Compartment syndromeDiagnostic difficulties & future developments

Henrik Grønborg, co-directorRigshospitalet Trauma Center

Copenhagen

• The past

• The present (difficulties)– Symptoms– Diagnosis

• The future ?

History

• Volkmann's ischaemic contracture

• Permanent flexion contracture• Claw-like deformity of the

hand and fingers

1830 - 1889

Development of acute CSIn an enclosed muscle (osteofascial) compartment:

Increase in volume of contentsand/or

Reduction in size of compartment

↓increased pressure within the compartment

↓compression of muscles, nerves & vessels

↓impaired blood flow

↓ischemia & necrosis

• Fracture (also open #’s)• Blunt trauma• Cast/dressing• Arterial injury• Post-ischemic

hyperperfusion• Burns/electrical injuries• Distorsion (ankle)• Tumour• Lithotomy position

• IM nailing (reaming)• Exertional states• Closure of fascial

defects• GSW / stabbings• IV & A-lines• Hemophil./coag.disorder• Intraosseous infusion• Snake bite

Numerous etiologies

……….and more

Symptoms

• Pain out of proportion• Pain on passive stretch• Paraesthesia• Paresis• Pulses present • Palpatory pain

• ACS is a surgical emergency !

20042008

Patient characteristics

JBJS1996

Patient characteristics

CJEM 2003

• 17% of consultant anaesthetists• 9% of nonconsultant anaesthetistshad seen CS masked by regional anaesthesia !

Injury2006

Diagnostic delay

CJEM 2003

JOT2002

The clinical findings

• Bayes’ theorem– Estimating the probability of a diagnosis based

on a series of clinical findings

– The likelihood ratio that compartmentsyndrome exists in a patient with a tibial shaft #

• based on pain, paresthesia, PPS, paresis:

JOT2002

JOT2002

Clinical features of ACS of the lower leg are:

• more useful by their absence in excluding ACS• than they are when present in confirming ACS

JOT2002

Measurement ofintracompartmental

pressure

Pressure monitoring

Kodiag

Stryker

Whitesidetechnique

AJEM2003

JBJS2005

SP

S

SL

• A-line manometer with:– side-port needle

or– slit catheter

• Available at ICU’s !

JBJS2005

Pressure measurementsshould be performed in:

1. both the anterior and the deepposterior compartments

2. at the level of the fracture+

3. at locations proximal and distalto the fracture zone

HeckmanJBJS-A, 1994

• A pressure threshold of 30 mmHg seemsto give an unacceptably high rate offasciotomies– ”Even if the absolute pressure limit had been

increased to 40 or 50 mmHg, we would have 19% or 14%, respectively”

Arch OrthopTrauma Surg

1998

– 116 patients with tibial #’s– Continuous monitoring of anterior tibial

compartment for 24 hrs– P=30 mmHg threshold for fasciotomy

• 3 patients (2.6%) fasc.• no missed cases

– If P=30mmHg• 50 patients (43%) fasc.

– If P=40mmHg• 27 patients (23%) fasc.

JBJS1996

95 patients with 97 tibial #’s• ICP > 30mmHg

or• PP = P = (DBP – ICP) <30 mmHg

– acceptable sensitivitybut

– poor specificity too many fasciotomies

• PP = P = (MAP – ICP) <30 mmHg, used in combinationwith clinical symptoms or a second measurement after 1hr– excellent specificity

but– low sensitivity too many missed CS’s

Injury2001

• ↑ fracture complexity => ↓ P• ↑ delay to diagnosis => ↓ P

• Open vs. closed # => ns diff. in P

• IM nail vs. Ex-Fix => ns diff. in P

JBJS1996

• CCPM is– invasive– requires hourly nursing attention– regular in-service training of nursing staff

• not cost effective

• CCPM is not indicated in alert patients who are adequately observed

JBJS1996

Management of acute compartmentsyndrome - how do we do it ?

Injury1998

ANZ J.Surg2007

• 100 questionaires to consultants at different centres

• 78 answers– 36/78 had equipment for pressure monitoring

• 12/36 used equipmet routinely• 24/36 used it selectively or not at all

Injury1998

Injury1998

• 264 valid responses– (29% of all eligible respondents).

• 78% of respondents regularly measuredcompartment pressure– 33% used an absolute P threshold– 28% used a P threshold– 39% took both into consideration

ANZ J.Surg2007

ANZ J.Surg2007

ANZ J.Surg2007

ANZ J.Surg2007

Immediate actions• Limb elevation =>↓ compartment pressure

BUT• BP ↓ in elevated limb• 53% ↓ in perfusion pressure

NO

Wiger & Styf, J Orthop Trauma. 1998

• Cut & spread plaster• Cut webril• Remove cast

YES

• Fasciotomy most efficacious when performed early• However, when performed late

– similar rates of limb salvage as compared to early fasc– but increased risk of infection

• Results support aggressive use of fasciotomyregardless of time of diagnosis

Surgery1997

• 5 patients• Average delay 56 hrs (35-96 hrs)• 9 fasciotomies in lower limbs

– 1 death of septicaemia and MOF– 4 required amputations

• If CP in a closed lower limb injury > 8 to 10 hours:– ICP recordings after an 8-hour period is not useful– Treatment of potential acute renal failure must be considered– Viable skin left intact; no exposure of necrotic muscle to infection– Late reconstructive procedures to correct muscle contractures

JOT1996

The future ?

JBJS 1999

Physiol Meas2004

J OrthopTrauma

2006

Identifying the patient at risk

• Unconsciousness• Intoxication• Concomitant nerve injury• Multiple injuries• Young children• Individual patients with equivocal

symptoms and signs • Epidural anaesthesia

”seek, and ye shall find”Matthew (ch. VII, v. 7-8)

Trauma 2007

Take home message• ACS is a surgical emergency• High level of suspicion (”seek, and ye shall find”)

• Classic clinical symptoms have:– low sensitivity & pos+ predictive value– high specificity & neg- predictive value

• ICP easily measured with A-line manometer• P=30 mmHg useful threshold for fasciotomy• Screening protocols for patients at risk• Non-invasive pressure monitoring is coming

This lecture is available at:

www.flims.dk