Orthopaedic Teaching for Junior Doctors

Aims & Objectives

Identify patients at risk of compartment syndrome Recognize signs and symptoms Understand the treatment pathway Be aware of compartment syndrome complications

Definition

What is Compartment syndrome? How does it occur? Who is at risk?

Pathogenesis

Elevation of tissue pressure within encapsulated muscles due to:

Increased vascular permeability Interstitial oedema formation

Results in:
Progressive skeletal muscle microvascular

ischaemia Muscle cell death Loss of motor function Loss of limb

Pathogenesis
1

Vein collapse as pressure increases Arterial Spasm due to directly increasing interstitial pressure Critical closing pressure on arterioles

Aetiology

Fractures (Closed & Open) Nailing procedures Soft tissue injuries Casting material Lithotomy position Burns Revascularization Military anti-shock trousers Anticoag treatment Skin traction

History & Examination

Mechanism of injury is 1st warning Remember 6 Ps:

Pain Pallor Paraesthesia Paralysis Pressure Pulseless

2 signs = 25% positive 3 signs = 93% positive

Clinical Assessment
Clinical Signs Painful passive toe flexion First web space numbness Anterior tenseness
Weak foot eversion Numbness to dorsum of foot Painful dorsiflexion Numbness to lateral of foot Painful passive toe extension Plantar numbness

Leg Compartment Anterior

Lateral Posterior Superficial Posterior Deep

Intra-compartmental Pressure monitoring

Muscle ischaemia occurs when compartment pressure is within 2030mmHg of diastolic BP Normal pressure is less than 30mmHg Inaccurate as a sole indicator Studies have found increased pressures in fractured tibia patients without compartment syndrome Link to Stryker pressure monitoring

Lab findings

Increased Creatine Phosphokinase Increased Lactate Dehydrogenase

Treatment
Remove dressings (decrease 15%) 2. Remove cast (decrease 15%) 3. Limb at level of heart, not elevated to maximize tissue perfusion 4. Rehydrate with IV fluids 5. Keep fasted for Fasciotomy
1.

Fasciotomy
Aim to open all compartments

Use the Two-IncisionTechnique

Landmarks are: 2cm anterior to fibula shaft 2cm posterior to the posterior border of the medial tibia Length of incision should be extensive Leave wounds open Video of fasciotomy

Complications

Rorabeck studied 18 patients with double fasciotomies:

72% (13) acceptable 22% (4) neurological squelae 6% (1) required amputation

Mortality rate 10% is quoted Amputation rate 10% is quoted Renal failure Ischaemic contracture

Medico-Legal

Biggest payouts when:

Neurological examination without

intervention
Poor physician-patient communication

Increased time to fasciotomy

Summary
Increased pressure within fascial compartment 6 Ps to look for High clinical suspicion in trauma Remember to put on consent forms Early intervention can save lives & limbs Double incision technique