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Acute Compartment Syndrome

Acute Compartment Syndrome. Marc Hirner. Demographics. Incidence: Men 7.3/100,000 Women 0.7/100,000 69% due to trauma 36% fx tibia 9.8% distal radius 23% soft tissue injury without fx 10% on anticoagulants. Case 1.

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Acute Compartment Syndrome

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  1. Acute Compartment Syndrome Marc Hirner

  2. Demographics • Incidence: • Men 7.3/100,000 • Women 0.7/100,000 • 69% due to trauma • 36% fx tibia • 9.8% distal radius • 23% soft tissue injury without fx • 10% on anticoagulants

  3. Case 1 Patient with ? Trivial knee injury Seen in ED and admittedRegistrar to ward , pulseless limbWas in fact a knee dislocation that reduced spontaneouslyEnd result popliteal artery repair , fasciotomy , ligament reconstruction and eventual BKA

  4. Case 2 Simple fibula fracture Referred to White Cross several days after injury with tight swollen calfDiagnosed acute compartment syndrome 5 days lateFasciotomy of no use as muscles necrotic

  5. Case 3 Child required IV access so the tibia was used for rapid infusionFluid into the calf Acute compartment syndrome Orthopaedics notified late Fasciotomy no use as muscles necrotic

  6. Etiology

  7. Pathophysiology Increased compartment pressure Increased venous pressure Decrease A-V gradient resulting in muscle and nerve ischemia.

  8. Diagnosis • History • Clinical exam: the Ps • Compartment pressures • Laboratory tests • CPK • Urine myoglobin

  9. Clinical Diagnosis • The six ‘Ps’: • Pressure • Pain • Paresthesia • Paralysis • Pallor • Pulselessness

  10. Pressure • Early finding • Only objective finding • Refers to palpation of compartment and its tension or firmness

  11. Pain • Out of portion to injury • Exaggerated with passive stretch • Earliest symptom but inconsistent • Not available in obtunded patient

  12. Paresthesia • Early sign • Peripheral nerve tissue is more sensitive than muscle to ischemia • Permanent damage may occur in 75 minutes • Difficult to interpret • Will progress to anesthesia if pressure not relieved

  13. Paralysis • Very late finding • Irreversible nerve and muscle damage present • Paresis may be present early • Difficult to evaluate because of pain

  14. Pallor & Pulselessness • Rarely present • Indicates direct damage to vessels rather than compartment syndrome • Vascular injury more of contributing factor to syndrome rather than result

  15. Compartment Pressure • When • Confirm clinical exam • Obtunded patient with tight compartments • Regional anesthetic • Vascular injury • Technique • Whiteside infusion • Stic technique: side port needle • Wick catheter • Slit catheter

  16. Stryker Stic System • Easy to use • Can check multiple compartments • Different areas in one compartment

  17. Distance From Fracture Effects Pressure

  18. What is Critical Pressure? • >30 mm Hg as absolute number (Roraback)

  19. Treatment • Lower leg to level of the heart • Remove cast • Split all dressings down to skin

  20. Treatment If concerned refer these patients early • Fasciotomy if continued clinical findings and/or elevated compartment pressure

  21. Treatment

  22. Wound Care • Soft tissue coverage by 5-7 days • Delayed closure • Vascular loop ‘lace technique’ • Split thickness skin graft • Flaps or free tissue transfer

  23. NO ONE EVER BLAMES US FOR DOING A FASCIOTOMY BUT MISSING COMPARTMENT SYDROME IS A DISASTER

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