COMPARTMENT SYNDROME Elevated tissue pressure within a closed fascial space Reduces tissue perfusion - ischemia Results in cell death - necrosis True Orthopaedic EmergencyLimb Compartment Syndrome Acute ChronicAbdominal Compartment Syndrome
HISTORYRichard von Volkmann 1881 Volkmann published an article in which he attempted to describe the condition of irreversible contractures of the flexor muscles of the hand to ischemic processes occurring in the forearm Application of restrictive dressing to an injured limbGerman surgeon, Halle1830 - 1889, Volkmanns Ischæmic Contracture. When the wrist is flexedborn in Leipzig, died in Jena. to a right angle it is possible to extend the fingers.
HISTORY: TIMELINEHildebrand 1906First used the term Volkmann ischemiccontracture to describe the final result of anyuntreated compartment syndrome, and wasthe first to suggest that elevated tissuepressure may be related to ischemiccontracture.Thomas 1909Reviewed the 112 published cases ofVolkmann ischemic contracture and foundfractures to be the predominant cause. Also,noted that tight bandages, an arterialembolus, or arterial insufficiency could alsolead to the problem.Murphy 1914First to suggest that fasciotomy might preventthe contracture. Also, suggested that tissuepressure and fasciotomy were related to thedevelopment of contracture.
HISTORY: TIMELINEEllis 1958Reported a 2% incidence ofcompartment syndrome with tibiafractures, and increased attentionwas paid to contractures involving thelower extremitiesSeddon, Kelly, and Whitesides 1967Demonstrated the existence of 4compartments in the leg and to theneed to decompress more than justthe anterior compartment. Sincethen, compartment syndrome hasbeen shown to affect many areas ofthe body, including the hand, foot,thigh, and buttocks
AETIOLOGYFractures-closed and open Exertional statesBlunt trauma GSWTemp vascular occlusion IV/A-linesCast/dressing Hemophiliac/coagClosure of fascial defects Intraosseous IV(infant)Burns/electrical Snake bite Arterial injury Patients with a coagulopathy are at particular risk of compartment syndrome.
FRACTUREThe most common causeIncidence of accompanying compartment syndrome of 9.1%The incidence is directly proportional to the degree of injury to softtissue and boneACS may be more prevalent after a low energy injury (lack ofcompartment disruption)Tibial diaphyseal #Distal radius #Forearm # Blick et al JBJS 1986
BLUNT TRAUMA2nd most common causeAbout 23% of CS25% due to direct blow McQueen et al; JBJS Br 2000
Hematoma after arterial puncture resulting in compartment syndromeMannitol extravasation during partial nephrectomy leading to forearm compartment syndrome
INCIDENCEMcQueen et al; JBJS Br 2000164 pts with CS,149 male, 15 femaleMost pts were usually under 35 y69% with associated fx, about half were tibial shaft23% soft tissue injury without fxRanges of 2-12% have been publishedType of Fx % of Incidence Incidence ACS all ages <35Tibial 36% 4.3% 5.9%(3 fold)diaphysisDistal 9.8% 0.25% 1.4%(30 fold)radiusForearm 7.9% 3.1% 3.2%diaphysis McQueen et al; JBJS Br 2000
Patient PositioningLeaving the calf free when the leg isplaced in the hemilithotomy positioninstead of using a standard well-legholderIncreases the difference between thediastolic blood pressure and theintramuscular pressureMay decrease the risk of compartmentsyndrome Elevation of leg Pressure on posterior compartment Circumferential inflated devices Wraps Meyer, Mubarak JBJS 2002
Role of Traction• Pressure increases linear with increasing weight – Posterior compartment of leg most effected – 1 kg added weight • 5% increase in posterior compartment • <2% increase in anterior compartment• Calcaneal traction increases dorsiflexion
Compartment Syndrome and Intramedullary NailingNassif et al, J Orthop Trauma, 2000Effect of acute reamed vs unreamed intramedullary nailing on compartmentpressure when treating closed tibial shaft fractures: a randomised prospectivestudy.Highest pressures occurred during reaming in reamed group and during nail insertionin unreamend group.However no significant difference in pressures between the two groupsSPRINT TrialNo significant difference in rates of fasciotomy following reamed and unreamed tibialnailing.
PATHOPHYSIOLOGYNormal tissue pressure 0-4 mm Hg 8-10 with exertionAbsolute pressure theory 30 mm Hg - Mubarak 45 mm Hg – MatsenPressure gradient theory < 30 mm Hg of diastolic pressure – Whitesides McQueen, et alReperfusion Injury
HOW DO WE DIAGNOSE PRESENCE OFCOMPARTMENT SYNDROME IN A TRAUMATISED LIMB?
DIAGNOSISHistory Pain out of proportionClinical exam: the Ps Palpably tense compartmentCompartment pressures Pain with passive stretchLaboratory tests Paresthesia/hypoesthesia CPK Paralysis Pulselessness/pallor Urine myoglobinPulse oximetryPulse oximetry is helpful in identifying limb hypoperfusion.Pulse oximetry is not sensitive enough to exclude compartment syndrome. “Pain and the aggravation of pain by passive stretching of the muscles in the compartment in question are the most sensitive (and generally the only) clinical finding before the onset of ischemic dysfunction in the nerves and muscles.” Whitesides AAOS 1996
CLINICAL PARAMETERSPain First symptom Classically out of portion to injury, ischemic character Exaggerated with passive stretch of the involved muscles in compartment Earliest symptom but inconsistent, minimal in deep post compartment. Not available in obtunded patientPressure Early finding Only objective finding Refers to palpation of compartment and its tension or firmnessParesthesia Also early sign Peripheral nerve tissue is more sensitive than muscle to ischemia Permanent damage may occur in 75 minutes Difficult to interpret Will progress to anesthesia if pressure not relieved
CLINICAL PARAMETERSParalysis Very late finding Irreversible nerve and muscle damage present Paresis may be present early Difficult to evaluate because of pain If motor deficit develops, full recovery is rarePallor & Pulselessness Rarely present Indicates direct damage to vessels rather than compartment syndrome (therefore arteriography indicated) Vascular injury may be more of contributing factor to syndrome rather than result
CLINICAL PARAMETERSPain – most important.Especially pain out of proportion tothe injury (child becoming more andmore restless /needing moreanalgesia)Most reliable signs are pain onpassive stretching and pain onpalpation of the involvedcompartmentOther features like pallor,pulselessness, paralysis, paraesthesiaetc. appear very late and we shouldnot wait for these things. Missing the boat Pale Willis &Rorabeck OCNA 1990 Pulseless Paralyzed
VALUE OF THESE CLINICAL PARAMETRS IN DIAGNOSIS OF COMPARTMENT SYNDROME ?Ulmer T:The clinical diagnosis of compartment syndrome of the lower leg: are clinical findingspredictive of the disorder?J Orthop Trauma 2002
Clinical Sensitivity (Ulmer T 02) Pain Paresthesia PPS Paresis Sensitivity 0.19 0.13 0.19 0.13 Specificity 0.97 0.98 0.97 0.97 PPV 0.14 0.15 0.14 0.11 NPV 0.98 0.98 0.98 0.98 Do these numbers reflect anything more than a low incidence? MISSED CASES To achieve a probability of over 90% of ACS being present 3 clinical findings must bepresent. The third clinical finding is paresis, thus to achieve an accurate clinical diagnosisof ACS the condition must be allowed to progress until late which is clearly unacceptable.
CLINICAL EVALUATIONBeware of epidural analgesia Strecker JBJS 1986 Morrow J. Trauma 1994Beware long acting nerve blocks Hyder JBJS Br 1995Beware controlled intravenous opiate analgesia
COMPARTMENT PRESSURE MONITORINGRaised tissue pressure is primary event in ACS, changes in ICP will precede the clinical signs and symptoms When to monitor? How to monitor – continuous or single measurement? Threshold for diagnosis of Compartment syndrome and Fasciotomy?
Compartment Pressure MonitoringWhen? Confirm clinical exam, Suspected compartment syndrome Patients on Ventilators Obtunded patient with tight compartments Regional anesthetic Vascular injury Alcoholics, drug additctsClinical adjunctContraindication Clinically evident compartment syndrome
Compartment Pressure MonitoringHarris et al, J Trauma, 2006:Continuous compartment pressure monitoring for tibia fractures: does itinfluence outcome?Randomized 200 Extraarticular tibial shaft fracturesMonitored (36 h continuous pressure monitoring) and unmonitored groupsLevel of Evidence : 1Results:05 cases of CS in nonmonitored group, 0 cases in monitored groupMonitored group 18 pts had ∆P(DBP-ICP) of < 30 mm Hg, none developed CS orlate sequelae.In awake and alert pt, diagnosis of CS using clinical signs in appropriate timepossible and continuous pressure monitoring in these pt not necessary.
Pressure Measurements Whitesides TechniqueSimpleDisadv - injection of saline into the compartment and this way aggravates animpending syndrome (Whitesides, CORR 1975)
Pressure Measurements Slit CatheterThe “slit” and “wick” techniquesrequired a polyethylene tubing filledwith air and no air bubbles presentwithin the tubing, connected to apressure transducer, these cancontinuous monitoring and moreaccurate.However, the end of the tubing maybe blocked by a blood clot. Moed et al JBJS 1993
Pressure Measurements Stryker STIC Monitor. A solid-state transducer intracompartmental catheter (STIC) may be used, which is more accurate and reliable. Can monitor ICP for up to 16 hours.
Pressure MeasurementsNear-Infrared Spectroscopy (NIRS)A technique that allows tracking of variations in the oxygenation of muscle tissue.It can be useful for chronic compartment syndrome in adults, but it is of little value inacute CS as changes in the relative oxygenation may have already occurred, at themoment of measurement.NIRS measures soft tissue oxygenation (StO 2 ) noninvasively, is potentially a newnoninvasive technique for the early detection of acute compartment syndrome (ACS).Animal models of ACS have shown that StO 2 correlates with perfusion pressure inthe compartment. The StO2 difference (measured noninvasively) was significantlylower among patients with an ACS, suggesting that NIRS can detect decreasing tissueoxygenation in trauma patients who are developing an ACS.
Pressure MeasurementsLaser Doppler FlowmetryLaser Doppler Flowmetry (LDF) is anon-invasive method to estimatethe blood perfusion in themicrocirculation.Uses a flexible fibre optic wirewhich is introduced into themuscle compartment and thesignals from this wire are recordedon a computer.It can be used as an adjuvantdiagnostic tool for chronic CS.
Pressure MeasurementsMeasurements must be made in allcompartmentsAnterior and deep posterior are usuallyhighestMeasurement made within 5 cm of fx Distance From Fracture Effects PressureMarginal readings must be followed withrepeat physical exam and repeatcompartment pressure measurement Heckman, Whitesides JBJS 1994
What is Critical Pressure? Significant individual variations in tolerance to raised ICP is largely because of variation in Systemic BP>30 mm Hg as absolute number (Roraback)>45 mm Hg as absolute number (Matsen)<30 mm Hg for ∆p (where ∆p =diastolic pressure – compartment pressure, McQueen)<40 mm Hg for ∆P (where ∆P mean arterial pressure* – compartment pressure, Heppenstall) *mean arterial pressure is diastolic pressure plus 1/3 of pulse pressure Whether the Absolute pressure or ∆P should be used to diagnose Compartment Syndrome ?
Threshold for fasciotomyMcQueen, Court-Brown JBJS Br 1996116 pts with tibial diaphyseal fx had continuous monitoring of anteriorcompartment pressure for 24 hours 53 pts had ICP over 30 mmHg 30 pts had ICP over 40 mmHg 04 pts had ICP over 50 mmHgOnly 03 had ∆P(DBP-ICP) of < 30, they had fasciotomyNone of the patients had any sequelae of the compartment syndrome Decompression should be performed if the differential pressure level drops to under 30 mmHg (∆P)
SUSPECTED COMPARTMENT SYNDROMEUnequivocal + Findings Pt. not alert/polytrauma/inconc. Comp. pressure measurement w/i 30 mm Hg >30 mm Hg of DBP Serial exams FASCIOTOMY FASCIOTOMY McQueen JBJSB 1996
Management• High index of Clinical Suspicion• Ensure patient is normotensive, as hypotension reduces prefusion pressure and facilitates further tissue injury.• Remove cicumferential bandages and cast• Maintain the limb at level of the heart as elevation reduces the arterial inflow and the arterio-venous pressure gradient on which perfusion depends. Perfusion pressure = A pr(30-35mmHg) – V pr(10-15mmHg)• Supplemental oxygen administration.
Removal of Circumferential CastsCompartmental pressure falls by 30% when cast is split on one sideFalls by 65% when the cast is spread after splitting.Splitting the padding reduces it by a further 10% and complete removal of cast byanother 15%Total of 85-90% reduction by just taking off the plaster! Garfin, Mubarak JBJS 1981
Surgical TreatmentFasciotomy,Fasciotomy,Fasciotomy, All compartments !!!
Surgical TreatmentFasciotomyProphylactic release of pressure before permanent damage occurs.Will not reverse injury from trauma.Fracture care – stabilization Ex-fix IM Nail
Indications for FasciotomyUnequivocal clinical findingsPressure within 15-20 mm hg of DBPRising tissue pressureSignificant tissue injury or high risk pt> 6 hours of total limb ischemiaInjury at high risk of compartment syndromeCONTRAINDICATION -Missed compartment syndrome (>24-48 hrs)
Fasciotomy PrinciplesMake early diagnosisLong extensile incisionsRelease all fascial compartmentsPreserve neurovascular structuresDebride necrotic tissuesCoverage within 7-10 days
Lower Leg4 compartments Lateral Peroneus longus and brevis Anterior EHL, EDC, Tibialis anterior, Peroneus tertius Supeficial posterior Gastrocnemius, Soleus Deep posterior Tibialis posterior, FHL, FDL
Lower LegSingle IncisionParafibular 4 compartment Fasciotomy Matsen et al (1980) Single incision just posterior to fibula Common peroneal nerve
Lower LegIsolated faciaotomy of Anterior Compartment
Lower LegDouble Incision (Recommended)In most instances it affords betterexposure of the four compartments2 vertical incisions separated by minimum8 cmOne incision over anterior and lateralcompartments Superficial peroneal nerveOne incision located 1-2 cm behindpostero-medial aspect of tibia Saphenous nerve and vein Mubarak et al JBJS 1977
Lower extremity four component fasciotomy - two incision technique.
Fasciotomy: Medial Leg Gastroc-soleus Flexor digitorum longus
Fasciotomy: Lateral Leg Intermuscular septum Superficial peroneal nerve
Lower LegLook for Superficial Peroneal NerveSuperficial peroneal nerve exits from lateralcompartment about 10 cm above lateralmalleolus and courses into the anteriorcompartmentRisk of injuryUse a Generous IncisionLengthening the skin incisions to an average of 16 cmdecreases intracompartmental pressures significantly.The skin envelope is a contributing factor in acutecompartment syndromes of the leg and The use ofgenerous skin incisions is supported Cohen, Mubarak JBJS Br 1991
Forearm3 compartments Mobile wad BR,ECRL,ECRB Volar Superficial and deep flexors Dorsal Extensors Pronator quadratus described as a separate compartment
ForearmVolar-Henry approach Include a carpal tunnel releaseRelease lacertus fibrosus and fasciaProtect median nerve, brachial arteryand tendons after releaseConsider dorsal release
Foot9 compartments Medial, Superficial, Lateral, Calcaneal Interossei(4), AdductorCareful exam with any swellingClinical suspicion with certain mechanisms of injury Lisfranc fracture dislocation Calcaneus fracture
FootDorsal incision To release the interosseous and adductorMedial incision To release the medial, superficial lateral and calcaneal compartments
Hand10 separate osteofascial compartments dorsal interossei (4) palmar interossei (3) thenar and hypothenar (2) adductor pollicis (1)non specific aching of the handdisproportionate painloss of digital motion & continued swelling MP extension and PIP flexiondifficult to measure tissue pressure
ThighLateral to release anterior and posterior compartmentsMay require medial incision for adductor compartment Vastus lateralis Lateral septum
Delayed Fasciotomy - Is it Safe?Sheridan, Matsen.JBJS 1976 Infection rate of 46% and amputation rate of 21% after a delay of 12 hours 4.5 % complications for early fasciotomies and 54% for delayed onesRecommendations If the CS has existed for more than 8-10 hrs, supportive treatment of acute renal failure should be considered. Skin is left intact and late reconstructions maybe planned.
Delayed Fasciotomy - Is it Safe?Finkelstein et al. J Trauma 1996 5 pts, nine fasciotomies in lower limbs Avg delay 56 h. (35-96 hrs). 1 pt died of septicaemia and multi organ failure, the others required amputationsRecommendations: In delayed cases, routine fasciotomy may not be successful Should we do Fasciotomy in delayed cases? If there is no likelihood of any surviving muscles and ICP is low, withhold Fasciotomy. If any possibility of viable muscle or if ICP more than critical levels, Fasciotomy should be done.
Wound ManagementAfter the fasciotomy, a bulky compression dressing and a splint are applied.“VAC” (Vacuum Assisted Closure) can be usedFoot should be placed in neutral to prevent equinus contracture.Incision for the fasciotomy usually can be closed after 3 - 5 days
Wound ManagementWound is not closed at initial surgerySecond look debridement with consideration for coverage after 48-72 hrs Limb should not be at risk for further swelling Pt should be adequately stabilized Usually requires skin graft DPC possible if residual swelling is minimal Flap coverage needed if nerves, vessels, or bone exposedGoal is to obtain definitive coverage within 7-10 days
Wound ClosureSTSGDelayed primary closure with relaxing incisions
Complications Related to Fasciotomies• Altered sensation within the margins of the wound (77%)• Dry, scaly skin (40%)• Pruritus (33%)• Discolored wounds (30%)• Swollen limbs (25%)• Tethered scars (26%)• Recurrent ulceration (13%)• Muscle herniation (13%)• Pain related to the wound (10%)• Tethered tendons (7%) Fitzgerald, McQueen Br J Plast Surg 2000
Complications related to CSLate Sequelae Volkmann’s contracture Weak dorsiflexors Claw toes Sensory loss Chronic pain Amputation
Chronic Compartment SyndromeChronic CS usually occurs in young active patients afterintense muscular activity.It is usually detected in the tibial shaft (anterior orposterior deep compartment).Main symptoms involve pain, parasthesia of the musclewithin the affected compartment, after intense andcontinuing (over than 20-30 min) streching of musclegroups.The symptoms recess progressively by interrupting anykind of exercise (15-20min).Differential diagnosis include stress fracture, superficialfibular nerve entrapment syndrome, posterior tibialmuscle tendonitis.
CASEA 27 year-old man sustained an undisplacedmidshaft fracture of his left tibia.Following an orthopedic consult, he was put in along leg cast and sent home, with orthopedicsfollow up arranged for the next day.Overnight he re-presented to the emergencydepartment with increased pain in his leg andparaesthesiae in his toes.The cast was removed.Peripheral pulses were intact, but the anteriorcompartment of the leg, in particular, was tenseand tender to palpation.He was taken to the operating theatre in themiddle of the night after an anterior compartmentpressure measurement of 60 mmHg was obtained.
CASE REPORTS Simvastatin-induced bilateral leg compartment syndrome and myonecrosis associated with hypothyroidismA 54-year-old hypothyroid maletaking thyroxine and simvastatinpresented with bilateral legcompartment syndrome andmyonecrosis.Urgent fasciotomies wereperformed and the patientmade an uneventful recoverywith the withdrawal ofsimvastatin.It is likely that this complicationwill be seen more often withthe increased worldwide use ofthis drug and its approval for allarteriopathic patients. Postgrad Med J 2007;83:152-153 doi:10.1136/pgmj.2006.051334
CASE REPORTS Bilateral compartment syndrome in thighs and legs by methanol intoxicationMethanol intoxication is infrequent eventhough it is easily obtainable. One of thecomplications in locomotor apparatus is thedevelopment of a compartment syndrome ofthe lower extremities.A 49-year-old man with a compartmentsyndrome in all compartments of both legsand the anterior compartment of both thighsdue to methanol intoxication.The patient underwent a bilateral fasciotomyof the legs and thighs.He also had haemodialysis sessions becauseof acute renal insufficiency.After 4 weeks of haemodialysis, covering ofthe fasciotomies with cutaneous autograftand rehabilitation treatment, the patient was Emerg Med J 2008;25:540-541 doi:10.1136/emj.2008.058461able to walk on his own again.
CASE REPORTS65 y M, H/o a street fight 5 days backPresented with tachycardia,hypotension, fever, confusion.O/E - secretion through a small injuryon the dorsal aspect of the proximalphalanx of 3 finger in left hand;increase of local temperature, slowcapillary reflux, edema on theforearm, flictenas on dorsum of handand forearm, exacerbated pain atfinger mobilization, and decrease indistal sensibility (median nerveterritory), no crepitation wasdetected.X Rays – No fractures, No gas, No FBTLC - 22000 The Internet Journal of Emergency Medicine 2003 : Volume 1 Number 2
CASE REPORTSDiagnosis - Hand and forearm compartmentalsyndrome secondary to hand infection.Rx-Antitetanic immunizationAntibioticsPressure in dorsal compartment was (20mmHg) and in palmar compartment (42 mm Hg).A Henry approach was performed,decompressing palmar spaces including carpaltunnel, observing edema in muscles andvenous congestion, with no infection signs.Dorsal approach on hand and forearm wasdone, purulent material (about 120 ml)drained from preretinacular space, carefullycleaning was performed, leaving the woundopen and material was sent to culture andpathology.
CASE REPORTSThe upper limb splinted and remainedelevated.Sensibility and capillary reflux improveimmediately surgery, and systemic symptomsdisappear after 6 hours.A beta hemolytic streptococcus was isolated.At 24/48 and 72 hours new toilettes wereperformed, with daily evaluation.The patient was discharged after a week oftreatment, and started hand rehabilitation,and occupational therapy.After 3 weeks the wound was closed by secondintention and mobility was acceptable.