compartment syndrome
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This document provides information on compartment syndromes, including: - The pathophysiology of increased pressure within closed muscle compartments leading to reduced blood flow and tissue ischemia. - Risk factors, signs and symptoms including disproportionate pain and elevated compartment pressures measured via needle technique. - Diagnosis is clinical with compartment pressures helping to confirm. - Treatment involves urgent surgical fasciotomy to decompress all affected compartments before irreversible muscle and nerve damage occurs. - Post-fasciotomy care and complications are also discussed.
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compartment syndrome
- 1. Compartment Syndromes Dicky Aligheri ,MD Dept of CardioThoracic & Vascular Surgery National CardioVascular Centre Harapan Kita Jakarta 2013
- 2. Today • What is it • Pathophysiology • Diagnosis • Treatment
- 3. Increase in hydrostatic pressure in closed osteofascial space resulting in decreased perfusion of muscle and nerves within compartment
- 4. • RAISED PRESSURERAISED PRESSURE WITHIN A CLOSEDWITHIN A CLOSED SPACESPACE with a potential to cause irreversible damageirreversible damage to the contents of the closed space
- 5. Richard Von Volkmann, 1881 • “For many years I have noted on occasion, following the use of bandages too tightly appliedbandages too tightly applied, the occurrence of paralysis and contraction of the limb, NOT … due toparalysis and contraction of the limb, NOT … due to thethe paralysis of the nerve by pressureparalysis of the nerve by pressure, but as a quick and massive disintegration of the contractile substance and the effect of the ensuing reaction and degeneration.”
- 6. Definition • Symptoms resulting from increased pressure within a limited space – compromising • circulation • function
- 7. Pathophysiology • Local Blood Flow is reduced as a consequence: LBF=Pa-Pv / R (A-V Gradient)
- 8. Pathophysiology • A continuous increase in pressure within a compartment occurs until the low intramuscularlow intramuscular arteriolar pressure isarteriolar pressure is exceededexceeded and blood cannot enter the capillaries
- 9. Pathophysiology • Increased compartment pressure Increased venous pressure Decreased blood flow Decreases perfusion
- 10. Pathophysiology • Autoregulatory mechanisms may compensate: – Decrease in peripheral vascular resistance – Increased extraction of oxygen • As system becomes overwhelmed: – Critical closing pressure is reached – Oxygen perfusion of muscles and nerves decreases
- 11. Muscle Ischemia • 4 hours - reversible damage • 8 hours - irreversible changes • 4-8 hours - variable Hargens JBJS 1981
- 12. Muscle Ischemia • Myoglobinuria after 4 hours –Renal failure –Maintain a high urinary output –Alkalinize the urine • Cell death initiates a “vicious cycle” –increase capillary permeability –increased muscle swelling
- 13. Increased muscle swelling Increased permeability Increased compartment pressure
- 14. • Increased pressure Increased venous pressure Decreased blood flow Decreases perfusion
- 15. Increased muscle swelling Increased permeability Increased compartment pressure Repetitive Cycle
- 16. Nerve Ischemia • 1 hour - normal conduction • 1- 4 hours - neuropraxic damage reversible • 8 hours - axonotmesis and irreversible change Hargens et al. JBJS 1979
- 17. Pathophysiology: • CAUSES: • Increased Volume - internal :Increased Volume - internal : hemmorhage, fractures, swelling from traumatized tissue, increased fluid secondary to burns, post- ischemic swelling • Decreased volume - external:Decreased volume - external: tight casts, dressings • Most common cause of hemmorhage into a compartment:Most common cause of hemmorhage into a compartment: fractures of the tibia, elbow, forearm or femur
- 18. Etiology • Fractures • Soft Tissue Injury (Crush) • Arterial Injury – Post-ischemic swelling – Reperfusion injury • Drug Overdose (limb compression) • Burns
- 19. Pathophysiology: Most common causeMost common cause of compartment syndrome is muscle injurymuscle injury that leads to edema
- 20. Arterial Injuries • Secondary toSecondary to revascularizationrevascularization: • Ischemia causes damage to cellular basement membrane that results in edema • With reestablishment of flow, fluid leaks into the compartment increasing the pressure
- 21. Diagnosis • Clinical diagnosis – High index of suspicion • Syndrome – History – Physical Exam
- 22. Difficult Diagnosis • Classic signs of the 5 P’s - ARE NOT RELIABLE: – pain – pallor – paralysis – pulselessness – paresthesias • These are signs of an ESTABLISHED compartment syndrome where ischemic injury has already taken place • These signs may be present in the absence of compartment syndrome.
- 23. Diagnosis • Pain • Compartment pressure – Confirmatory test – Don’t just measure
- 24. Diagnosis • Palpable pulses are usually present in acute compartment syndromes unless an arterial injury occurs • Sensory changes and paralysisSensory changes and paralysis do not occur until ischemia has been present for about 11 hour or morehour or more
- 25. Diagnosis • The most importantmost important symptomsymptom of an impending compartment syndrome is PAINPAIN DISPROPORTIONATEDISPROPORTIONATE TO THAT EXPECTEDTO THAT EXPECTED FOR THE INJURYFOR THE INJURY
- 26. Signs & Symptoms • Pain –Passive muscle stretching –Out of proportion –Progressive –Not relieved by immobilization
- 27. Signs & Symptoms • Pain –May be worse with elevation –Patient will not initiate motion on own • Be careful with coexisting nerve injury
- 28. Signs & Symptoms • Parasthesia –Secondary to nerve ischemia • Must be differentiated from nerve injury
- 29. Signs & Symptoms • Paralysis (Weakness) – Ischemic muscles lose function
- 30. Signs & Symptoms • Tense compartment on palpation • Elevated compartment pressure
- 31. Tissue Pressure • Normal tissue pressure – 0-4 mm Hg – 8-10 with exertion • Absolute pressure theory – 30 mm Hg - Mubarak – 45 mm Hg - Matsen • Pressure gradient theory – < 20 mm Hg of diastolic pressure – Whitesides – < 30 mm Hg of diastolic pressure McQueen, et al
- 32. Tissue-Pressure: Principles • Originally, fasciotomies for tissue-pressures greater-than 30mmHg • Whitesides et al in 1975Whitesides et al in 1975 was the first to suggest that the significance of tissue pressures was in their relation torelation to diastolic blood pressurediastolic blood pressure. • McQueen et al: absolute compartment pressure is anabsolute compartment pressure is an UNRELIABLE indication for the need for fasciotomies.UNRELIABLE indication for the need for fasciotomies. BUT, pressures within 30mmHg of DP indicate compartment syndrome
- 33. Tissue-Pressure: Principles • Heckman et al demonstrated that pressure within a givenpressure within a given compartment is not uniformcompartment is not uniform • They found tissue pressures to be highest at the site or within 5cmhighest at the site or within 5cm of the injuryof the injury • 3 of their 5 patients requiring fasciotomies had sub-critical pressure values 5cm from the site of highest pressure
- 34. Who is at high risk?
- 35. High energy fractures • Severe comminution • Joint extension • Segmental injuries • Widely displaced • Bilateral • Floating knee • Open fractures
- 36. Impaired Sensorium • Alcohol • Drug • Decreased GCS • Unconscious • Chemically unconscious • Neurologic deficit • Cognitively challenged
- 37. Diagnosis • The presence of an open fracture does NOT rule out the presenceopen fracture does NOT rule out the presence of a compartment syndromeof a compartment syndrome • 6-9% of open tibial fractures are associated with compartment syndromes • McQueen et al found no significant differences in compartmentno significant differences in compartment pressures between open and closed tibial fracturespressures between open and closed tibial fractures • No significant difference in pressures between tibial fracturesNo significant difference in pressures between tibial fractures treated with IM Nails and those treated with Ex-Fixtreated with IM Nails and those treated with Ex-Fix
- 38. Criteria-Compartment Pressure • Accurately examine – Difference < 30mm Hg • Impaired – Absolute > than 30mm Hg
- 39. Needle Infusion Technique-Historical • Needle inserted into muscle, tube with air/saline interval kept at this height, manometer indicates pressure • Air injected by syringe via 3-way stopcock • When the pressure of the injected air exceeds the compartment pressure pressure, the saline interval moves in the tube • AT this point, the second personthe second person reads the pressure from thereads the pressure from the manometermanometer NEED 2 PEOPLE !NEED 2 PEOPLE ! saline
- 40. Pressure Measurement • Infusion – manometer – saline – 3-way stopcock (Whitesides, CORR 1975) • Catheter – wick – slit catheter • Arterial line – 16 - 18 ga. Needle (5-19 mm Hg higher) – transducer – monitor • Stryker device – Side port needle
- 41. • Needle – 18 gauge – Side ported • Catheter – wick – slit • Performed within 5 cm of the injury if possible-Whitesides, Heckman Side port Pressure Measurement
- 42. • Unit and needle set • Assemble unit and prime • Hold at angle to measure • Zero machine • Test each of 4 compartments – Keep calf off of bed
- 43. Most Common Locations • Leg: deep posterior and thedeep posterior and the anterioranterior compartmentscompartments • Forearm: volar compartmentvolar compartment, especially in the deep flexor area
- 44. Where to Measure
- 45. Pressure • Deeper muscles are initially involved • Distance from fracture affects pressure Heckmen et al. JBJS 1994
- 46. Compartments • Anterior • Lateral • Posterior –Deep –Superficial
- 47. Compartments • Anterior • Lateral • Posterior –Deep –Superficial EDL FDLTP Gastroc Soleus TA EHL FHL Peroneus
- 48. Treatment • Remove restricting bandages • Serial exams • When diagnosis made – Immediate surgery • 4 compartment fasciotomy
- 49. Treatment THE ONLY EFFECTIVE WAY TO DECOMPRESS AN ACUTE COMPARTMENT SYNDROME IS BY SURGICAL FASCIOTOMY!!! (unless missed compartment syndrome)
- 50. Treatment • Fasciotomy –One incision • With or without Fibulectomy –Two incisions • All 4 compartments must be released –Not selective
- 51. One Incision • Direct lateral incision
- 52. Perifibular Fasciotomy • One incision • Head of fibula to proximal tip of lateral malleolus • Incise fascia between soleus and FHL distally and extended proximally to origin of soleus from fibula • Deep posterior compartment released off of the interosseous membrane, approached from the interval between the lateral and superfical posterior compartments
- 56. Two incisions • Lateral • Medial
- 58. Double Incision • 2 vertical incisions separated by a skin bridge of at least 8 cm • Anterolateral Incision: from knee to ankle, centered over interval between anterior and lateral compartments
- 59. Double Incision • Posteromedial Incision: centered 1-2cm behind posteromedial border of tibia • Soleus must be detached from tibia in order to adequately decompress proximal portion of deep posterior compartment
- 60. Thigh • Rare • Crush injury with femur fracture • Over distraction – relative under distraction
- 61. Thigh • Quadriceps –Lateral • Hamstrings –Posterior • Abductor –Medial
- 62. Treatment • Based upon involvement • Usually Quadriceps and Hamstrings • Usually, a single lateral incision will suffice
- 63. Compartments of the Forearm • Forearm can be divided into 3 compartments: Dorsal, Volar and “Mobile Wad” • Mobile Wad: Brachioradialis, ECRL, ECRB • Dorsal: EPB, EPL, ECU, EDC • Volar: FPL, FCR, FCU, FDS, FDP, PQ
- 64. Henry Approach • Incision begins proximal to antecubital fossa and extends across carpal tunnel • Begins lateral to biceps tendon, crosses elbow crease and extends radially, then it is extended distally along medial aspect of brachioradialis and extends across the palm along the thenar crease • Alternatively, a straight incision from lateral biceps to radial styloid can be used.
- 65. Henry Approach • Fascia over superficial muscles is incised • Care of NV structures
- 66. Henry Approach • Brachioradialis and superficial radial n. are retracted radially and FCR and radial artery are retracted ulnar to expose the deep volar muscles • Fascia of each of the deep muscles is then incised
- 67. Post Fasciotomy… • Must get bone stability – IMN – exfix • ~48hrs after procedure patient should be brought back to OR for further debridement • Delayed skin closure or skin-grafting 3-7 days after the fasciotomies
- 68. Aftercare • Xeroform • VAC dressings • Elevation of limb • Delayed wound closure – Split thickness skin graft
- 69. Remember… • Fasciotomies are not benign • Complications are real >25% – Chronic swelling – Chronic pain – Muscle weakness – Iatrogenic NV injury – Cosmetic concerns *** BUT if they are needed do not come up with*** BUT if they are needed do not come up with excuses to not do them !!!excuses to not do them !!!
- 70. Chronic (Exertional) Compartment Syndrome • Transient rise in compartmental pressure following activity • Symptoms –Pain –Weakness –Neurologic deficits
- 71. Chronic Compartment Syndrome • Stress Test –Serial Compartment Pressure • Resting >15mm Hg • 5 min post-ex. >25mm Hg » Rydholm et al CORR 1983 –Volumetrics –Nerve conduction Velocities » Pedowitz et al. JHS 1988
- 72. Chronic Compartment Syndrome • Treatment – Modification of activity – Splinting – Elective Fasciotomy
- 73. Conclusion • Very important to make diagnosis • Missed compartment is devastating • Physical exam • Re-examine patient!
Editor's Notes
- Normal resting muscle tissue pressure is up to 4 mm Hg and 8-10 with exertion. Exercise induced CS may have a resting based line of 10-15 mmHg. Many studies utilizing clinical evaluations and animal models by Whitesides, Mubarak, Matsen, Heckman, Heppenstall and Matava have help to establish a better understanding of the pathophysiology and thresholds of ischemia. Two schools of though prevail: 1. The Absolute Pressure Theory of Murbarak and Matsen who suggest surgical decompression in CS with pressures that reach or exceed these thresholds. 2. The Perfusion Theory of Whitesides who demonstrated in animal models and human subjects the relationship of tissue perfusion and diastolic blood pressure. His group recommends surgical decompression when the tissue pressure is within 20mm Hg of the DBP. McQueen suggested a differential &lt;30mmHg of the diastolic pressure and the intramuscular pressure as a threshold for release as being more reliable. Mean arterial pressure can also serve as a benchmark with a release suggested when intramuscular pressure is within 45 mm Hg. Caution must be exercised in traumatized tissue and especially in hypotensive patients
- Whitesides described the use of a 3-way stop cock connected to a mercury manometer(now against JCAH rules-biohazard) An arterial line using a large bore needle hooked up to a transducer and monitor in any ICU, OR or the recovery room will work. Remember that a standard needle will give higher results than a side port (Srtyker) or wick catheter. (Moed and Thorderson, JBJS(A), 1993) The stryker device is one of the more commonly used portable hand-held devices used for the tissue pressure measurements and since the redesign of the side port needle is very accurate. All devices must have the transducer at the level of the needle to be zeroed for an accurate reading.
- Whitesides et al have demonstrated that the pressure measurements should be done within 5 cm of the fracture (tibia) to obtain a true pressure reading within the suspected compartment.