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Traumagram summer 2016
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- 2. 2 1) Which of the following is not generally considered a risk factor for DVT? a) Obesity b) Multiple long bone fractures c) History of atrial fibrillation d) renal failure 2) What proportion of DVTs are diagnosed accurately by physical exam findings? a) < 5% b) 25% c) 50% d) > 75% 3) Which of the following is not a non-invasive test to diagnose a DVT? a) Impedance plethysmography b) duplex ultrasound c) CT-venogram d) straight leg raise 4) For which of the following procedures should pharmacologic DVT prophylaxis be held to reduce the risk of bleeding? a) Operative repair of a ruptured diaphragm b) Posterior fusion of spinal fracture c) Open reduction and internal fixation of the femur d) Closure of open abdomen 5) Which of the following prophylactic regimens is the most effective at preventing DVTs? a) Unfractionated Heparin b) LMWH c) Sequential Compression Devices (SCDs) d) LMWH + SCDs Answer Key for Spring 2016 Trauma IEP Newsletter (answers are in bold and Italics below)
- 3. 3 Rich Lesperance, MD Case Study: A 19 year old male is arrives at the trauma center as a Level 1 trauma for multiple gunshot wounds, approximately one hour after the event. In addition to several intra-abdominal injuries, one projectile traversed his upper thigh. His work-up revealed a Superficial Femoral Artery (SFA) and Vein (SFV) injury, as well as intraabdominal findings. After temporization of his intra-abdominal injuries, he underwent an interposition graft repair of his SFA and ligation of his SFV. The operative intervention required approximately two hours. In order to prevent the occurrence of a lower extremity compartment syndrome in the at risk limb, a prophylactic lower leg fasciotomy was performed. Introduction Extremity compartment syndrome is a common problem dealt with by orthopedic, vascular and trauma surgeons, and failing to diagnose and treat appropriately can leave a patient with severe life-long disability. When taking care of trauma patients we can encounter “compartment syndromes” in other body cavities, but this review will focus on acute extremity compartment syndrome. Extremity compartment syndrome was first recognized as a clinical entity by Richard von Volkmann in the late 19th century, identifying tissue ischemia as the untreated result. The debilitating forearm contractures from untreated upper extremity compartment syndrome were named “in his honor.”1 Compartment syndrome of an extremity is frequently associated with a long bone fracture up to 75% of the time; and approximately 9% of all tibial shaft fractures can be complicated by compartment syndrome.2 Young men seem to be at a higher risk for developing compartment syndrome, possibly due to higher muscle mass in a non-distensible fascial compartment, while conversely the elderly appear to have a lower risk.3 Extremity compartment syndrome can also be associated with direct trauma to the limb in the absence of a fracture (even without a clinical crush injury), and this may be associated with a higher incidence of delay in treatment and muscle necrosis.4 Other causes of extremity compartment syndrome are burns, tight casts or dressings, penetrating trauma, and inappropriate positioning in the operating room (especially during lithotomy position).2 Unusual non-trauma conditions such as Group A Streptococcal infections have been described as etiologies as well.5 Vascular injuries can also cause an extremity compartment syndrome, either through bleeding into the muscular compartment directly or via edema from ischemia-reperfusion syndrome.6 It should be noted that the arterial injury does not need to be located in the compartment at risk; proximal injuries can obviously cause ischemia in distal compartments. Combined arterial and venous injuries, such as in our patient, are at higher risk than either alone.6 Pathophysiology The fascial compartments enclosing major extremity muscle groups are relatively non-distensible, so any edema or inflammation in the compartment can cause intra-compartment pressures to rise. Ischemia occurs when compartment pressure exceeds the capillary perfusion pressure. If allowed to occur, this may lead to cellular necrosis promoting inflammation and increased pressures in a positive-feedback cycle.7
- 4. 4 Peripheral sensory nerves are the most sensitive to ischemia, showing signs of dysfunction in as little as one hour, but after four to six hours of ischemia permanent nerve and muscle damage is likely.2 Clinical presentation The classical physical exam findings of compartment syndrome are pulselessness, pain (out of proportion to injury), paresthesias, paresis (muscle weakness) and pain with passive stretching of the muscle.8 Additionally, palpation of the limb in question may allow the practitioner to detect a “tense” compartment. None of these physical exam findings have been found to be very accurate for diagnosis, however. The presence of distal pulses does not exclude compartment syndrome. As mentioned above, the syndrome exists when the compartment pressure exceeds the capillary perfusion pressure; distal arterial flow is not lost until the pressure exceeds the (much higher) systolic BP, which means significant compartment syndrome can exist even without distal arterial insufficiency. Manual detection of “tense” compartments does not seem to be very accurate either. When orthopedic surgeons were tested on a fresh cadaver leg model, their sensitivity in detecting increased compartment pressures was only 24% with specificity a little better at 55%, but presumably half of the patients undergoing a fasciotomy did not actually have elevated pressures.9 A systematic review8 of the literature evaluating the accuracy of clinical findings for diagnosis of compartment syndrome found that the classical signs of pain, paresthesia, pain with passive stretch and paresis were not very sensitive (13-19%) individually, but the presence of two or more of the signs increased the accuracy. If three or more of those classic signs were present, the authors found the odds of compartment syndrome being correctly diagnosed rose to 93%. Most of the studies agreed that pain is the earliest clinical finding, but there was a wide variety of opinions on which findings were most significant. Pain is obviously a problematic sign to rely on for diagnosis. Since a common inciting event for lower- extremity compartment syndrome is a tibial shaft fracture, it takes an experienced practitioner to differentiate fracture pain from that of compartment syndrome. Commonly used pain control adjuncts such as epidural catheters and regional anesthesia may mask worsening pain from a developing compartment syndrome,10 although this is somewhat disputed in the orthopedic literature.11 Pain assessment becomes difficult in the multi-system trauma patient, especially in ICU settings, with multiple distracting injuries and, possibly, intubated. However, pain in an ‘uninjured’ extremity should raise heavy suspicion if the limb is otherwise at risk (as in our case study, above.) Measurement of Compartment Pressures Due to the difficulty diagnosing compartment syndrome clinically, it has been suggested that direct measurement of the pressures within the compartment in question could be beneficial. Different methods of measuring pressures have been described, including a simple arterial catheter pressure-monitoring setup, side-hole catheters, or a hand-held “Stryker” device. Catheters may be left in-dwelling in certain circumstances to allow continuous monitoring of compartment pressures, as well.12 Normal compartment pressures are 8-15 mm Hg.2 It has been suggested that intra-compartment pressures greater than 30 mm Hg indicate the need for decompression.13 However, as mentioned above, ischemia results when the compartment pressure exceeds the capillary perfusion pressure and higher systemic blood pressures would presumably overcome a higher compartment pressure. For that reason, other authors have advocated using the pressure difference (“Δp”) between the diastolic blood pressure and the compartment pressure (capillary perfusion pressure is rather hard to measure). By only choosing to decompress patients with a Δp of less than 30 mm Hg, instead of using an using the absolute compartment
- 5. 5 pressure, one group found that they saved 43% of their patients an unnecessary surgery without missing any injuries.14 It is difficult to determine the pressure cutoff for decompression since there is no “gold standard” for diagnosing compartment syndrome. The surgeon’s assessment of whether the muscles “bulged” out of a compartment during fasciotomy has been historically used, but this is subjective. If the syndrome is properly treated there are no sequelae, so there are no histologic or laboratory findings to confirm retrospectively. This may suggest that compartment syndrome is over-diagnosed using current techniques.2 Due to the uncertainty regarding measurement of compartment pressures, extremity compartment syndrome remains a clinical diagnosis and pressure measurements should be used only in support.2,15 Clinical suspicion should remain high and rapid treatment performed, if suspected. Treatment of Compartment Syndrome The treatment of extremity compartment syndrome is prompt surgical decompression of the affected compartments.15 The lower leg consists of 4 separate compartments (figure), all of which will require release. This can be accomplished either through a single incision on the lateral leg, or a “two-incision” technique using a medial incision as well. General (trauma) and Vascular surgeons tend to use a two- incision technique, whereas some Orthopedic surgeons prefer the single-incision technique, which may miss the deep posterior compartment but may be beneficial for future fracture repair. As long as all four leg compartments are appropriately released, however, there is no difference in outcomes.16,17 A delay in fasciotomy increases morbidity. As mentioned above, nerves become ischemic in approximately one hour, and muscle tissue suffers irreversible damage after four to six hours. The compartments should be decompressed urgently when the diagnosis of compartment syndrome is made. Delay in surgical therapy is associated with more wound complications, worse functional outcomes, and higher rates of limb loss and mortality.18-20 Even with known deficit, decompression should still be performed urgently if there is any residual neuromuscular function in the affected extremity,21 although this is controversial and some authors claim better outcomes if surgery is not performed for a seriously delayed diagnosis.22 While fasciotomy is necessary to treat extremity compartment syndrome, it is not an entirely benign procedure, even when done prophylactically before the onset of symptoms, there is a high incidence of wound complications18,23 and need for skin grafting for definitive closure. Neurovascular structures can be easily injured during the procedure, the superficial peroneal nerve is the most frequently identified injured structure, occurring in up to 6% of fasciotomies.23 In addition, fasciotomy for compartment syndrome has been associated with increased rates of infection and mal-union of tibial fractures,24,25 although presumably the complications result from the compartment syndrome itself, and outcomes would be worse without treatment. Conclusion Extremity compartment syndrome is a difficult diagnosis that often must be made based on clinical prowess in the at risk patient population. All practitioners caring for trauma patients must be familiar with the warning signs. Direct trauma to the limb is not always required for compartment syndrome to occur; proximal vascular trauma or arterial insufficiency may cause the syndrome in distal extremities. Direct measurement of compartment pressures is invasive, and not itself diagnostic, but may be helpful in patients otherwise difficult to examine. Prompt surgical decompression of all compartments at risk is the recommended treatment, although the procedure carries a significant complication rate.
- 6. 6 References: 1. Dente CJ, Wyrzykowski AD, Feliciano DV. Fasciotomy. Curr Probl Surg. Oct 2009;46(10):779-839. 2. von Keudell AG, Weaver MJ, Appleton PT, et al. Diagnosis and treatment of acute extremity compartment syndrome. Lancet. Sep 26 2015;386(10000):1299-1310. 3. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone Joint Surg Br. Mar 2000;82(2):200-203. 4. Hope MJ, McQueen MM. Acute compartment syndrome in the absence of fracture. J Orthop Trauma. Apr 2004;18(4):220-224. 5. Kleshinski J, Bittar S, Wahlquist M, Ebraheim N, Duggan JM. Review of compartment syndrome due to group A streptococcal infection. Am J Med Sci. Sep 2008;336(3):265-269. 6. Feliciano DV. Management of peripheral arterial injury. Curr Opin Crit Care. Dec 2010;16(6):602-608. 7. Mauser N, Gissel H, Henderson C, Hao J, Hak D, Mauffrey C. Acute lower-leg compartment syndrome. Orthopedics. Aug 2013;36(8):619-624. 8. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma. Sep 2002;16(8):572-577. 9. Shuler FD, Dietz MJ. Physicians' ability to manually detect isolated elevations in leg intracompartmental pressure. J Bone Joint Surg Am. Feb 2010;92(2):361-367. 10. Azam MQ, Ali MS, Al Ruwaili M, Al Sayed HN. Compartment syndrome obscured by post-operative epidural analgesia. Clin Pract. Jan 1 2012;2(1):e19. 11. Walker BJ, Noonan KJ, Bosenberg AT. Evolving compartment syndrome not masked by a continuous peripheral nerve block: evidence-based case management. Reg Anesth Pain Med. Jul-Aug 2012;37(4):393- 397. 12. Shadgan B, Menon M, O'Brien PJ, Reid WD. Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma. Sep 2008;22(8):581-587. 13. Mubarak SJ, Owen CA, Hargens AR, Garetto LP, Akeson WH. Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg Am. Dec 1978;60(8):1091-1095. 14. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br. Jan 1996;78(1):99-104. 15. Shadgan B, Menon M, Sanders D, et al. Current thinking about acute compartment syndrome of the lower extremity. Canadian journal of surgery. Journal canadien de chirurgie. Oct 2010;53(5):329-334. 16. Bible JE, McClure DJ, Mir HR. Analysis of single-incision versus dual-incision fasciotomy for tibial fractures with acute compartment syndrome. J Orthop Trauma. Nov 2013;27(11):607-611.
- 7. 7 17. Neal M, Henebry A, Mamczak CN, Ruland R. The Efficacy of a Single-Incision Versus Two-Incision Four-Compartment Fasciotomy of the Leg: A Cadaveric Model. J Orthop Trauma. May 2016;30(5):e164-168. 18. Velmahos GC, Theodorou D, Demetriades D, et al. Complications and nonclosure rates of fasciotomy for trauma and related risk factors. World J Surg. Mar-Apr 1997;21(3):247-252; discussion 253. 19. Ritenour AE, Dorlac WC, Fang R, et al. Complications after fasciotomy revision and delayed compartment release in combat patients. J Trauma. Feb 2008;64(2 Suppl):S153-161; discussion S161-152. 20. Williams AB, Luchette FA, Papaconstantinou HT, et al. The effect of early versus late fasciotomy in the management of extremity trauma. Surgery. Oct 1997;122(4):861-866. 21. Konstantakos EK, Dalstrom DJ, Nelles ME, Laughlin RT, Prayson MJ. Diagnosis and management of extremity compartment syndromes: an orthopaedic perspective. Am Surg. Dec 2007;73(12):1199-1209. 22. Glass GE, Staruch RM, Simmons J, et al. Managing missed lower extremity compartment syndrome in the physiologically stable patient: A systematic review and lessons from a level I trauma center. J Trauma Acute Care Surg. May 18 2016. 23. Kashuk JL, Moore EE, Pinski S, et al. Lower extremity compartment syndrome in the acute care surgery paradigm: safety lessons learned. Patient Saf Surg. 2009;3(1):11. 24. Reverte MM, Dimitriou R, Kanakaris NK, Giannoudis PV. What is the effect of compartment syndrome and fasciotomies on fracture healing in tibial fractures? Injury. Dec 2011;42(12):1402-1407. 25. Blair JA, Stoops TK, Doarn MC, et al. Infection and Nonunion After Fasciotomy for Compartment Syndrome Associated With Tibia Fractures: A Matched Cohort Comparison. J Orthop Trauma. Jul 2016;30(7):392-396. Melissa Smith – Trauma Program Mgr melissa.d.smith@vanderbilt.edu Oscar Guillamondegui – Trauma Medical Director Oscar.guillamondegui@vanderbilt.edu Brad Dennis – Trauma PI Director Bradley.m.dennis@vanderbilt.edu Cathy Wilson – Trauma Outreach & Injury Prevention Coordinator Catherine.s.wilson@vanderbilt.edu Rich Lesperance– ACS Fellow/IEP editor Richard.lesperance@vanderbilt.edu Upcoming Courses 2016 Courses: ATLS Provider: Aug 11th & 12th ASSET: Sept 2nd ATLS Provider: Sept 22nd & 23rd ATLS Refresher: Oct 13th ATLS Provider: Nov 17th & 18th ATLS Refresher: Dec 8th Sum m er 2016 Contributors Traum a IEP New sletter
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- 10. 10 Division ofTrauma and Surgical Critical Care For any questions in regards to the IEP or Trauma cases please contact: Melissa Smith: 322.6745 Oscar Guillamondegui: 936.0180 or Brad Dennis: 936.0286