Compartment syndrome Diagnostic difficulties & future - - PowerPoint PPT Presentation

Compartment syndrome

Diagnostic difficulties & future developments

Henrik Grønborg, co-director Rigshospitalet 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 CS

In an enclosed muscle (osteofascial) compartment: Increase in volume of contents

and/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 !

2004 2008

Patient characteristics

JBJS 1996

Patient characteristics

CJEM 2003

• 17% of consultant anaesthetists
• 9% of nonconsultant anaesthetists

had seen CS masked by regional anaesthesia ! Injury 2006

Diagnostic delay

CJEM 2003

JOT 2002

The clinical findings

• Bayes’ theorem

– Estimating the probability of a diagnosis based

• n a series of clinical findings

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

• based on pain, paresthesia, PPS, paresis:

JOT 2002

JOT 2002

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

JOT 2002

Measurement of intracompartmental pressure

Pressure monitoring

Kodiag Stryker Whiteside technique

AJEM 2003

JBJS 2005

SP S SL

• A-line manometer

with:

– side-port needle

• r

– slit catheter

• Available at ICU’s !

JBJS 2005

Pressure measurements should be performed in:

1. both the anterior and the deep posterior compartments 2. at the level of the fracture + 3. at locations proximal and distal to the fracture zone

Heckman

JBJS-A, 1994

• A pressure threshold of 30 mmHg seems

to give an unacceptably high rate of fasciotomies

– ”Even if the absolute pressure limit had been increased to 40 or 50 mmHg, we would have 19% or 14%, respectively”

Arch Orthop Trauma 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.

JBJS 1996

95 patients with 97 tibial #’s

• ICP > 30mmHg
• r
• PP = P = (DBP – ICP) <30 mmHg

– acceptable sensitivity

but

– poor specificity too many fasciotomies

• PP = P = (MAP – ICP) <30 mmHg, used in combination

with clinical symptoms or a second measurement after 1hr

– excellent specificity but – low sensitivity too many missed CS’s

Injury 2001

• ↑ fracture complexity

=> ↓ P

• ↑ delay to diagnosis

=> ↓ P

• Open vs. closed #

=> ns diff. in P

• IM nail vs. Ex-Fix

=> ns diff. in P

JBJS 1996

• 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

JBJS 1996

Management of acute compartment syndrome - how do we do it ?

Injury 1998 ANZ J.Surg 2007

• 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

Injury 1998

Injury 1998

• 264 valid responses

– (29% of all eligible respondents).

• 78% of respondents regularly measured

compartment pressure

– 33% used an absolute P threshold – 28% used a P threshold – 39% took both into consideration

ANZ J.Surg 2007

ANZ J.Surg 2007

ANZ J.Surg 2007

ANZ J.Surg 2007

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 fasciotomy

regardless of time of diagnosis

Surgery 1997

• 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

JOT 1996

The future ?

JBJS 1999

Physiol Meas 2004

J Orthop Trauma 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