Compartment Syndrome- an overview

1. Compartment Syndrome- an overview By Suvarna Maharaj

2. Intro • Compartment syndrome is a limb and life threatening condition that occurs when perfusion pressure falls below tissue pressure in a closed anatomical compartment . • If left untreated -tissue necrosis and sequele • Ultimately death • It is found wherever a compartment is present.

3. Causes • Simple cause: THE PRESSURE IS TOO HIGH. • Either –decreased compartment size or increased fluid content. • Increased fluid content- intensive muscle use burns intra-arterial injection infiltrated infusion haemorrhage envenomation

4. Causes • Decreased compartment pressure Burns Casts Military aftershock trousers

5. Pathophysiology • This follows the path of ischemic injury. When fluid is introduced into a fixed volume or when volume decreases, pressure rises. • In the case of CS, compartments have a relatively fixed volume. An introduction of excess fluid or extraneous constriction increases pressure and decreases tissue perfusion until no O2 is available for cellular metabolism.

6. Pathophysiology cont. Elevated perfusion pressure is the physiological response to rising intracompartmental pressure (IP). When IP rises, autoregulatory mechanisms are overwhelmed and a cascade of injury develops. Tissue perfusion pressure is measured by subtracting the interstitial fluid pressure from the capillary perfusion pressure. When this pressure falls below a critical level, injury results.

7. Pathophysiology cont. • When intracompartmentalpresssure rises, venous pressure rises. When venous pressure exceeds CPP, capillaries collapse. Generally, an intracompartmental pressure greater than 30mmHg requires intervention. • At this point, blood flow stops, resulting in decreased O2 delivery. Hypoxic injury causes cells to release vasoactive substances which increases endothelial permeability.

8. Pathophysiology cont. • Capillaries allow continued fluid loss which increases tissue pressures and advances injury. • Nerve conduction slows,tissue ph falls due to anaerobic metabolism,surrounding tissue suffers further damage, and muscle tissue suffers necrosis releasing myoglobin. • The end is loss of the extremity and possibly, the loss of life.

9. Clinical- History • Suspect CS whenever significant pain occurs in an extremity • Mechanism of injury- long bone fracture, high energy trauma, penetrating injuries, crush injuries • Remember to ask about anticoagulation-increases risk of CS

10. Signs • 5 P’s parasthesia, pallor,pulselessness, pain, poikilothermia are not diagnostic of CS. Except for pain and parasthesia , the other traditional signs are not reliable. • Severe pain at rest or with any movement especially passive stretching of the muscles should raise suspicion

11. Less common sites of CS • FOOT • -Classic signs What are they? expected with foot fractures and injury so tense tissue bulging maybe the most reliable sign. -associated with CS of deep posterior compartment of leg.

12. CS of the hand Symptoms from compression causes pain, loss of sensation and decreased hand function due to pressure on blood vessels and the median nerve within the wrist compartment .

13. CS of the gluteal region The large gluteal muscle mass is confined in fascia hence area prone to CS. How? Signs include pain especially on passive flexion at the hip and tense swelling of the buttock. Late signs include foot drop with a loss of sensation along distribution of sciatic nerve and no active movements of the ankle.

14. Workup • LAB STUDIES • Often normal and not helpful in diagnosing or excluding CS • Definitive diagnosis is compartment pressure measurement using a tonometer if available. • Remember PITFALLS

15. Measurement Methods • Simple needle • Wick Catheter • Slit catheter • Side Port catheter • Transducer –Tipped Catheter

16. Technique • STRYKER TECHNIQUE • MERCURY MANOMETER

17. Technique

18. Demonstration • Go to www.emprocedures.com/compartment

19. ED care • Stabilize the patient • Ischemic injury is basis for CS. Additional O2 should be given. • IV hydration is essential. Hypovolemia worsens ischemia. • Do not elevate the affected limb-decreases arterial pressure • Fasciotomy is definitive treatment so early referral is warranted.

20. Fasciotomies • Two Incision Technique • Used to adequately decompress all four compartments • Medial Incision made longitudinally just posterior to tibia • Lateral incision made posterior to fibula from level of head to lat malleolus • Closure • Post-op

21. Complications • Permanent nerve damage • Infection • Loss of limb • Death • Cosmetic deformity from fasciotomy

22. References • Emedicine Compartment Syndrome by Richard Paula MD Director of Research, Assistant Professor of Emergency Medicine,University of South Florida • Mutimedia Procedure Manual- Compartment pressure Measurement • Gluteal Compartment Syndrome following Joint Arthroplasty Under Epidural Anaesthesia,Journal of Orthopaedics Surgery

23. References • April 2007 By Kumar V Saeed, A Panagopoulos, PJ Parker • Wheeless’ Textbook of Orthopaedics- Compartment syndrome of the Foot. • Acute Compartment Syndrome Update on Diagnosis and treatment by TE Whitesides and MM Heckman Academy of Orthopaedic Surgery July 1996

24. The end Thank you