 4-6 mmHg. 13

Pathophysiology of ACS : 

Pathophysiology of ACS Local blood flow = (Pa-Pv)/R. Perfusion pressure ∆P = DBP – ICP (Whiteside theory) The elevated ICP increases the local venous pressure leading to narrowed arterio-venous perfusion gradient and compartment tamponade, resulting in nerve injury and muscle ischemia in 4-6 hrs. ICP: normal <10 mmHg 10 – 30: latent CS >30: manifest CS 14 Emedicine online/acute compartment syndrome physiopathology

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Ischemia – oedema cycle 15 Further cell damage Raised ICP Injury raised capillary permeability Oedema Cell death/ mediator release Hypoxia Vascular compromise Rhabdomyolysis & Nerves injury

Clinical evaluation: 6P’s : 

Clinical evaluation: 6P’s History: - aetiological factor - mechanism of injury - additional info (coagulopathy, CRF, angiopathy…) Complaints: - Pain - Paresthesia - Weakness of limb 16

Physical examination: : 

Limb: Pale, tensely swollen & shiny Wooden feeling, Tenderness* Dysesthesia with loss of 2 points discrimination - Paresis / Paralysis - Pulselessness* - Poikilothermia 17 Physical examination:

Clinical Evaluation : 

Clinical Evaluation The diagnosis of ACS may be delayed in : - patients with multiple injuries, - altered consciousness*, - drug abuse - patients with altered neurological function caused by vascular injuries, peripheral nerve injury - continuous epidural anesthesia 18

Intracompartment pressure measurement : 

Intracompartment pressure measurement N.B: Diagnosis of ACS is always clinical, pressure measurement provides additional information Compartment pressure measurement should be taken on the maximum swelling site (see the diagram) 19

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20

Intracompartmental pressure measurement : 

Intracompartmental pressure measurement ICP can be measured using different devices: - stryker pressure monitor (hand-held) - slit catheter - wick catheter - fiberoptic transducer (Camino catheter) 21

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Measurement technique : 

Measurement technique Patient in a comfortable position Mark the site, skin disinfection Assemble the system Zero the stryker monitor Subfascial catheter tip insertion Get the reading in mmHg. For intermittent ICP monitoring 23

Gadgets for ICP measurement : 

Gadgets for ICP measurement 24

If the electronic gadget not available: : 

If the electronic gadget not available: - intravenous tubing filled by NS - NS 15 mls in - a syringe (20mls) - a 3 way stopcock - a G18 side-port needle / cannula - Mercury manometer 25

ICP measurement procedure : 

ICP measurement procedure Prepare the site Connect the system set at horizontal level with puncture site Insert the needle into muscle Depress gradually the syringe plunger vs. ICP and watch the mercury column; When the pressure in the system surpasses the ICP, a small amount of NS will be injected in muscle Get the reading 26

Management of ACS : 

Management of ACS NON INVASIVE Rx - Release of constrictive - Correction of coagulopathy - Elevation of limb - Treat systemic hypotension / shock - Antivenin* - Hyperbaric oxygen* - Use of mannitol* 27 Mannitol treatment for acute compartment syndrome. Nephron. Aug 1998;79(4):4923.  - www.emedecine.com/acute compartment syndrome/ updated Feb. 2009

Management of ACS : 

Management of ACS If symptoms don’t resolve in 30 to 60 min after appropriate treatment, repeat pressure measurement, and if equivocal fasciotomy is indicated. 28

INVASIVE Rx: FASCIOTOMY : 

INVASIVE Rx: FASCIOTOMY Kuri JA, Difelice GS. Acute compartment syndrome of the thigh following rupture of the quadriceps tendon. J Bone Joint Surg Am 2006;88:418–20. 29

Surgical emergency Fasciotomy : 

Surgical emergency Fasciotomy ACS clinically suspected and not resolving after 1h of non invasive Rx; Elevated pressure - ICP > 30 mmH - or ∆P < 30 mmHg (∆P = DBP – ICP Kuri JA, Difelice GS. Acute compartment syndrome of the thigh following rupture of the quadriceps tendon, 2006;88:418–20. 30

Fasciotomy : 

Fasciotomy Pre-op antibiotics (antistaphylo.) Local anaesthesia Limb disinfection Dermato-fasciotomy* Other relevant procedures Muscle debridement should be kept to a minimum 31

Slide 32: 

Fasciotomy follow-up After decompression: wound is packed with moist dressing Splinting in functional position OR for 2nd look in 2-5 days: debridement. If no evidence of muscle necrosis the skin is loosely closed the debridement is repeated after another 72h, then skin closure/skin grafting 32

Slide 33: 

Correction of associated disorder Hyperkalemia Dehydration ARF Infection Coagulopathy Etc. 33

Lab studies : 

Lab studies Serum: - serial CK, Myoglobin - electrolytes (K+) - BUN - Creatinine CBC - anemia (worsens ischemia) - wbc Coagulation profile Culture/sensitivity… 34

DDg of ACS : 

DDg of ACS Cellulitis Osteomyelitis / periostitis DVT Gas gangrene Necrotizing fasciitis Peripheral vascular injury Rhabdomyolysis 35

Prognosis : 

Prognosis Excellent to poor, depending on how quickly it is diagnosed and treated; 20% of patients may have persistent sensory or motor deficits at 1-year follow-up. 36

Acute complications : 

Acute complications Rhabdomyolysis - Acidosis Hyperkalemia - DIC and sepsis Myoglobinuric renal failure ARDS Loss of limb Death (sepsis-MOF) 37

Chronic complications : 

Chronic complications Persistent sensory or motor deficits at 1-year f-up: 20% Volkmann’s syndrome Rockwood CA Jr, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green's Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1996, quoted in www.emedicine.com 38

Summary : 

Summary High index of suspicion remains the cornerstone of diagnosing ACS ACS is a clinical Dg ICP measurement gives additional info. In doubt, cut! Avoid delays in management Promptly recognize vascular compromise Vacuum sealing 39

References : 

References M. King & P. Bewes, primary surgery vol 2, 81.14, ed. Oxford NY, 2009, p. 345-346 JP Wyatt, RN Illingworth, CA Graham, MJ Clancy, CE Robertson, Oxford Handbook of Emergency medicine 3rd ed, 2008, p. 396 Whitesides TE, Heckman MM, Acute compartment syndrome: update on diagnosis and treatment. J Am Acad Orthop Surg. 1996;4(4):209‑218. quoted by the American Journal of Orthopedics European Journal of Emergency Surgery, 2007 – NO. 6, Urban & Vogel 40

References : 

References Daniels M, Reichman J, Brezis M. , Mannitol treatment for acute compartment syndrome.  Nephron. Aug 1998;79(4):492- 3. [Medline]. Kuri JA, Difelice GS. Acute compartment syndrome of the thigh following rupture of the quadriceps tendon, 2006;88:418–20. www\CochranFirm\resources\doc-compartment-syndrome.html on line by Samuel E. Greenberg 41

thanks : 

thanks 42