Acute Compartment Syndrome in Extremities

Diagnostic and Management

Asep Aminudin Aziz

Introduction
Acute
Compartment
Closed anatomic space bound by relatively rigid walls of bone and fascia

Syndrome

Osseofascial compartment

Thigh 3 Osseofascial compartment Cruris 4 Osseofascial compartment Forearm 3 Osseofascial compartment

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Introduction
Acute Compartment Syndrome (ACS) is a
potentially devastating condition in which the pressure within an osseofascial compartment rises to a level that decreases the perfusion gradient across tissue capillary beds, leading to cellular anoxia, muscle ischemia and death

ACUTE COMPARTMENT SYNDROME

Incidence
45% ACS caused by tibial fx 23% ACS caused by soft tissue injury 16% ACS caused forearm fx

Tibial fx : 1 10% develop ACS Close tibial fx : 1,5 29% Open tibial fx : 1,2 10,2% Vascular injury : - 19 30% develop ACS - other ref. 0 21%

Incidence
7.3 per 100.000 in men ( 30 years old) 0.7 per 100.000 in women ( 44 years old) 1,2 % of patients with Closed Tibia fractures developed CS Mc Quenn et al: studied 164 pts with ACS
69 % was fractured, 36 % Tibial diaphyses; 9,8 % Distal radius 23.2 % Soft tissue injury (fracture - ), 10 % pts taking anticoagulants or bleeding disorder High or Low energy was equal
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Outcomes
ACS underwent fasciotomy Sheridan and Matsen 1)
Clinical outcomes of 44 pts Before 12 hours 68 % had normal lower extremity function After 12 hours 8%

Finkelstein et al.2)
Reported 5 pts underwent fasciotomy after 35 hours One died directly related MOF Four pts required amputation
1) 2)
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Sheridan GW, Matsen FA: Fasciotomy in the treatment of the acute compartment syndrome. JBJS Am, 1976;58:112-115. Finkelstein JA, Hunter GA, Hu RW: Lower limb compartment syndrome: Course after delayed fasciotomy. J Trauma 1996; 40:342-344
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Pathophysiology of Ischemia

HUT Halmahera

Causes of Compartment Syndrome

Fracture Soft-tissue trauma without fracture Intracompartmental bleeding Extravasations of intravenous infusion Venous obstruction Reperfusion injury following prolonged ischemia Snake envenomation Penetrating trauma Tight casts, dressings, or external wrappings Thermal injury, burn eschar

HUT Halmahera

HUT Halmahera

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Diagnostic
Patient history Associated risk factors The classic clinical diagnosis

Six Ps
1. 2. 3. 4. 5. 6. Pain Pressure Pulselessness Paralysis Paresthesia Pallor

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ACUTE COMPARTMENT SYNDROME

Diagnosis
Direct ICP measurement / objective method
1/. Injection/infusion technique (Whitesides) equipment in expensive and readily available in most hospitals, emergency rooms NOT accurate 2/. Wick catheter (Mubarak) 3/. Slit catheter (Rorabeck) 4/. Solid state transducer intracomp catheter (STIC) 1 4 : Fluid filled system 5/. Fiber optic transducer tipped very expensive 6/. Latest device : Electronic Transducer Tipped Catheter best device

 The measurement devices P value of 30 mm Hg to diastolic blood pressure is an absolute indicator for fasciotomy

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ACUTE COMPARTMENT SYNDROME

Interpretation of ICP measurement

Absolute : 30 mm Hg as cut off point for fasciotomy

Differential Pressure (Whitesides) : Delta Pressure Diastolic BP minus ICP cut off point < 30 mm Hg

Many UNNECESSARY fasciotomies can be avoided

Management : Medical therapy

Place the affected limbs at the level of the heart Elevation is contraindicated because decreased arterial flow & narrows the arterial venous pressure Releasing the cast Correct hypo-perfusion with crystalloid and blood products In case of snake envenomation, administration of antivenom

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Management : Surgical therapy

The definitive surgical therapy is Emergent Fasciotomy Within 6 hours One or two incisions Subsequent :
Fracture stabilization Vascular repair if needed

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One incision

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Two incisions

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ACUTE COMPARTMENT SYNDROME

Complication

Volkmann contracture : 1 10% of all cases of ACS

Infection : Matsen in late cases surgical decomp. 11/24 cases develop infection 5 cases need AMPUTATION Hypesthesia / Painful dysesthesia Systemic : Acute Renal Failure, sepsis, Acute Resp Distress Syndrome (ARDS)

Upper extremity

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Post Operative care

Monitor haemodynamic status and maintain adequate blood pressure If rhabdomyolysis occurs,
continue hydration monitor urine output and kidney function Potassium status closely

Re-dress wound daily IV lines adequate Antibiotic Delayed primary suture or STSG within 7 days

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Complication

Volkmann contracture : 1 10% of all cases of ACS

Infection : Matsen in late cases surgical decomp. 11/24 cases develop infection 5 cases need AMPUTATION Hypoesthesia / Painful dysesthesia Systemic : Acute Renal Failure, sepsis, Acute Resp Distress Syndrome (ARDS)

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Conclusions
Acute Compartment Syndrome is true emergency case
Timely diagnose and management

Clinical diagnose quite simple & easy

Surgical treatment within 6-8 hours

Delayed treatment caused high morbidity and mortality

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