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Greetings,Welcometotheinternaleducationalprogram(IEP)oftheVanderbiltUniversityDivisionofTrauma,EmergencySurgeryandSurgicalCriticalCare.Ourgoalistoprovideanopportunitytopursuetopicsgermanetotraumafromallaspectsoftheteam.Myhopeistoexploreallareasofinterestthroughoutthecourseoftheyearincludingpre-hospitalcare,acutecareissues,post-dischargerequirements,aswellasinjuryprevention.Wewillattempttooutlinethecareprovidedtoourtraumapatientpopulationfrompointofinjuryuntilthepatientscareiscompleted.Asyouknow,thetraumateamconsistsoftheChiefoftheDivision,Dr.RickMiller,ourTraumaProgramManager,MelissaSmith,RN,thePerformanceImprovementDirector,Dr.BradDennis,theOutreachandPreventioncoordinator,CathyWilson,RN,theTraumaResuscitationManager,KevinHigh,RN,aswellastheentiretraumafacultyandAcuteCareSurgeryFellows.OurmultidisciplinaryliaisonteamincludesTylerBarrett(EM),RobertBoyce(Ortho),ReidThompson(Neurosurgery),ShannonKilkelly(Anesthesia),PeterBream(Radiology)andtheLifeFlightteam.OurgoalistoimprovethecareofthetraumapatientinacaringandconsistentmannerandtohelpminimizeinjuryintheMiddleTennesseeregionthroughoutreachandpreventioneffortsdeterminedbytheneedsofthecommunity.Pleasetakeafewminutestoreviewthismaterialandcompletethesurvey.YoursTruly,OscarGuillamondegui
TheACStraumaeducationrequirement(forfacultywhoarenotliaisons)maybemetbydocumentingacquisitionof16hoursoftrauma-relatedCMEper
yearonaverageorbydemonstratingparticipationinaninternaleducationalprocess(IEP)conductedbythetraumaprogrambasedontheprinciplesofpractice-basedlearningandthePIPsprogram.
AMessagefromtheTraumaMedicalDirector,OscarGuillamondegui,MD Summer2016
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1)WhichofthefollowingisnotgenerallyconsideredariskfactorforDVT?
a)Obesity b)Multiplelongbonefractures c)Historyofatrialfibrillation d)renalfailure2)WhatproportionofDVTsarediagnosedaccuratelybyphysicalexamfindings?
a)<5% b)25% c)50% d)>75%3)Whichofthefollowingisnotanon-invasivetesttodiagnoseaDVT?
a)Impedanceplethysmography b)duplexultrasound c)CT-venogram d)straightlegraise
4)ForwhichofthefollowingproceduresshouldpharmacologicDVTprophylaxisbeheldtoreducetheriskofbleeding?
a)Operativerepairofaruptureddiaphragm b)Posteriorfusionofspinalfracture c)Openreductionandinternalfixationofthefemur d)Closureofopenabdomen
5)WhichofthefollowingprophylacticregimensisthemosteffectiveatpreventingDVTs?
a)UnfractionatedHeparin b)LMWH c)SequentialCompressionDevices(SCDs) d)LMWH+SCDs
AnswerKeyforSpring2016TraumaIEPNewsletter
(answersareinboldandItalicsbelow)
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RichLesperance,MD CaseStudy:A19yearoldmaleisarrivesatthetraumacenterasaLevel1traumaformultiplegunshotwounds,approximatelyonehouraftertheevent.Inadditiontoseveralintra-abdominalinjuries,oneprojectiletraversedhisupperthigh.Hiswork-uprevealedaSuperficialFemoralArtery(SFA)andVein(SFV)injury,aswellasintraabdominalfindings.Aftertemporizationofhisintra-abdominalinjuries,heunderwentaninterpositiongraftrepairofhisSFAandligationofhisSFV.Theoperativeinterventionrequiredapproximatelytwohours.Inordertopreventtheoccurrenceofalowerextremitycompartmentsyndromeintheatrisklimb,aprophylacticlowerlegfasciotomywasperformed.
Introduction
Extremitycompartmentsyndromeisacommonproblemdealtwithbyorthopedic,vascularandtraumasurgeons,andfailingtodiagnoseandtreatappropriatelycanleaveapatientwithseverelife-longdisability.Whentakingcareoftraumapatientswecanencounter“compartmentsyndromes”inotherbodycavities,butthisreviewwillfocusonacuteextremitycompartmentsyndrome.
ExtremitycompartmentsyndromewasfirstrecognizedasaclinicalentitybyRichardvonVolkmanninthelate19thcentury,identifyingtissueischemiaastheuntreatedresult.Thedebilitatingforearmcontracturesfromuntreatedupperextremitycompartmentsyndromewerenamed“inhishonor.”1
Compartmentsyndromeofanextremityisfrequentlyassociatedwithalongbonefractureupto75%ofthetime;andapproximately9%ofalltibialshaftfracturescanbecomplicatedbycompartmentsyndrome.2Youngmenseemtobeatahigherriskfordevelopingcompartmentsyndrome,possiblyduetohighermusclemassinanon-distensiblefascialcompartment,whileconverselytheelderlyappeartohavealowerrisk.3Extremitycompartmentsyndromecanalsobeassociatedwithdirecttraumatothelimbintheabsenceofafracture(evenwithoutaclinicalcrushinjury),andthismaybeassociatedwithahigherincidenceofdelayintreatmentandmusclenecrosis.4Othercausesofextremitycompartmentsyndromeareburns,tightcastsordressings,penetratingtrauma,andinappropriatepositioningintheoperatingroom(especiallyduringlithotomyposition).2Unusualnon-traumaconditionssuchasGroupAStreptococcalinfectionshavebeendescribedasetiologiesaswell.5
Vascularinjuriescanalsocauseanextremitycompartmentsyndrome,eitherthroughbleedingintothemuscularcompartmentdirectlyorviaedemafromischemia-reperfusionsyndrome.6Itshouldbenotedthatthearterialinjurydoesnotneedtobelocatedinthecompartmentatrisk;proximalinjuriescanobviouslycauseischemiaindistalcompartments.Combinedarterialandvenousinjuries,suchasinourpatient,areathigherriskthaneitheralone.6
Pathophysiology
Thefascialcompartmentsenclosingmajorextremitymusclegroupsarerelativelynon-distensible,soanyedemaorinflammationinthecompartmentcancauseintra-compartmentpressurestorise.Ischemiaoccurswhencompartmentpressureexceedsthecapillaryperfusionpressure.Ifallowedtooccur,thismayleadtocellularnecrosispromotinginflammationandincreasedpressuresinapositive-feedbackcycle.7
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Peripheralsensorynervesarethemostsensitivetoischemia,showingsignsofdysfunctioninaslittleasonehour,butafterfourtosixhoursofischemiapermanentnerveandmuscledamageislikely.2
Clinicalpresentation
Theclassicalphysicalexamfindingsofcompartmentsyndromearepulselessness,pain(outofproportiontoinjury),paresthesias,paresis(muscleweakness)andpainwithpassivestretchingofthemuscle.8Additionally,palpationofthelimbinquestionmayallowthepractitionertodetecta“tense”compartment.Noneofthesephysicalexamfindingshavebeenfoundtobeveryaccuratefordiagnosis,however.
Thepresenceofdistalpulsesdoesnotexcludecompartmentsyndrome.Asmentionedabove,thesyndromeexistswhenthecompartmentpressureexceedsthecapillaryperfusionpressure;distalarterialflowisnotlostuntilthepressureexceedsthe(muchhigher)systolicBP,whichmeanssignificantcompartmentsyndromecanexistevenwithoutdistalarterialinsufficiency.
Manualdetectionof“tense”compartmentsdoesnotseemtobeveryaccurateeither.Whenorthopedicsurgeonsweretestedonafreshcadaverlegmodel,theirsensitivityindetectingincreasedcompartmentpressureswasonly24%withspecificityalittlebetterat55%,butpresumablyhalfofthepatientsundergoingafasciotomydidnotactuallyhaveelevatedpressures.9
Asystematicreview8oftheliteratureevaluatingtheaccuracyofclinicalfindingsfordiagnosisofcompartmentsyndromefoundthattheclassicalsignsofpain,paresthesia,painwithpassivestretchandparesiswerenotverysensitive(13-19%)individually,butthepresenceoftwoormoreofthesignsincreasedtheaccuracy.Ifthreeormoreofthoseclassicsignswerepresent,theauthorsfoundtheoddsofcompartmentsyndromebeingcorrectlydiagnosedroseto93%.Mostofthestudiesagreedthatpainistheearliestclinicalfinding,buttherewasawidevarietyofopinionsonwhichfindingsweremostsignificant.
Painisobviouslyaproblematicsigntorelyonfordiagnosis.Sinceacommonincitingeventforlower-extremitycompartmentsyndromeisatibialshaftfracture,ittakesanexperiencedpractitionertodifferentiatefracturepainfromthatofcompartmentsyndrome.Commonlyusedpaincontroladjunctssuchasepiduralcathetersandregionalanesthesiamaymaskworseningpainfromadevelopingcompartmentsyndrome,10althoughthisissomewhatdisputedintheorthopedicliterature.11Painassessmentbecomesdifficultinthemulti-systemtraumapatient,especiallyinICUsettings,withmultipledistractinginjuriesand,possibly,intubated.However,paininan‘uninjured’extremityshouldraiseheavysuspicionifthelimbisotherwiseatrisk(asinourcasestudy,above.)
MeasurementofCompartmentPressures
Duetothedifficultydiagnosingcompartmentsyndromeclinically,ithasbeensuggestedthatdirectmeasurementofthepressureswithinthecompartmentinquestioncouldbebeneficial.Differentmethodsofmeasuringpressureshavebeendescribed,includingasimplearterialcatheterpressure-monitoringsetup,side-holecatheters,orahand-held“Stryker”device.Cathetersmaybeleftin-dwellingincertaincircumstancestoallowcontinuousmonitoringofcompartmentpressures,aswell.12
Normalcompartmentpressuresare8-15mmHg.2Ithasbeensuggestedthatintra-compartmentpressuresgreaterthan30mmHgindicatetheneedfordecompression.13However,asmentionedabove,ischemiaresultswhenthecompartmentpressureexceedsthecapillaryperfusionpressureandhighersystemicbloodpressureswouldpresumablyovercomeahighercompartmentpressure.Forthatreason,otherauthorshaveadvocatedusingthepressuredifference(“Δp”)betweenthediastolicbloodpressureandthecompartmentpressure(capillaryperfusionpressureisratherhardtomeasure).ByonlychoosingtodecompresspatientswithaΔpoflessthan30mmHg,insteadofusinganusingtheabsolutecompartment
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pressure,onegroupfoundthattheysaved43%oftheirpatientsanunnecessarysurgerywithoutmissinganyinjuries.14
Itisdifficulttodeterminethepressurecutofffordecompressionsincethereisno“goldstandard”fordiagnosingcompartmentsyndrome.Thesurgeon’sassessmentofwhetherthemuscles“bulged”outofacompartmentduringfasciotomyhasbeenhistoricallyused,butthisissubjective.Ifthesyndromeisproperlytreatedtherearenosequelae,sotherearenohistologicorlaboratoryfindingstoconfirmretrospectively.Thismaysuggestthatcompartmentsyndromeisover-diagnosedusingcurrenttechniques.2Duetotheuncertaintyregardingmeasurementofcompartmentpressures,extremitycompartmentsyndromeremainsaclinicaldiagnosisandpressuremeasurementsshouldbeusedonlyinsupport.2,15Clinicalsuspicionshouldremainhighandrapidtreatmentperformed,ifsuspected.
TreatmentofCompartmentSyndrome
Thetreatmentofextremitycompartmentsyndromeispromptsurgicaldecompressionoftheaffectedcompartments.15Thelowerlegconsistsof4separatecompartments(figure),allofwhichwillrequirerelease.Thiscanbeaccomplishedeitherthroughasingleincisiononthelateralleg,ora“two-incision”techniqueusingamedialincisionaswell.General(trauma)andVascularsurgeonstendtouseatwo-incisiontechnique,whereassomeOrthopedicsurgeonspreferthesingle-incisiontechnique,whichmaymissthedeepposteriorcompartmentbutmaybebeneficialforfuturefracturerepair.Aslongasallfourlegcompartmentsareappropriatelyreleased,however,thereisnodifferenceinoutcomes.16,17
Adelayinfasciotomyincreasesmorbidity.Asmentionedabove,nervesbecomeischemicinapproximatelyonehour,andmuscletissuesuffersirreversibledamageafterfourtosixhours.Thecompartmentsshouldbedecompressedurgentlywhenthediagnosisofcompartmentsyndromeismade.Delayinsurgicaltherapyisassociatedwithmorewoundcomplications,worsefunctionaloutcomes,andhigherratesoflimblossandmortality.18-20Evenwithknowndeficit,decompressionshouldstillbeperformedurgentlyifthereisanyresidualneuromuscularfunctionintheaffectedextremity,21althoughthisiscontroversialandsomeauthorsclaimbetteroutcomesifsurgeryisnotperformedforaseriouslydelayeddiagnosis.22
Whilefasciotomyisnecessarytotreatextremitycompartmentsyndrome,itisnotanentirelybenignprocedure,evenwhendoneprophylacticallybeforetheonsetofsymptoms,thereisahighincidenceofwoundcomplications18,23andneedforskingraftingfordefinitiveclosure.Neurovascularstructurescanbeeasilyinjuredduringtheprocedure,thesuperficialperonealnerveisthemostfrequentlyidentifiedinjuredstructure,occurringinupto6%offasciotomies.23Inaddition,fasciotomyforcompartmentsyndromehasbeenassociatedwithincreasedratesofinfectionandmal-unionoftibialfractures,24,25althoughpresumablythecomplicationsresultfromthecompartmentsyndromeitself,andoutcomeswouldbeworsewithouttreatment.
Conclusion
Extremitycompartmentsyndromeisadifficultdiagnosisthatoftenmustbemadebasedonclinicalprowessintheatriskpatientpopulation.Allpractitionerscaringfortraumapatientsmustbefamiliarwiththewarningsigns.Directtraumatothelimbisnotalwaysrequiredforcompartmentsyndrometooccur;proximalvasculartraumaorarterialinsufficiencymaycausethesyndromeindistalextremities.Directmeasurementofcompartmentpressuresisinvasive,andnotitselfdiagnostic,butmaybehelpfulinpatientsotherwisedifficulttoexamine.Promptsurgicaldecompressionofallcompartmentsatriskistherecommendedtreatment,althoughtheprocedurecarriesasignificantcomplicationrate.
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References:
1. DenteCJ,WyrzykowskiAD,FelicianoDV.Fasciotomy.CurrProblSurg.Oct2009;46(10):779-839.2. vonKeudellAG,WeaverMJ,AppletonPT,etal.Diagnosisandtreatmentofacuteextremitycompartmentsyndrome.Lancet.Sep262015;386(10000):1299-1310.3. McQueenMM,GastonP,Court-BrownCM.Acutecompartmentsyndrome.Whoisatrisk?JBoneJointSurgBr.Mar2000;82(2):200-203.4. HopeMJ,McQueenMM.Acutecompartmentsyndromeintheabsenceoffracture.JOrthopTrauma.Apr2004;18(4):220-224.5. KleshinskiJ,BittarS,WahlquistM,EbraheimN,DugganJM.ReviewofcompartmentsyndromeduetogroupAstreptococcalinfection.AmJMedSci.Sep2008;336(3):265-269.6. FelicianoDV.Managementofperipheralarterialinjury.CurrOpinCritCare.Dec2010;16(6):602-608.7. MauserN,GisselH,HendersonC,HaoJ,HakD,MauffreyC.Acutelower-legcompartmentsyndrome.Orthopedics.Aug2013;36(8):619-624.8. UlmerT.Theclinicaldiagnosisofcompartmentsyndromeofthelowerleg:areclinicalfindingspredictiveofthedisorder?JOrthopTrauma.Sep2002;16(8):572-577.9. ShulerFD,DietzMJ.Physicians'abilitytomanuallydetectisolatedelevationsinlegintracompartmentalpressure.JBoneJointSurgAm.Feb2010;92(2):361-367.10. AzamMQ,AliMS,AlRuwailiM,AlSayedHN.Compartmentsyndromeobscuredbypost-operativeepiduralanalgesia.ClinPract.Jan12012;2(1):e19.11. WalkerBJ,NoonanKJ,BosenbergAT.Evolvingcompartmentsyndromenotmaskedbyacontinuousperipheralnerveblock:evidence-basedcasemanagement.RegAnesthPainMed.Jul-Aug2012;37(4):393-397.12. ShadganB,MenonM,O'BrienPJ,ReidWD.Diagnostictechniquesinacutecompartmentsyndromeoftheleg.JOrthopTrauma.Sep2008;22(8):581-587.13. MubarakSJ,OwenCA,HargensAR,GarettoLP,AkesonWH.Acutecompartmentsyndromes:diagnosisandtreatmentwiththeaidofthewickcatheter.JBoneJointSurgAm.Dec1978;60(8):1091-1095.14. McQueenMM,Court-BrownCM.Compartmentmonitoringintibialfractures.Thepressurethresholdfordecompression.JBoneJointSurgBr.Jan1996;78(1):99-104.15. ShadganB,MenonM,SandersD,etal.Currentthinkingaboutacutecompartmentsyndromeofthelowerextremity.Canadianjournalofsurgery.Journalcanadiendechirurgie.Oct2010;53(5):329-334.16. BibleJE,McClureDJ,MirHR.Analysisofsingle-incisionversusdual-incisionfasciotomyfortibialfractureswithacutecompartmentsyndrome.JOrthopTrauma.Nov2013;27(11):607-611.
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17. NealM,HenebryA,MamczakCN,RulandR.TheEfficacyofaSingle-IncisionVersusTwo-IncisionFour-CompartmentFasciotomyoftheLeg:ACadavericModel.JOrthopTrauma.May2016;30(5):e164-168.18. VelmahosGC,TheodorouD,DemetriadesD,etal.Complicationsandnonclosureratesoffasciotomyfortraumaandrelatedriskfactors.WorldJSurg.Mar-Apr1997;21(3):247-252;discussion253.19. RitenourAE,DorlacWC,FangR,etal.Complicationsafterfasciotomyrevisionanddelayedcompartmentreleaseincombatpatients.JTrauma.Feb2008;64(2Suppl):S153-161;discussionS161-152.20. WilliamsAB,LuchetteFA,PapaconstantinouHT,etal.Theeffectofearlyversuslatefasciotomyinthemanagementofextremitytrauma.Surgery.Oct1997;122(4):861-866.21. KonstantakosEK,DalstromDJ,NellesME,LaughlinRT,PraysonMJ.Diagnosisandmanagementofextremitycompartmentsyndromes:anorthopaedicperspective.AmSurg.Dec2007;73(12):1199-1209.22. GlassGE,StaruchRM,SimmonsJ,etal.Managingmissedlowerextremitycompartmentsyndromeinthephysiologicallystablepatient:AsystematicreviewandlessonsfromalevelItraumacenter.JTraumaAcuteCareSurg.May182016.23. KashukJL,MooreEE,PinskiS,etal.Lowerextremitycompartmentsyndromeintheacutecaresurgeryparadigm:safetylessonslearned.PatientSafSurg.2009;3(1):11.24. ReverteMM,DimitriouR,KanakarisNK,GiannoudisPV.Whatistheeffectofcompartmentsyndromeandfasciotomiesonfracturehealingintibialfractures?Injury.Dec2011;42(12):1402-1407.25. BlairJA,StoopsTK,DoarnMC,etal.InfectionandNonunionAfterFasciotomyforCompartmentSyndromeAssociatedWithTibiaFractures:AMatchedCohortComparison.JOrthopTrauma.Jul2016;30(7):392-396.
MelissaSmith–[email protected]
OscarGuillamondegui–TraumaMedical
[email protected]
BradDennis–[email protected]
CathyWilson–TraumaOutreach&Injury
[email protected]
RichLesperance–ACSFellow/[email protected]
UpcomingCourses
2016 Courses: ATLSProvider:Aug11th&12thASSET:Sept2ndATLSProvider:Sept22nd&23rdATLSRefresher:Oct13thATLSProvider:Nov17th&18thATLSRefresher:Dec8th
Summer2016Contributors
TraumaIEPNewsletter
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NewFaces
Dr.AllanPeetzTraumaFaculty
AssistantProfessoratCaseWesternTraumaandAcuteCareSurgeryFellowshipfromBrighamand
Woman’sHospitalMDfromUniversityOfMichigan
Dr.CallieThompsonBurn/TraumaFaculty
Burn,Trauma,CriticalCareFellowshipfromWashingtonMDfromMeharryMedical
College
Dr.BrackenArmstrongSCC/ACSFellow2016-2018Residency:UnivofNevadaMD:GeorgetownUnivSchool
ofMedicine
Dr.SethBellisterSCC/ACSFellow2016-2018Residency:UTHouston
MD:UnivofNevadaSchoolofMedicine
Dr.RichardBetzoldSCC/ACSFellow2016-2018
Residency:ArkansasMD:UnivofArkansasSchool
ofMedicine
Dr.JillStreams
SCC/ACSFellow2016-2018Residency:NorthwesternMD:VanderbiltUnivSchool
ofMedicine
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Division of Trauma and Surgical Critical Care
For any questions in regards to the IEP or Trauma cases
please contact:
Melissa Smith: 322.6745 Oscar Guillamondegui: 936.0180
or Brad Dennis: 936.0286
