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Acute Compartment
syndrome
Acute Compartment
syndromeDavid Agolley
department of orthopaedicsDavid Agolley
department of orthopaedics
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DefinitionDefinition
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
Acute Compartment Syndrome
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VariationsVariations
Acute Compartment Syndrome
Exertional Compartment syndrome
Crush Syndrome
Acute Compartment Syndrome
Acute Compartment Syndrome
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Historical ReviewHistorical ReviewLate 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
Acute Compartment Syndrome
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Acute Compartment Syndrome
Acute Compartment Syndrome
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EpidemiologyEpidemiology
3.1 per 100,000
Young Male 10 fold increase
MVA
sports
muscle volume
Acute Compartment Syndrome
Acute Compartment Syndrome
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PathophysiologyPathophysiology
Acute Compartment Syndrome
Acute Compartment Syndrome
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PathophysiologyAetiology
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
Acute Compartment Syndrome
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PathophysiologyPathophysiology
Acute Compartment Syndrome
Acute Compartment Syndrome
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PathophysiologyPathophysiologyNormal 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
Acute Compartment Syndrome
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Tissue SurvivalTissue SurvivalMuscle
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 damageAcute Compartment
SyndromeAcute Compartment
Syndrome
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Night intern, Call from Paeds“Dr, I think little Jimmy has compartment syndrome”
Night intern, Call from Paeds“Dr, I think little Jimmy has compartment syndrome”
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Assessment of Compartment
Syndrome
Assessment of Compartment
Syndrome
Acute Compartment Syndrome
Acute Compartment Syndrome
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AssessmentAssessmentPrioritise
History
mechanism injury
intervention
analgesic requirements
Examination
InvestigationsAcute Compartment
SyndromeAcute Compartment
Syndrome
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Diagnosisthe 6 Ps
Hargens and Mubarak
Diagnosisthe 6 Ps
Hargens and Mubarak
Pain out of proportion / Passive stretch
Palpably tense compartment
Parasthesia
Paresis
Pink skin colour
Pulse presentAcute Compartment
SyndromeAcute Compartment
Syndrome
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DiagnosisDifferentialsDiagnosis
Differentials
Arterial Occlusion
Peripheral nerve injury
Muscle rupture
Acute Compartment Syndrome
Acute Compartment Syndrome
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Emergent TreatmentEmergent TreatmentPlace at level of heart
Cut dressing or cast - MUST SEE SKIN
Alert senior Dr, OR, Anaesthetist and fast patient
ReviewAcute Compartment
SyndromeAcute Compartment
Syndrome
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InvestigationsInvestigationsRadiographs
MRI USS not routine
Arterial doppler flow
Pulse Oximetry
Pressure measurements
Suspected CS
Equivocal or unreliable exam
Clinical adjunct
Acute Compartment Syndrome
Acute Compartment Syndrome
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At risk PatientsAt risk PatientsDemographic
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
Acute Compartment Syndrome
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Pressure MonitoringPressure Monitoring
Acute Compartment Syndrome
Acute Compartment Syndrome
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Surgical TreatmentIndications for fasciotomy
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
Acute Compartment Syndrome
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Surgical treatmentPrinciples
Surgical treatmentPrinciples
Early diagnosis
Long extensile incision
Release all fascial compartments
Preserve neurovascular structures
Rigid fracture stabilisation
Debride necrotic tissues
Cover 7-10 daysAcute Compartment
SyndromeAcute Compartment
Syndrome
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Forearm FasciotomyForearm Fasciotomy
Acute Compartment Syndrome
Acute Compartment Syndrome
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Forearm FasciotomyForearm Fasciotomy
Acute Compartment Syndrome
Acute Compartment Syndrome
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Leg FasciotomyLeg Fasciotomy
Acute Compartment Syndrome
Acute Compartment Syndrome
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Leg FasciotomyLeg Fasciotomy
Acute Compartment Syndrome
Acute Compartment Syndrome
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Leg FasciotomyLeg Fasciotomy
Acute Compartment Syndrome
Acute Compartment Syndrome
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Thigh FasciotomyThigh Fasciotomy
Acute Compartment Syndrome
Acute Compartment Syndrome
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Foot FasciotomyFoot Fasciotomy
Acute Compartment Syndrome
Acute Compartment Syndrome
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Other Compartments
Other Compartments
Hand, forearm, arm, deltoid
Abdomen
Buttock
Acute Compartment Syndrome
Acute Compartment Syndrome
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Temporary CoverageTemporary Coverage
Simple dressing
Progressive suturing
Vessel loop “Bootlace”
Vacuum Assisted Closure
Acute Compartment Syndrome
Acute Compartment Syndrome
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Definitive CoverageDefinitive CoverageSecond look
Cover 7-10 days after risk of necrotic tissue passed
Split skin graft
Local flap
Free flapAcute Compartment
SyndromeAcute Compartment
Syndrome
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SummarySummary
Acute Compartment Syndrome
High Index of suspicion
Early diagnosis
Early intervention
Expedite time to surgery
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Questions?Questions?