Acute Compartment Syndrome Marc Hirner. Demographics Incidence: Incidence: Men 7.3/100,000 Men...
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Transcript of Acute Compartment Syndrome Marc Hirner. Demographics Incidence: Incidence: Men 7.3/100,000 Men...
DemographicsDemographics
Incidence:Incidence: Men Men 7.3/100,0007.3/100,000 WomenWomen 0.7/100,0000.7/100,000
69% due to trauma69% due to trauma 36% fx tibia36% fx tibia 9.8% distal radius9.8% distal radius 23% soft tissue injury without fx23% soft tissue injury without fx
10% on anticoagulants10% on anticoagulants
Case 1Case 1
Patient with ? Trivial knee injury Patient with ? Trivial knee injury Seen in ED and admittedSeen in ED and admittedRegistrar to ward , pulseless limbRegistrar to ward , pulseless limbWas in fact a knee dislocation that Was in fact a knee dislocation that reduced spontaneouslyreduced spontaneously
End result popliteal artery repair , End result popliteal artery repair , fasciotomy , ligament reconstruction fasciotomy , ligament reconstruction and eventual BKAand eventual BKA
Case 2Case 2
Simple fibula fracture Simple fibula fracture Referred to White Cross several days Referred to White Cross several days after injury with tight swollen calfafter injury with tight swollen calf
Diagnosed acute compartment Diagnosed acute compartment syndrome 5 days latesyndrome 5 days late
Fasciotomy of no use as muscles Fasciotomy of no use as muscles necroticnecrotic
Case 3Case 3
Child required IV access so the tibia Child required IV access so the tibia was used for rapid infusionwas used for rapid infusion
Fluid into the calf Fluid into the calf
Acute compartment syndrome Acute compartment syndrome
Orthopaedics notified late Orthopaedics notified late Fasciotomy no use as muscles necroticFasciotomy no use as muscles necrotic
Pathophysiology
Increased compartment pressure
Increased venous pressure
Decrease A-V gradient resulting in muscle and nerve ischemia.
DiagnosisDiagnosis
HistoryHistory Clinical exam:Clinical exam: the Psthe Ps Compartment pressuresCompartment pressures Laboratory testsLaboratory tests
CPKCPK Urine myoglobinUrine myoglobin
Clinical DiagnosisClinical Diagnosis
The six ‘Ps’:The six ‘Ps’: PressurePressure PainPain ParesthesiaParesthesia ParalysisParalysis PallorPallor PulselessnessPulselessness
PressurePressure
Early findingEarly finding
Only objective findingOnly objective finding
Refers to palpation of compartment Refers to palpation of compartment and its tension or firmness and its tension or firmness
PainPain
Out of portion to injuryOut of portion to injury
Exaggerated with passive stretchExaggerated with passive stretch
Earliest symptom but inconsistentEarliest symptom but inconsistent
Not available in obtunded patientNot available in obtunded patient
ParesthesiaParesthesia
Early signEarly sign Peripheral nerve tissue is more sensitive Peripheral nerve tissue is more sensitive
than muscle to ischemiathan muscle to ischemia Permanent damage may occur in 75 minutesPermanent damage may occur in 75 minutes
Difficult to interpretDifficult to interpret
Will progress to anesthesia if pressure Will progress to anesthesia if pressure not relievednot relieved
ParalysisParalysis
Very late findingVery late finding Irreversible nerve and muscle damage Irreversible nerve and muscle damage
presentpresent
Paresis may be present earlyParesis may be present early Difficult to evaluate because of painDifficult to evaluate because of pain
Pallor & PulselessnessPallor & Pulselessness
Rarely presentRarely present
Indicates direct damage to vessels Indicates direct damage to vessels rather than compartment syndromerather than compartment syndrome
Vascular injury more of contributing Vascular injury more of contributing factor to syndrome rather than factor to syndrome rather than resultresult
Compartment PressureCompartment Pressure WhenWhen
Confirm clinical examConfirm clinical exam Obtunded patient with tight compartmentsObtunded patient with tight compartments Regional anestheticRegional anesthetic Vascular injuryVascular injury
TechniqueTechnique Whiteside infusionWhiteside infusion Stic technique: side port needleStic technique: side port needle Wick catheterWick catheter Slit catheterSlit catheter
Stryker Stic SystemStryker Stic System
Easy to useEasy to use Can check multiple compartmentsCan check multiple compartments Different areas in one compartmentDifferent areas in one compartment
What is Critical What is Critical Pressure?Pressure?
>30 mm Hg as absolute number >30 mm Hg as absolute number (Roraback)(Roraback)
TreatmentTreatment
Lower leg to level of the heartLower leg to level of the heart
Remove castRemove cast
Split all dressings down to skinSplit all dressings down to skin
TreatmentTreatment
If concerned refer these patients earlyIf concerned refer these patients early
Fasciotomy if continued clinical Fasciotomy if continued clinical findings and/or elevated findings and/or elevated compartment pressurecompartment pressure
Wound CareWound Care
Soft tissue coverage by 5-7 daysSoft tissue coverage by 5-7 days
Delayed closureDelayed closure Vascular loop ‘lace technique’Vascular loop ‘lace technique’
Split thickness skin graftSplit thickness skin graft
Flaps or free tissue transferFlaps or free tissue transfer