Acute Compartment Syndrome Grand Rounds

1. Acute Compartment SyndromeGrand Rounds Paris Lovett, MD November 2003

2. Compartment Syndrome Bugbears of Emergency Medicine What is it? Causes When to test Making the Diagnosis Management

3. Bugbear Diagnoses Failure to diagnose is threatening to life, limb and wallet Clinical findings suggesting need to test are extremely common Clinical findings excluding disease are not reliable Actual disease may be uncommon Onerous, expensive, or risky test Ability of test to rule out disease may be limited Large number of negative studies Large number of false positive tests

4. Bugbear diagnoses PE DVT TAD (Ansari-Ritter Disease) Traumatic Aortic Rupture Ovarian Torsion Testicular Torsion Ischemic Bowel Subarachnoid Hemorrhage Cavernous Sinus Thrombosis Intussusception Compartment Syndrome

5. What is compartment syndrome?

6. What is compartment syndrome? Limb Compartment Syndrome Acute Chronic Abdominal Compartment Syndrome

7. Acute Limb Compartment Syndrome Raised Pressure within a closed fascial space Reduction in capillary perfusion below level needed for tissue viability Describes local manifestations and complications Don�t confuse with crush injury (systemic: acidosis, hyperkalemia, myoglobinemia, shock, ARF)

8. (Chronic Compartment Syndrome) Athletes with hypertrophied leg muscles Hyperemic muscles become painful during exercise Pain relieved by rest Compartment pressures elevated even at rest Treated with fasciotomy

9. (Abdominal Compartment Syndrome) An ICU diagnosis, rarely an ED diagnosis Round, tense abdomen Trauma, post-op Decreased Cardiac Output Increased Peak Inspiratory Pressure and decreased ventilation Oliguria and Renal Failure from venous and renal compression Treated with laparotomy

10. Limb Compartment Syndrome: Causes Orthopedic Fractures: open or closed Management of fractures Vascular/Iatrogenic Vascular puncture: esp. anticoagulated Intra-arterial drug administration Extravasation Others Soft-tissue injury Crush Burns Hypotension: worsens all causes

11. Orthopedic Causes Tibial Fx. Incidence ranges 1.5 to 29%. Depends upon threshold for diagnosis/treamtent Anterior compartment most common Forearm Fx Volar (Flexor/Ventral) compartment most common Comminuted fractures increased risk Open fractures roughly halve risk Treatment of fractures increasing risk of CS: cylindrical casting; padding; traction; manipulation; intramedullary nail; elevation (Matsen)

14. Vascular Causes Arterial Injection Venous Extravasation Traumatic Vessel Injury esp. popliteal Revascularization and re-perfusion: up to 20% of re-perfused limbs. Dependent upon ischemic time. 8-12h is the critical period for irreversible damage (Whitesides) Aortic Balloon pump: 6-19% Phlegmasia Cerulea Dolens: Profound distal propagation of iliofemoral thrombosis, and venous gangrene, usu. in setting of malignancy IVDA

16. Soft Tissue Injury Causes Direct blow to compartment Crushing injury Burns Much more common in hypocoagulable Continued use of limb may increase risk

17. Where? Lower leg Forearm Also: Femoral, Foot, Hand, Calcaneal, Buttocks, Shoulder

18. Demographics (McQueen) Pediatrics and young adults Male > Female

21. Mechanisms Issue is venous return Initial problem is edema, hemorrhage, or external compression This raises compartment pressure

22. Mechanisms Raised compartment pressure causes compression of small venules Wosening edema and raised compartmental pressure Eventually arteriolar compression Muscle and nerve ischemia

23. Some History �For years I have called attention to the fact that the pareses and contractures of limbs following application of tight bandages are caused not by pressure paralysis of nerves, as formerly assumed, but by the rapid and massive deterioration of contractile substance and by�reactive and regenerative processes.� Die isch�mischen Muskell�hmungen und Kontracturen. Centralblatt f�r Chirurgie, Leipzig, 1881, 8: 801-803

24. Volkmann Advanced the introduction of antiseptic wound treatment in Germany Performed the first excision of carcinoma of the rectum in 1878 Under the pen name Richard Leander wrote poetry and a book entitled "Dreams by French Firesides� Described Volkmann-Kontraktur, or Isch�mische Muskelnekrose

25. Volkmann�s Ischemic Contracture

26. Historical Development 1881 Volkmann condition of irreversible contractures of the flexor muscles of the hand due to ischemic processes occurring in the forearm. The problem: massive venous stasis and arterial insufficiency secondary to overly tight bandages 1906 Hildebrand: term Volkmann ischemic contracture for result of untreated compartment syndrome. Elevated tissue pressure cause. 1909 Thomas reviewed 112 published cases. Fractures predominant cause. Also tight bandages, arterial embolus or insufficiency 1914, Murphy: fasciotomy might prevent the contracture 1958 Ellis 2% incidence with tibia fractures mid-1960s Seddon, Kelly, and Whitesides 4 compartments in the leg 1970s: Mubarak: Wick method of measurement

27. Clinical Features Pain out of proportion to injury Paresthesia / Altered sensation (esp. 2-point) Tense, swollen compartment Pain on passive stretch Weakness (late) Progression over a short time period According to Rorabeck CH, Halpern AA, Ellis H, Pain on passive stretch and progression of pain most reliable in making an early diagnosis

28. Missing the boat Pale Pulseless Paralyzed

29. Clinical Sensitivity (Ulmer T 02)

31. Who gets tested? Anyone you truly suspect Mechanism Clinical features Progression Pediatrics and Sedated/Altered Inability to obtain accurate clinical data

32. Testing Wick Catheter: suture material. Continuous Simple needle Infusion Side-ported needle Digital: Stryker Give tissue pressure in mmHg

33. What number to treat?1. Using the absolute CP Normal resting intramuscular 0-8 mmHg 20-30 mmHg: pain and paresthesia 30 mmHg+ for 6+ hours: irreversible necrosis (Mubarak SJ 78) 25 mmHg without signs; 15 mmHg with signs (Ouellette EA 96; 17 patients) 40 mmHg observe; 50 mmHg operate (Allen MJ 85) No adverse sequelae.

34. What number to treat?2. Using a relative CP DBP � Compartment Pressure. If < 30 perform fasciotomy (Whitesides, McQueen). Greater specificity without any sacrifice in sensitivity (116 patients). MAP � CP. Treat if < 30 (Mars and Hadley). More accurate, in a study involving children, and a dog study Balancing minimization of unneccesary surgery against minimization of an appalling outcome

35. What does this tell us? The receiver operator characteristics of compartment pressure are by no means a perfect way of predicting who would develop ischemic contracture in the absence of a fasciotomy. �As you drive up the sensitivity curve, how much specificity do you have to sacrifice?�

36. So, what do we do? Serial exam Clinically obvious ? Call Surgery Clinically equivocal ? Measure CP Serial CP measurement 30 mmHg is the �standard� Low threshold

37. Surgery

38. Treatment

39. And what else? Elevation of limb?? (May increase compartment pressures by worsening ischemia) Hyperbaric Oxygen Therapy (better wound healing post-op) Mannitol (Animal studies; Small non-randomized human study by Shah et. al.)

40. Summary You have to suspect it Early versus late clinical findings Pain out of proportion Palpably Tense Compartment Pain on passive stretch Progressive pain Paresthesia (Altered sensation) Weakness Serial observations Serial CP measurements No definitive numbers for Compartment Pressures

41. Bibliography Allen MJ. Stirling AJ. Crawshaw CV. Barnes MR. Intracompartmental pressure monitoring of leg injuries. An aid to management. [Journal Article] Journal of Bone & Joint Surgery - British Volume. 67(1):53-7, 1985 Elliott KGB. J. Bone Joint Surg 2003;85(5) 625-632 Jensen SL. Sandermann J. Compartment syndrome and fasciotomy in vascular surgery. A review of 57 cases. [Journal Article] European Journal of Vascular & Endovascular Surgery. 13(1):48-53, 1997 Matsen FA, Krugmire RB, King, RV. Increased Tissue Pressure and its Effects on Muscle Oxygenation in Level and Elevated Human Limbs. Clinical Orthopedics and Related Research. 1979;144:311-320 McQueen, M. M.; Gaston, P.; Court-Brown, C. M Acute compartment syndrome: WHO IS AT RISK? Mubarak SJ. A practical approach to compartmental syndromes part II: diagnosis. In: Everts CM, (ed): American Association of Orthopedic Surgeons: Instructional Course Lectures. St. Louis: Mosby, 1983 Tiwari A et. al. Acute Compartment Syndromes. Brit. J. Surg. 2002; 89: 397-412. Ulmer T. Journal of Orthopaedic Trauma 16, No. 8, pp. 572�577 Whitsides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop 1975; 113:43-51