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Acute Compartment syndrome David Agolley department of orthopaedics David Agolley department of orthopaedics.

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Presentation on theme: "Acute Compartment syndrome David Agolley department of orthopaedics David Agolley department of orthopaedics."— Presentation transcript:

1 Acute Compartment syndrome David Agolley department of orthopaedics David Agolley department of orthopaedics

2 Definition Acute Compartment Syndrome occurs when there is elevated pressure in a closed fascial (osteofascial) space, resulting in a critical reduction of blood flow to the tissues contained within. Acute Compartment Syndrome

3 Variations Acute Compartment Syndrome Exertional Compartment syndrome Crush Syndrome Acute Compartment Syndrome

4 Historical Review Late complications of ischaemic contracture Volkman, 1881 Paralysis and ischaemia, too-tight bandaging of the forearm and hand,arterial blockage and irreversible contracture. Leser animal studies Brooks venous obstruction Griffiths Pain with.., Painful onset, Pallor, Puffiness Bardenheuer fasciotomy forearm Whitesides, Hargens and Mubarak, and Matsen 1970’s - tissue pressure measurement techniques. Current - sustained microcirculatory impairment, Still occurs. Not uncommon Acute Compartment Syndrome

5

6 Epidemiology 3.1 per 100,000 Young Male 10 fold increase MVA sports muscle volume Acute Compartment Syndrome

7 Pathophysiology Acute Compartment Syndrome

8 Pathophysiology Aetiology Fracture (69%) Soft tissue injury Crush syndrome (2) arterial injury / revascularisation High pressure injection exercise fluid infusion arterial puncture ruptured ganglia / cysts Osteotomy Snake bite nephrotic syndrome leukaemic infiltration viral myosis acute haematogenous osteomyelitis coagulopathy (1) cast / dressings repair fascia, hernia burns Acute Compartment Syndrome

9 Pathophysiology Acute Compartment Syndrome

10 Pathophysiology Normal tissue pressure 0-4 mm Hg mm Hg with exertion Absolute compartment pressure theory 30mmHg - Mubarak and Hargens 45 mmHg - Matsen AV gradient theory LBF = Pa - Pv / R <30mmHg diastolic pressure ‘do not elevate arm’ Microvascular occlusion theory Acute Compartment Syndrome

11 Tissue Survival Muscle hrs = reversible damage 6 hrs = variable damage 8 hrs = irreversible damage Nerve 2 hrs = loose nerve conduction 4 hrs = Neuropraxia 8 hrs = irreversible damage Acute Compartment Syndrome

12 Night intern, Call from Paeds “Dr, I think little Jimmy has compartment syndrome”

13 Assessment of Compartment Syndrome Acute Compartment Syndrome

14 Assessment Prioritise History mechanism injury intervention analgesic requirements Examination Investigations Acute Compartment Syndrome

15 Diagnosis the 6 Ps Hargens and Mubarak Pain out of proportion / Passive stretch Palpably tense compartment Parasthesia Paresis Pink skin colour Pulse present Acute Compartment Syndrome

16 Diagnosis Differentials Arterial Occlusion Peripheral nerve injury Muscle rupture Acute Compartment Syndrome

17 Emergent Treatment Place at level of heart Cut dressing or cast - MUST SEE SKIN Alert senior Dr, OR, Anaesthetist and fast patient Review Acute Compartment Syndrome

18 Investigations Radiographs MRI USS not routine Arterial doppler flow Pulse Oximetry Pressure measurements Suspected CS Equivocal or unreliable exam Clinical adjunct Acute Compartment Syndrome

19 At risk Patients Demographic Youth Male Tibia fracture High energy Bleeding diathesis /anticoagulants Altered Pain Perception Altered consciousness Regional anaesthesia Patient-Controlled Analgesia Central or peripheral neurological injury Children Associated nerve injury Acute Compartment Syndrome

20 Pressure Monitoring Acute Compartment Syndrome

21 Surgical Treatment Indications for fasciotomy Clinical findings Pressure absolute above 30mmHg, or within 20mmHg Diastolic Rising tissue pressure >6hours of total limb ischaemia High risk injury CONTRAINDICATION - Missed CS 24-48hrs Acute Compartment Syndrome

22 Surgical treatment Principles Early diagnosis Long extensile incision Release all fascial compartments Preserve neurovascular structures Rigid fracture stabilisation Debride necrotic tissues Cover 7-10 days Acute Compartment Syndrome

23 Forearm Fasciotomy Acute Compartment Syndrome

24 Forearm Fasciotomy Acute Compartment Syndrome

25 Leg Fasciotomy Acute Compartment Syndrome

26 Leg Fasciotomy Acute Compartment Syndrome

27 Leg Fasciotomy Acute Compartment Syndrome

28 Thigh Fasciotomy Acute Compartment Syndrome

29 Foot Fasciotomy Acute Compartment Syndrome

30 Other Compartments Hand, forearm, arm, deltoid Abdomen Buttock Acute Compartment Syndrome

31 Temporary Coverage Simple dressing Progressive suturing Vessel loop “Bootlace” Vacuum Assisted Closure Acute Compartment Syndrome

32 Definitive Coverage Second look Cover 7-10 days after risk of necrotic tissue passed Split skin graft Local flap Free flap Acute Compartment Syndrome

33 Summary Acute Compartment Syndrome High Index of suspicion Early diagnosis Early intervention Expedite time to surgery

34 Questions?


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