Acute Compartment syndrome

1. Acute Compartment syndrome • David Agolley • department of orthopaedics

2. Definition • Acute Compartment Syndrome occurs when there is elevated pressure in a closed fascial (osteofascial) space, resulting in a critical reduction of blood flow to the tissues contained within. Acute Compartment Syndrome

3. Variations • Acute Compartment Syndrome • Exertional Compartment syndrome • Crush Syndrome Acute Compartment Syndrome

4. Historical Review • Late complications of ischaemic contracture • Volkman, 1881 • Paralysis and ischaemia, too-tight bandaging of the forearm and hand,arterial blockage and irreversible contracture. • Leser 1884 - animal studies • Brooks 1922 - venous obstruction • Griffiths 1940 - Pain with.. , Painful onset, Pallor, Puffiness • Bardenheuer 1911 - fasciotomy forearm • Whitesides, Hargens and Mubarak, and Matsen 1970’s - tissue pressure measurement techniques. • Current - sustained microcirculatory impairment, • Still occurs. Not uncommon Acute Compartment Syndrome

5. Acute Compartment Syndrome

6. Epidemiology • 3.1 per 100,000 • Young Male 10 fold increase • MVA • sports • muscle volume Acute Compartment Syndrome

7. Pathophysiology Acute Compartment Syndrome

8. PathophysiologyAetiology • Fracture (69%) • Soft tissue injury • Crush syndrome (2) • arterial injury / revascularisation • High pressure injection • exercise • fluid infusion • arterial puncture • ruptured ganglia / cysts • Osteotomy • Snake bite • nephrotic syndrome • leukaemic infiltration • viral myosis • acute haematogenous osteomyelitis • coagulopathy (1) • cast / dressings • repair fascia, hernia • burns Acute Compartment Syndrome

9. Pathophysiology Acute Compartment Syndrome

10. Pathophysiology • Normal tissue pressure • 0-4 mm Hg • 8 - 10 mm Hg with exertion • Absolute compartment pressure theory • 30mmHg - Mubarak and Hargens • 45 mmHg - Matsen • AV gradient theory • LBF = Pa - Pv / R • <30mmHg diastolic pressure • ‘do not elevate arm’ • Microvascular occlusion theory Acute Compartment Syndrome

11. Tissue Survival • Muscle • 3 - 4 hrs = reversible damage • 6 hrs = variable damage • 8 hrs = irreversible damage • Nerve • 2 hrs = loose nerve conduction • 4 hrs = Neuropraxia • 8 hrs = irreversible damage Acute Compartment Syndrome

12. Night intern, Call from Paeds“Dr, I think little Jimmy has compartment syndrome”

13. Assessment of Compartment Syndrome Acute Compartment Syndrome

14. Assessment • Prioritise • History • mechanism injury • intervention • analgesic requirements • Examination • Investigations Acute Compartment Syndrome

15. Diagnosisthe 6 PsHargens and Mubarak • Pain out of proportion / Passive stretch • Palpably tense compartment • Parasthesia • Paresis • Pink skin colour • Pulse present Acute Compartment Syndrome

16. DiagnosisDifferentials • Arterial Occlusion • Peripheral nerve injury • Muscle rupture Acute Compartment Syndrome

17. Emergent Treatment • Place at level of heart • Cut dressing or cast - MUST SEE SKIN • Alert senior Dr, OR, Anaesthetist and fast patient • Review Acute Compartment Syndrome

18. Investigations • Radiographs • MRI USS not routine • Arterial doppler flow • Pulse Oximetry • Pressure measurements • Suspected CS • Equivocal or unreliable exam • Clinical adjunct Acute Compartment Syndrome

19. At risk Patients • Demographic • Youth • Male • Tibia fracture • High energy • Bleeding diathesis /anticoagulants • Altered Pain Perception • Altered consciousness • Regional anaesthesia • Patient-Controlled Analgesia • Central or peripheral neurological injury • Children • Associated nerve injury Acute Compartment Syndrome

20. Pressure Monitoring Acute Compartment Syndrome

21. Surgical TreatmentIndications for fasciotomy • Clinical findings • Pressure absolute above 30mmHg, or within 20mmHg Diastolic • Rising tissue pressure • >6hours of total limb ischaemia • High risk injury • CONTRAINDICATION - Missed CS 24-48hrs Acute Compartment Syndrome

22. Surgical treatmentPrinciples • Early diagnosis • Long extensile incision • Release all fascial compartments • Preserve neurovascular structures • Rigid fracture stabilisation • Debride necrotic tissues • Cover 7-10 days Acute Compartment Syndrome

23. Forearm Fasciotomy Acute Compartment Syndrome

24. Forearm Fasciotomy Acute Compartment Syndrome

25. Leg Fasciotomy Acute Compartment Syndrome

26. Leg Fasciotomy Acute Compartment Syndrome

27. Leg Fasciotomy Acute Compartment Syndrome

28. Thigh Fasciotomy Acute Compartment Syndrome

29. Foot Fasciotomy Acute Compartment Syndrome

30. Other Compartments • Hand, forearm, arm, deltoid • Abdomen • Buttock Acute Compartment Syndrome

31. Temporary Coverage • Simple dressing • Progressive suturing • Vessel loop “Bootlace” • Vacuum Assisted Closure Acute Compartment Syndrome

32. Definitive Coverage • Second look • Cover 7-10 days after risk of necrotic tissue passed • Split skin graft • Local flap • Free flap Acute Compartment Syndrome

33. Summary • Acute Compartment Syndrome • High Index of suspicion • Early diagnosis • Early intervention • Expedite time to surgery

34. Questions?