Compartment syndrone

management of compartment syndrome

1. COMPARTMENT SYNDROME ORTHOPEDICS UNIT PRESENTATION DR. BASHIR YUNUS 4/3/14 14-Oct-14 1

2. OUTLINE INTRODUCTION AETIOLOGY RELEVANT ANATOMY CLASSIFICATION PATHOPHYSIOLOGY CLINICAL FEATURES DIAGNOSIS TREATMENT PREVENTION PROGNOSIS 14-Oct-14 2

3. INTRODUCTION An elevation of interstitial pressure in a closed osteofascial compartment that would lead to microvascular compromise with resultant ischemia and necrosis 14-Oct-14 3

4. INTRODUCTION Normal intra compartmental pressure is 0-10mmHg . Acute compartment syndrome occurs if pressure increase to 25-30mmHg or about 30mmHg below diastolic 14-Oct-14 4

5. INTRODUCTION Usually occurs in younger patients( usu males under 35years) Site: any where skeletal muscle is surrounded by an unyielding fascial compartment; legs, forearm, thigh, arm, abdomen, buttocks, hand, feet of DM patient, lumber paraspinal muscles 14-Oct-14 5

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9. AETIOLOGY The causes results from either increase in content of the compartment or a reduction in its volume from external compression. Common causes TRAUMA : - About 40% accompany tibia fracture(ant> lat >post) 23% accompany soft tissue trauma 18% complicate fore-arm fracture In the US 2-12% anterior distal LL injuries result in CS 30% of Limbs devp CS fol vascular injury 14-Oct-14 9

10. AETIOLOGY Constrictive dressings/ Tight casts TBS Splinting Ischaemic reperfusion injuries following vascular injuries Burns esp circumferential Prolonged limb compression Poor prolonged positioning during surgery & in drug users Envenomations e.g Snake bites 14-Oct-14 10

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12. RELEVANT ANATOMY LEG : muscle compartments Lat compart . Ant. Compart . Post. Compart . - superficial - deep 14-Oct-14 12

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14. FOREARM: - superficial flexor deep flexor extensor 14-Oct-14 14

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17. RELEVANT ANATOMY These compartment are separated and enclosed by tight fascial separation. Running through these areas are blood vessels and nerves. The functions of all the above mentioned structures are affected if ICP rises above Capillary pressure. 14-Oct-14 17

18. CLASSIFICATION ACUTE : is a surgical emergency which if not recognised and treated early can lead to devastating disabilities, amputation and even death in some situations CHRONIC : Seen in long standing runners 14-Oct-14 18

19. CLASSIFICATION CHRONIC Transient rise in compartmental pressure following activity Symptoms Pain Weakness Neurologic deficits. 14-Oct-14 19

20. PATHOPHYSIOLOGY Local blood flow= arteriovenous pressure gradient(Pₐ -Pᵥ) local vascular resistance Injury to tissue leads to oedema with increase tissue pressure and increase Pᵥ. There is deminished arteriovenous pressure gradient with resultant deminished or absent local blood flow.(Pᵥ >30mmHg for a prolong period) Arterial blood flow however continued until late stages. 14-Oct-14 20

21. Pathophysiology Increased compartment pressure Increased venous pressure Decreased blood flow Decreases perfusion

22. Increased muscle swelling Increased permeability Increased compartment pressure

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25. CLINICAL FEATURES Pain Paraesthesia Pallor Pulselesness Paralysis – loss of vibration sense is early. ‘Perishing cold ’– Patients prone to compartment syndrome; Hypotension External compression Coagulopathy Vascular injury or repair Less prone if well resuscitated 14-Oct-14 25

26. CLINICAL FEATURES PAIN Earliest symptom & most important Severe & out of proportion, rest pain and pain on passive stretch Occasionally not reliable eg . Unconscious anaesthesized , children and in nerve injury It is 19% sensitive and 97% specific There is false negative or missed cases 14-Oct-14 26

27. CLINICAL FEATURES PARASTHESIA/HYPOESTHESIA Occur in the territory of the Nerve within the compartment. It is the first sign of Nerve ischaemia It can be due to N. injury 13% sensitive and 98% specific 14-Oct-14 27

28. CLINICAL FEATURES PARALYSIS It affects the muscle within the compartment It is a late sign Can be due to inhibition by pain, muscle injury or N injury It has a low sensitivity ACS with muscle deficit, complete recovery is rare 14-Oct-14 28

29. CLINICAL FEATURES PERISHING COLD The part of the body affected feels cold due to decreased blood flow PULSELESSNESS It is a very late features,it follows onset of gangrene It can be as a result of major vascular injury SWELLING The affected compartment is usually swollen It may be difficult to assess b/cos of cast ,dressing or the location of the compartment Skin changes are late features ACS 14-Oct-14 29

30. DIAGNOSIS Mainly clinical There should be high index of suspicion. Passive stretching of fingers or toes (muscle stretch)will lead to severe pain (diagnostic sign ) Never wait for signs of ischemia (5Ps): irreversible damage 14-Oct-14 30

31. Objective method of diagnosing ACS Involves dynamic measurement of ICP which was introduced in 1970 following Matson unified concept of identifying increase ICP irrespective of aetiology . 14-Oct-14 31

32. Indications include: Unconscious patient Uncooperative patient Children Equivocal features Multiply injured patients Assessment of adequacy of decompressive fasciotomy . Current Concept is that ICP should be measured in all cases of suspected 14-Oct-14 32

33. Devices adopted for measurement include: Hand-held needle manometer The wick – catheter The Slit – catheter Solid – state transducer intra-compartment catheter (STIC )- stryker Transducer – tipped – probe Whiteside manuever 14-Oct-14 33

34. Stryker STIC Monitor 14-Oct-14 34

35. Wick hand held instrument 14-Oct-14 35

36. Whiteside maneuver 14-Oct-14 36

37. Interpretations of measurement of intra- compartmental pressure Absolute intracompartment pressure level of >30mmHg (ii) Differential pressure: the concept is that the level of ICP at which ischaemic of tissue occurs is related to the perfusion pressure. 14-Oct-14 37

38. (iii) Delta pressure Diastolic – ICP range 10-35mmHg < 30mmHg Time factor - The intracompartmental pressure should however not be treated in isolation rather the trend of ICP over time or Delta Pressure should be observed. 14-Oct-14 38

39. Other supportive inx Lab studies : FBC,Creatine , phosphokinase & Urine myoglobin,Serum myoglobin,Urinalysis,PT & APTT, Urine toxicology screen, X-RAY of affected extremity 14-Oct-14 39

40. DIFFERENTIAL DIAGNOSIS Cellulitis Coelenterate and Jellyfish Envenomations DVT and Thrombophlebitis Gas Gangrene Necrotizing Fasciitis Peripheral Vascular injuries Rhabdomyolytis 14-Oct-14 40

41. Treatment Don’t wait so long 14-Oct-14 41

42. Treatment GENERAL: ABCD OF RESUSCITATION Since ACS is often due to trauma,follow the ATLS protocol to stabilize the patient SPECIFIC: Remove all the circumferential dressing down to the skin eg bandage, casts Do not elevate the limb above heart level fasciotomy . This must be prompt and adequate. 14-Oct-14 42

43. Treatment catastrophic clinical results were inevitable if fasciotomy were delayed for over 12hrs but full recovery was achieved if decompression was performed within six hours of making diagnosis . 14-Oct-14 43

44. INDICATIONS FOR FASCIOTOMY Clinical features highly suggestive of ACS Absolute compartment pressure >30-40 mmHg Mean arterial pressure – ICP >40mmHg Diastolic BP – ICP (delta p) < 30mmHg 14-Oct-14 44

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48. COMPLICTIONS OF FASCIOTOMY Complications are real >25% Chronic swelling Chronic pain Muscle weakness Iatrogenic NV injury Cosmetic concerns 14-Oct-14 48

49. Early complicatios of CS Myoglobinemia Hypercalemia Acidosis Infection Acute renal injury 14-Oct-14 49

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51. Prevention High index of suspicion on complaint of extremity pain esp post high velocity injury & px on cast Health education of px in cast on recognition of symptoms & early re-presentation in the hospital Waiting for swellings to resolve b4 application of cast Splitting of cast Routine measurement of ICP Prompt tx on diagnosis 14-Oct-14 51

52. prognosis Nerve dysfxn maybe reversible with time but infarcted muscle is damaged permanently. Early surgery gives good fxnal outcome but delay results in muscle ischaemia & necrosis 14-Oct-14 52

53. Role of TBS 14-Oct-14 53

54. Conclusion Compartment syndrome is a serious syndrome, Which needs to be diagnosed early. Palpable pulse doesn’t exclude compartment syndrome If diagnosis and fasciotomy were done within 24 hrs , the prognosis is good. If delayed, complications will develop. The earlier you diagnose, the safer you are 14-Oct-14 54

55. 1.Apley’s system of orthopedics and fractures; Louis et al, 9 th edition 2.Principles Of Surgery; Schwartz. 7 th edition.1999. 3. A.H.Crenshaw Campbell,s Operative Orthopedics; 8 th Edition,2002 4.E-medicine; 5.Ronald Mcrae , Max Esser ; Practical Fracture Treatment, 4 th ed. Churchill Livingstone,200 14-Oct-14 55