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

Numerous etiologies • Fracture (also open #’s) • IM nailing (reaming) • Blunt trauma • Exertional states • Cast/dressing • Closure of fascial defects • Arterial injury • GSW / stabbings • Post-ischemic hyperperfusion • IV & A-lines • Burns/electrical injuries • Hemophil./coag.disorder • Distorsion (ankle) • Intraosseous infusion • Tumour • Snake bite • Lithotomy position ……….and more

Symptoms • Pain out of proportion • Pain on passive stretch • Paraesthesia • Paresis • Pulses present • Palpatory pain • ACS is a surgical emergency !

2008 2004

Patient characteristics JBJS 1996

Patient characteristics CJEM 2003

Injury 2006 • 17% of consultant anaesthetists • 9% of nonconsultant anaesthetists had seen CS masked by regional anaesthesia !

Diagnostic delay CJEM 2003

JOT 2002 The clinical findings

JOT 2002 • Bayes’ theorem – Estimating the probability of a diagnosis based on 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:

Clinical features of ACS of the lower leg are: • more useful by their absence in excluding ACS JOT 2002 • than they are when present in confirming ACS

JOT 2002

Measurement of intracompartmental pressure

Pressure monitoring Kodiag Whiteside technique Stryker

AJEM 2003

JBJS 2005 SP SL S

JBJS 2005 • A-line manometer with: – side-port needle or – slit catheter • Available at ICU’s !

Heckman JBJS-A, 1994 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

Arch Orthop Trauma Surg 1998 • 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”

JBJS 1996 – 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.

Injury 2001 95 patients with 97 tibial #’s • ICP > 30mmHg or • 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

JBJS 1996 • ↑ fracture complexity => ↓ � P => ↓ � P • ↑ delay to diagnosis • Open vs. closed # => ns diff. in � P => ns diff. in � P • IM nail vs. Ex-Fix

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

Management of acute compartment syndrome - how do we do it ? Injury 1998 ANZ J.Surg 2007

Injury 1998 • 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

ANZ J.Surg 2007 • 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

Immediate actions • Limb elevation => • Cut & spread plaster ↓ compartment pressure • Cut webril BUT • Remove cast • BP ↓ in elevated limb • 53% ↓ in perfusion pressure YES NO Wiger & Styf, J Orthop Trauma. 1998

Surgery 1997 • 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

JOT 1996 • 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

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