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Acute Compartment Syndrome Viktoras Kubaitis 10/09/2012 Acute Compartment Syndrome Definition A compartment syndrome is a pathological condition in which high pressure within a closed fascio - osseus space reduces capillary blood perfusion below a level necessary for tissue viability, That requires urgent surgical release to prevent muscle necrosis and contractures. Acute Compartment Syndrome Compartment can develop anywhere Deltoid 1 Compartment Iliacus 1 Upper Arm 2 Gluteal 3 Thigh 3 Forearm 4 Hand 4 Leg 4 Foot 9 comp 4 groups Acute Compartment Syndrome Pathophysyology - Witeside theory DBP - TIP = MPP Diastolic blood pressure 60 - 70 mmHg Tissue intramuscular = Interstitial pressure 4 – 10 mmHg Muscle perfusion MPP = Capillary perfusion pressure SPP 25 – 30 mmHg Acute Compartment Syndrome Witeside theory easier 60 30 30 Acute Compartment Syndrome Pathophysiology - Mechanizm Injury causes bleeding or oedema, Increase in intracompartmental pressure or Decrease in compartmental size When interstitial pressure raises higher then 30 mmHg, Outgoing to venous system capillaries collapses Blood flow through the capillaries stops, Oxygen delivery to organ stops Cells sustain Hypoxic Injury Cells release vasoactive substances Histamine Serotonine Increase in permeability of endothelium Capillaries allow continued fluid loss Increase in interstitial pressure Nerve conduction and blood flow slows Myoneural ischemia Tissue pH falls due to anaerobic metabolism Irreversible Tissue damage - necrosis Myoglobin release Loss of extremity and kidneys insufficiency and loss of life Acute Compartment Syndrome Aetiology 1. Increased fluid content Fracture Big vessel injury Inflammation 2. Decreased Compartment size Cast Burn Lying on a limb long time Prolonged tourniquet time Malpositioning during traction procedure Acute Compartment Syndrome Aetiology – Demographics 36-45 % tibial shaft (open/closed) 23% soft tissue injury without fracture 19% isolated vascular injury 10% on anticoagulants High energy = low energy European journal of trauma & emergency surgery. 2007, MC queen & al. 2007 www.emedicine.com/Acute Compartment Syndrome Acute Compartment Syndrome Diagnosis - symptoms Pain is disproportional and not explainable by the situation Acute Compartment Syndrome Diagnosis – the 7 P •Pain out to proportion to the injury •Pain on passive movement •Palpably tight compartment •Paraesthesia •Palor •Paralysis •Pulseless (a pulse is not issue) Acute Compartment Syndrome Differential diagnosis Cellulitis Osteomyelitis DVT Gas gangrene Necrotizing fasciitis Periferal vascular injury Rhabdomyolysis Acute Compartment Syndrome Possible Delayed diagnosis due to •children are unable to verbalize feelings •Patients with multiple injuries •Unconscious patients •Drug abuse •Continuous epidural/spinal anaesthesia •Altered neurological function in a past •Vascular injuries in a past Acute Compartment Syndrome Laboratory tests 1. FBC Hg (anaemia worsens ischemia) WBC can be elevated 2. U/E CK Creatinine Kinase normal 10-186 U/l) Myoglobin BUN (Blood Urea Nitrogen normal 7-21 mg/dL) Creatinine Urea K GGT (Gamma Glitamyl transpeptidase) 3. Coagulation profile 4. Blood Culture/sensitivity Acute Compartment Syndrome Compartment measurement •Stryker pressure monitor •Slit catheter •Wick catheter Acute Compartment Syndrome Measurement technique •Should be taken on maximal swelling site •Patient in a comfortable position •Assemble the system •Zero the system •45 degrees angle •Subfascial catheter needle tip insertion •Get the reading in mmHg Acute Compartment Syndrome Complications of Compartment without treatment Muscle longstanding weakness Ulceration Acidosis Hypercalemia Rhabdomyolysis Disabling joint contractures DIC disseminated Intravascular Coagulation Sepsis Myoglobinuric renal Failure ARDS Acute Respiratory Distress Syndrome Loss of limb Multiple Organ Failure MOF Death Acute Compartment Syndrome Delayed diagnosis consequences. Is it safe? 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 ones. Sheridan, Matsen. JBJS 1976 Acute Compartment Syndrome Concervative treatment •Circular Cast and dressings down •Treat systemic hypotension/shock •Do not elevate the affected extremity. •Additional oxygen should be administered •Hyperbaric oxygen •Vascular surgeon review •Correction of Coagulopathy •Antivenin •Mannitol Mannitol treatment for acute compartment syndrome. Nephron. Aug. 1998; 79(4):4923 Acute Compartment Syndrome Correction of Associative disorders – bouquet of flowers Shock Hypovolemia Hypercalemia Dehytradion Renal Failure Infection Coagulopathy Acute Compartment Syndrome Indications for fasciotomy 1. When tissue pressure rises more than 30 mm Hg 2. When a difference between diastolic pressure and measured tissue pressure is 30 mm Hg or less 3. Clinically confirmed ACS Acute Compartment Syndrome Anatomy of lower leg muscles and Compartments To learn 4 Compartments Imagine a Tractor on Podium L 4A F T A PD PS Acute Compartment Syndrome Anatomy of lower leg muscles Acute Compartment Syndrome Anatomy of neurovascular bundles Acute Compartment Syndrome Double Incision Fasciotomy defended by Mubarak Acute Compartment Syndrome Single Incision Fasciotomy inovated by Matsen Acute Compartment Syndrome Postoperative care after fasciotomy Bulky dressings to promote oedema reduction Extremity elevation Skin graft when oedema resolved if needed STSG Split Thickness Skin Graft Delayed Primary Closure with relaxing incisions Active movements of joints to prevent stiffness Acute Compartment Syndrome Complications after Fasciotomies Altered sensation within the margins of the wound 77% Dry, scaly skin 40% Pruritus 33% Discoloured 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 Acute Compartment Syndrome Summary High index of suspicion remains the cornerstone of diagnosis ACS Treat as soon as you suspect ACS ICP measurement gives additional information ACS is a clinical diagnosis If ACS is clinically evident, do not measure pressures In doubt, cut! Avoid delays in management Fasciotomy is reliable, safe and effective the only treatment for compartment syndrome when performed in time