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Compartment Syndrome:Current Solutions

J O S E P H B O R R E L L I , J R . , M D , M B A

Acute Compartment Syndrome

“Acute compartment syndrome remains a vexing complication (commonly) of tibial shaft fractures. Although clinicians understand the clinical presentation, pathophysiology, and the potential for great morbidity, ACS is at times difficult to diagnose, and often clinical intuition (a “high index of suspicion”) remains the cornerstone of decision-making.”

Andrew H. Schmidt, MDInjury 2017

Acute Compartment Syndrome

Review ACS is a complication of any condition that causes an

increase mass within a myofascial compartment, Bleeding, edema, direct infusion, etc…

Increased mass causes increased intracompartmentpressures, Fascia relatively inelastic

Increased pressure is transmitted to the thin walled veins causing venous hypertension, decreased outflow,

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Acute Compartment Syndrome

Review This decreased outflow leads to decreased inflow and

ultimately tissue ischemia, Cellular death

Cell-membrane lysis releases cellular contents/metabolites into the interstitial space, causing further accumulation of fluid and further increase in intracompartment pressure

Acute Compartment Syndrome

In addition: Arteriolar perfusion can also be compromised, leading to

microvascular collapse,

Myonecrosis occurs within 2 h of injury,

And, within 6–8 h, irreversible ischemic injury occurs within the myofascial compartment,

Missed Compartment Syndrome

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Missed Compartment Syndrome

Acute Compartment Syndrome

Diagnosis: Historically Physical Examination

The SIX P’s!!!1. Pain out of proportion to the injury

2. Pain on passive stretch

muscle w/i the compartments in question

3. Paresthesia

4. Pallor

5. Pulselessness

6. Paralysis

Acute Compartment Syndrome

Ulmer T. The clinical diagnosis of CS of the lower leg: areclinical findings predictive of the disorder? J Ortho Trauma 2002; 16:572-7.

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Compartment Pressure Measurement Confirmatory

Obtunded patients

Unfortunately, not a direct indication of ongoing cellular loss

Acute Compartment Syndrome

Compartment Pressure Measurement

Acute Compartment Syndrome

Intra-compartmental Pressure Measurement Things to be conscious of:

Measurement relative to location of the fracture

Uncertainty and/or variability in measured values of IMP

only 60% of measurements done correctly were within 5 mm Hg of the known IMP.

When calculating perfusion pressure, what blood pressure value to use, especially if the patient is under general anesthesia.

Using diastolic bp while patient is under anesthesia may lead to an increased number of false positives

Make sure you measure the compartments of interest

Serial exams may be necessary particularly in obtunded pts

Acute Compartment Syndrome

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Interpreting the measurements Absolute Pressures

> 40 mmHg

Perfusion Pressures Diasytolic – intracompartment pressure = Perfusion Pressure

Acute Compartment Syndrome

Continuous Compartment Pressure Measurements

Evolving Techniques

Evolving Techniques

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Evolving Techniques

Evolving Techniques

Oxygen Tension and pH

Evolving Techniques

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Evolving Techniques

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“A Chance to Cut is a Chance to Cure”

Fasciotomies Prompt release of the fascia encompassing the compartments

Lower Extremity Leg: Generally means all four compartments

Thigh, Buttock

Upper Extremity Arm

Forearm

Distal Extremities Foot and Hand

Treatment: What Isn’t Evolving

Summary: ACS found in multiple clinical scenarios.

Diagnosis must be made in a timely fashion Understanding the process

Remaining vigilant

PE, Increased IMP, decreased perfusion pressures

Prompt action to release the pressure

Delay associated with sensory deficits, paralysis, infection, Volkman’s contracture, amputation

In an attempt to prevent cellular loss and disability

Treatment: What Isn’t Evolving