Casting & Splinting Compartment Syndrome

1. TOH Orthopaedics Off-Service Teaching Casting & SplintingCompartment Syndrome Sasha Carsen PGY-3

2. Agenda • Case • Casting & Splinting • Principles • Practical Pointers • How-to, and types • Compartment Syndrome: an Orthopaedic Emergency • Epidemiology, Pathophysiology • Diagnosis • Treatment • Summary

3. Case • 43yo F, “New-Age” Author, Vegan, suffers a slip and fall down outdoors stairs, lands on Left leg. • ++ Left Leg pain, swelling, unable to weight bear • Brought to ER by ambulance • What more would you like to know on Hx? • No other injuries. Pain excruciating in leg/calf area, unable to take any weight or pressure to area. Able to move ankle, toes well. No subjective sensory changes. • Allergies: NKDA • Meds: Various herbal, none with significant medical interactions • PMH: Healthy

4. Case Cont’d • Physical Exam • Describe a focused physical exam • Physical Exam Findings: • Swollen leg/calf, tender, compartments feel soft • Distally neurovascularly intact • Strong and equal pulses and good cap refill • T/SP/DP motor & sensory normal • Active and passive ankle ROM normal

5. Imaging • What imaging do we want? • Radiographs: • Left Knee and Ankle normal • Left Tibia/Fibula midshaft diaphyseal minimally displaced oblique fractures. • Angulation <5deg coronal/sagittal

6. Treatment • What are the treatment principles? • What are her treatment options? • Patient refuses surgery, would like to be treated non-operatively with a cast • Describe what type of cast is required and why • A long leg cast is required, as the tibia must be immobilized, which cannot be accomplished with a short leg cast (which actually levers on the tibia). Knee should be flexed, allowing for pt comfort especially while seated.

7. Follow-Up • Patient returns to the ER 8 hours after discharge complaining of excruciating and increasing pain in her leg • Differential? • Poorly controlled pain, DVT, swelling, Compartment Syndrome • Work-up and Treatment? • Begin with detailed neurovascular exam • Bivalve cast, R/A • After bivalving cast patient feels much better, NV exam normal. Patient monitored in ER, then D/C home with close F/U and detailed instructions on reasons to return to ER • What would you do next if bivalve did not relieve pain?

8. Casting & Splinting • Before advent of modern surgery was essentially the only intervention (with reduction) for orthopaedic injuries • Still the Mainstay and Foundation of orthopaedic treatment • The vast majority of MSK injuries do not need surgery

9. Principles • Goals of the Cast or Splint: • Immobilization • Comfort A good splint or cast accomplishes both of these goals • Anatomy/Character of the fracture/injury • Immobilization often requires involvement of joint above and below (though many exceptions)

10. Tips • Use water slightly warmer than room temp • Cold = long time to set • Hot = burn injury (remember plaster setting is exothermic rxn!) • Webril/Padding • General rule of ½ overlapping • Extra padding at bony prominences and cast ends • If goal is not immobilization of # (e.g. Achilles), then can use more padding

11. Tips • Role padding and plaster Distal to Proximal • Plaster rolled out roughly ½ overlapping. • Reinforce areas of motion • Reinforce are of concern/# • Cast should not be too tight, as expect further swelling in acute injury • Always get post-reduction radiographs!!

12. Tips • Send patients home with cast care info/pamphlet • Keep limbs at heart level • Appropriate pain control • Plaster care and F/U • Give patients info on reasons to return to ER • Perfusion, Pain

13. Types of Casts and Splints • SAC – Short Arm Cast • Prox to MTP to just distal to Elbow • “Classic” wrist/forearm cast • For Colles/DR # • Thumb Spica • SAC with support for Thumb • For Scaphoid or ?Scaphoid • Ulnar Gutter • Splint covering medial/ulnar side of forearm/wrist/hand • Can be distal, and used in Hand “Safe” position for MC/Boxer #’s

14. Types (non-exhaustive) • Sugar-Tong • Splint from Axilla up around elbow to over the shoulder • For Diaphyseal Humerus #’s • SLC – Short Leg Cast • From toes to below knee • “Classic” Ankle/Leg cast, for Ankle # • Make sure well padded at toes, reinforce around heel • Equinus SLC • For Achilles, SLC with ankle plantar-flexed • Very well padded and reinforced

15. Types (non-exhaustive) • Leg Posterior Slab • Length of Plaster (over padding) posterior of leg down to toes • 3-sided Ankle/Leg splint • Posterior slab with a “U” on medial and lateral sidesa

16. Casting/Splinting • http://www.med.uottawa.ca/procedures/cast/

17. Compartment Syndrome

18. Epidemiology Compartment Size • tight dressing;Bandage/Cast • localised external pressure;lying on limb • Closure of fascial defects Compartment Content • Bleeding; Fx, vas inj, bleeding disorders • Capillary Permeability; • Ischemia / Trauma / Burns / Exercise / Snake Bite / Drug Injection / IVF

19. incidence directly proportional to degree of injury to soft tissue and bone • most often with a comminuted, grade-III open injury to pedestrian

21. Pathophysiology Normal tissue pressure • 0-4 mm Hg • 8-10 with exertion Absolute pressure theory • 30 mm Hg - Mubarak • 45 mm Hg - Matsen Pressure gradient theory • < 20 mm Hg of diastolic pressure – Whitesides • <20 from DBP or <30 from MAP - Heckman

22. Pathophysiology – Natural history Tissue injury • muscle • 3-4 hours - reversible • 8 hours - irreversible • nerve • 2 hours – conduction loss • 4 hours - neuropraxia • 8 hours - irreversible

23. Diagnosis • 5 p’s are late finding • pain out of proportion • passive stretch with pain in stretched muscles • entire compartment is hard • pressure measurements

24. Differential diagnosis • Arterial occlusion • Peripheral nerve injury • Muscle rupture

25. Pressure Measurements • Infusion • manometer • saline • 3-way stopcock (Whitesides, CORR 1975) • Catheter • wick • slit wick • Arterial line • 16 - 18 ga. Needle (5-19 mm Hg higher) – Moed JBJS 1993 • transducer • monitor • Stryker device • Side port needle

26. Pressure Measurement • Performed within 5 cm of the injury if possible-Whitesides, Heckman

27. Diagnosis - Keys • Primarily a Clinical Diagnosis in the awake patient • Know your compartment anatomy: • Tense compartment? Pain on passive stretch? • Keep in mind both the importance of the diagnosis as well as the morbidity of the surgical intervention • A “never miss” diagnosis, as missed CS catastrophic • However, does this patient need fasciotomies, or do they just need their cast loosened/removed? • Orthopaedic consultation comes after other diagnoses have been ruled out

28. Indications for Fasciotomy • Unequivocal clinical findings • Pressure within 15-20 mmHg of DBP • Rising tissue pressure • Significant tissue injury or high risk pt • > 6 hours of total limb ischemia • Injury at high risk of compartment syndrome • CONTRAINDICATION - Missed CS (>24-48 hrs)

29. Management - nonoperative • normotension • cicumferential bandages + casts • level of the heart • oxygen

30. Non-op efficacy • split cast one side – 30% • spread cast after splitting – 65% • split padding – another 10% • remove cast completely - another 15% • re-check in 20min • won’t work for some etiologies

31. Management - Operative • Remove cast or dressing • Place at level of heart (DO NOT ELEVATE to optimize perfusion) • High Priority OR for compartment releases (not for missed CS) • Limb saving surgery • serial debridements • closure/grafting

32. incision length • skin is a contributing factor • 16 cm decreases pressures significantly Cohen, Mubarak JBJS Br 1991

33. how late is too late? • no contractile function • >8hrs • no confounders • nerve block/injury

34. outcomes • Finkelstein J Trauma 1996 5 patients >35 hrs 1 dead 4 amputations • Sheridan and Matsen JBJS 1976 <12 hrs 68% had normal function >12 hrs 8% normal

35. outcomes • fasciotomy site morbidity (60pts, Fitzgerald Br J Plastic Surgery 2000) • 7% tethered tendons • 13% recurrent ulcerations • 77% decreased sensation

36. Key points • high suspicion • crush • vascular injury • obtunded • releases and serial debridements • delayed closure

37. Surgical Intervention:Fasciotomies • foot • leg • thigh • buttock • arm • forearm • hand

38. Foot • 9 compartments • medial, superficial, lateral, calcaneal • interossei(4), adductor • Clinical suspicion • Lisfranc fracture dislocation • Calcaneus fracture

39. foot • dorsal incisions • interossei and adductor • medial incision • medial, superficial lateral and calcaneal compartments

40. leg • 2 vertical incisions • over anterior and lateral compartments • Superficial peroneal nerve • 1-2 cm behind postero-medial tibia • Saphenous nerve and vein

41. leg - medial Gastroc-soleus Flexor digitorum longus

42. leg - lateral Intermuscular septum Superficial peroneal nerve

43. thigh • lateral • anterior and posterior • medial • adductor Vastus lateralis Lateral septum

44. buttock • kocher approach (posterior)

45. forearm • Anatomy-3 compartments • Mobile wad-BR,ECRL,ECRB • Volar-Superficial and deep flexors • Dorsal-Extensors • Pronator quadratus

46. forearm - volar

47. hand • 10 compartments • dorsal interossei (4) • palmar interossei (3) • thenar and hypothenar (2) • adductor pollicis (1)

48. Summary • Casting & Splinting is both art and science • Think through the character of the injury and the goals of the immobilization, and treat accordingly • Get experience, and think about how to improve after each one. Work with the cast techs in clinic! • Tightness of cast: “Just right” • Not too loose, not too tight • Don’t tighten the plaster, just place it around with light tension • Compartment Syndrome is a surgical emergency • Diagnosis is key, don’t need to be a surgeon to diagnose • Tx for a true compartment is faciotomy, but be sure other interventions exhausted first

49. References • http://www.med.uottawa.ca/procedures/cast/ • McCormick, Will “Acute Compartment Syndromes”, September 2009 PPT presentation