Acute Compartment Syndrome

Current concepts & Management

Dr TN Nakale
08 May 2015

Outline

Introduction
Aetiology
Pathophysiology
Diagnosis
Management
Take Home Message
References

Introduction
occurs when perfusion pressure falls below
tissue pressure in a closed anatomical
compartment .
Requires high index of suspicion
Surgical Emergency

Introduction
1881: Volkmann => Irreversible forearm
Contracture from muscle Ischemia
1906: Hildebrand => First to apply the
term Volkmann Ischemic Contracture
end result of untreated CS
1914: Murphy => First to suggest
Fasciotomy to Rx CS
1967: Seddon, Kelly & Whiteside => Need
to decompress all 4 compartments in the
leg

Aetiology
Fractures

Compartment
Contents

Compartment
Volume

(Haemorrhage/Oedema)
Arterial Injury(Post Ischaemic
Swelling/Repurfusion injury)
Ruptured Ganglia/Cysts
Soft tissue injury/Crush Injury
Envenomation
Haemophilia/Coag Disorders
IV Infusions

Casts
Circumferential dressings
Burns
Repair of Muscle Hernia

Pathophysiology
Intracompartment
pressure >
Venous Capillary
pressure

Hydrostatic
Pressure

Oedema
Tissue
Ischemia +
Cell Death

Tissue
Perfussion

Arteriolar
Compression

Risk Factors
Young age
Type of Injury
Diaphyseal Tibial Fractures 36%
Forearm Fractures 20%
Blunt Soft tissue trauma 23.2%
Foot Injuries 6%
Revascularization

Open vs Closed Fractures : No difference

Shadgan et al, J orth trauma, 2014
McQueen et al, J orth trauma, 2015

Diagnosis
High Index of Suspicion Seek & Ye shall find
Serial Exams by One Examiner
S&S
Pain

Paresthesia

Out of Proportion/Passive Stretch/At

Rest/Absent (late )
1st signs of Nerve Ischemia => Hypoesthesia =>
Anaesthesia => Paresis => Paralysis
Light touch/ 2 point discrimination/ Pinprick

Pulseless

Late Finding
If early wt Pallor: ? Direct Arterial Injury

* Absence more useful than presence

Diagnosis
Patients @ Risk
Unconscious
Intoxicated
Concomitant Nerve Injury
Multiple Injuries
Young Children
Patients wt equivocal S & S
Epidural/Prolonged AnAesthesia

Diagnosis
Compartment Pressure Monitoring
AUTHOR

SUGGESTED
THRESHOLD FOR
FASCIOTOMY

Matsen et al; Mubarak

et al; Gelbermaman et
al

30 45 mmHg

May lead to
Unnecessary
Fasciotomies

Whitesides et al

P < 30

More reliable Indicator

* Continuous Monitoring in Patients at risk

* C/I : Clinically evident ACS

Diagnosis
Compartment Pressure
monitoring devices
Whiteside Apparatus
Stryker Needle device
Arterial transducer
* Measure pressures in all
compartments w/in 5 cm of
fracture site

Diagnosis
Accuracy in the measurement of
compartment pressures: a comparison of
three commonly used devices
Boody & Wongworawat, JBJS , 2005

Conclusion:
The arterial line manometer is the most accurate device.
The Stryker device is also very accurate. The Whitesides
manometer apparatus lacks the precision needed for
clinical use.

Diagnosis
Research: Where are we today?
BIOMARKERS

CK/Myoglobin /FABP
PH

Not Specific

Ongoing Research

MRI

T1 Weighed detects
oedema + Swollen
compartments

Cant
differentiate

Role limited

ULTRASOUND

PPLL: Detects
microfascial movements
in relation to arterial
pulsation

Noninvasive

Promising

SCINTIGRAPHY

Radionuclide imaging
Measures regional
perfusion

Limited by time
Lacks specificity
Repeated/Conti
nuous exam
difficult

Ongoing Research

Diagnosis
Research: Where are we today?
DOPPLER

LDF : Measures
microvascular perfusion
in tissue (rbc circulation)

Non-invasive
Highly sensitive
Abraham et al

Promising
Research ongoing

INFRARED
SPECTROSCOPY

NIRS: Optical technique

Measures local changes
in Oxygenation

Noninvasive/Co
ntinous
monitoring
Garr et al

Promising
Research Ongoing

Management
Initial Management
ATLS Principles
Loosen/Remove all dressings
Elevate Extremity (Inc venous
return/ dec Swelling)
Bloods: (Baseline/Group &
Screen
IVI fluids

Management
Fasciotomy Principles
Early Diagnosis
Long Extensile Incisions
Release all Fascial Compartments
Preserve neurovascular Structures
Debride Necrotic Tissues
Coverage w/in 7 10 days

Management
Fasciotomies: Leg

Fasciotomies

Management
Fasciotomy Complications
Metabolic
Repurfusion Injury
(Hyperkalemia/Acidosis/AKI)

Wound Complications
Infection
Altered Skin sensation
Muscle herniation
Wound pain
Tethered Scars/Tendons

Management
Fasciotomy Complications
Technical Complication
Incomplete Fasciotomy
Recurrent ACS
* 13% Fasciotomy revisions d/t inadequate release

Neurovascular Injury
Superficial peronial nerve injury
Peronial artery Injury

Venous Insufficiency
Leg Fasciotomy may predispose to Calf
pump dysfunction and Chronic Venous
Disease

Limb Loss : 5 20% (* Occluded vascular

repair)

Management
Fasciotomy Wound Mx
Interim Cover
Simple absorbent dressing/ Sterile saline
gauze
Vaccum Assisted Closure (Higher rate of
skin closure/earlier skin closure)

Delayed definitive coverage (7

10days)
Primary closure
Dermatraction (Skin staples/Elastic vessel
loops)
SSG
Flap

Take Home Message

ACS is a Surgical Emergency

High Level of Suspicion Seek, and ye shall find
Classical clinical S & S may not always ne reliable
Best Method of measing ICP is A-line manometer
P < 30mmHg is usefull threshold for fasciotomy
Screening protocols for patients at risk
Future: Non invasive Pressure monitoring
Fasciotomy not benign

References

Whitesides TE, Haney TC, Morimoto K, Harada H. Tissuepressure measurements as a determinant

for the need of fasciotomy. Clin Orthop Relat Res. 1975;113:43-51.
Garr JL, Gentilello LM, Cole PA, et al. Monitoring for compartmental syndrome using near-infrared
spectroscopy: a noninvasive, continuous, transcutaneous monitoring technique. J Trauma.
1999;46:613-616.
Mubarak SJ, Hargens AR, Owen CA, Garetto LP, Akeson WH. The wick catheter technique for
measurement of intramuscular pressure. A new research and clinical Tool. J Bone Joint Surg Am.
1976;58:1016-20.
McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk? J Bone
Joint Surg Br. 2000; 82:200-203.
T. Busch, H. Sirbu,D.Zenker,andH.Dalichau,Vascularcomplications related to intraaortic balloon
counterpulsation: an analysis of ten years experience, Thoracic and Cardiovascular
Surgeon,vol.45,no.2,pp.5559,1997
M. M. Heckman, T. E. Whitesides Jr., S. R. Grewe, and M. D. Rooks, Compartment pressure in
association with closed tibial fractures. The relationship between tissue pressure, compartment,
and the distance from the site of the fracture, Journal of Bone and Joint SurgerySeries
,vol.76,no.9,pp.12851292, 1994.
Matsen F, Winquist R, Krugmire R. Diagnosis and management of compartmental syndromes. J
Bone Joint Surg Am. 1980;162:286291.
McQueen MM. Acute compartment syndrome. In: Buchholz RW,Heckman JD, Court-Brown CM,
eds. Rockwood and Greens Fractures in Adults. Philadelphia, PA: Lippincott Williams & Wilkins;
2006: 425443.