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Compartment Syndrome When pressure is elevated within a confined space, capillary blood flow is compromised. The resulting edema within the soft tissue.

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Presentation on theme: "Compartment Syndrome When pressure is elevated within a confined space, capillary blood flow is compromised. The resulting edema within the soft tissue."— Presentation transcript:

1 Compartment Syndrome and the Stryker Intra-Compartmental Pressure Monitor System

2 Compartment Syndrome When pressure is elevated within a confined space, capillary blood flow is compromised. The resulting edema within the soft tissue from ischemia results in further swelling and increased pressure.

3 Terms Acute compartment syndrome: An elevation of intercompartmental pressure to a level and for a duration that without decompression will cause tissue necrosis. Exertional compartment syndrome: Elevation of intercompartmental pressure during exercise causing ischemia, pain, and possibly neurologic symptoms and signs. There is resolution with rest, but it may progress to acute compartment syndrome. Volkmann ischemic contracture: Irreversible muscle necrosis leading to ischemic contractures. Crush syndrome: The systemic result of muscle necrosis commonly caused by prolonged external compression of an extremity. Muscle necrosis is established by the time of presentation, but intracompartmental pressure may rise as a result of intracompartmental edema, causing a superimposed acute compartment syndrome.

4 History 1850: First report attributed to Hamilton by Hildebrand
1881: Richard von Volkmann published a summary of his findings: paralysis and contractures occurred after tight bandaging and were caused by prolonged blocking of arterial blood. He recognized that muscle cannot survive for longer than six hours with complete occlusion of blood and not for longer than 12 hours with partial occlusion. 1888: Peterson recognized that ischemic contracture can occur in the absence of bandaging. Early twentieth century: The first description of fasciotomy and the importance of its early application were suggested.

5 History World War I: The belief propagated that compartment syndrome was result of arterial injury and spasm. The excision of the “damaged” artery yielded successful results. Of course, the fascia was released during the exposure. So….can you have compartment syndrome and normal peripheral pulses?

6 Seddon17 challenged the arterial injury theory as the sole cause of compartment syndrome, noting normal pulses. In 1966, early and gross swelling in the compartments and pressure that was released with fasciotomy were noted. Nolan and McQuillan18 described a vicious circle of increasing tension in an enclosed compartment causing venous outflow obstruction and subsequent reduction in arterial inflow. They concluded that delay in fasciotomy was the single cause of failure of treatment.

7 Epidemiology Underlying conditions associated with injury causing acute compartment syndrome presenting to an orthopaedic trauma unit (percentage of cases): Tibial diaphyseal fracture (36.0%) Soft-tissue injury (23.2%) Distal radial fracture (9.8%) Crush syndrome (7.9%) Diaphyseal fracture forearm (7.9%) Femoral diaphyseal fracture (3.0%) Tibial plateau fracture (3.0%) Hand fracture(s) (2.5%) Tibial pilon fractures (2.5%) Foot fracture(s) (1.8%) Ankle fracture (0.6%) Elbow fracture dislocation (0.6%) Pelvic fracture (0.6%) Humeral diaphyseal fracture (0.6%) Tibial fixation and soft-tissue injury account for almost two-thirds of cases.

8 Compartment Syndrome Etiology
Compartment Size Tight dressing (bandage or cast) Localized external pressure, lying on limb Closure of fascial defects Compartment Content Bleeding, fixation, vascular injury, bleeding disorders Capillary permeability: ischemia, trauma, burns, exercise, snake bite, drug Injection, in vitro fertilization

9 Compartment Syndrome Etiology
Fractures (closed and open) Blunt trauma Temporary vascular occlusion Cast or dressing Closure of fascial defects Electrical burns Exertional states Gunshot wound Intravenous A lines Hemophilia and coagulation Intraosseous infusion (infant) Snake bite Causes range from minor trauma to major injuries and interosseous infusion of intravenous fluids. Open fractures can have a 9% incidence of compartment syndrome19. The incidence of compartment syndrome in electrical injuries is proportional to the amount of voltage to which the patient was exposed: minimal risk with low voltage (normal household current) and as high as 40% in higher voltage. Most burn literature uses the loss of pulses to decide when to perform escharotomies; however, tissue perfusion may still be compromised. Temporary vascular occlusion can occur in obtunded states (drug abuse), operative positioning (hemilithotomy and full lithotomy), and prolonged tourniquet use. If compartment syndrome is suspected, tissue pressure measurement is warranted and fasciotomies are performed as indicated and supported in the literature.

10 Measurement of pressures with the Stryker Intra-Compartmental Pressure Monitor
Turn on. Assemble the needle, transducer, and syringe. Seat into chamber and close lid. Tilt 45° and purge chamber and needle of air. Prep skin (not on pig). Just before the needle enters the skin, zero the Stryker Intra-Compartmental Pressure System, and don’t change the angle after this. Inject <1/3 mL of fluid provided by the manufacturer in the syringe to clear the side port. Allow time for the reading to stabilize; it may take 15 to 20 seconds.

11 Compartment Syndrome Pathophysiology
Normal tissue pressure 0 to 4 mm Hg 8 to 10 mm Hg with exertion Absolute pressure theory 30 mm Hg (Mubarak et al.20) Pressure gradient theory <20 mm Hg of diastolic pressure (Whitesides et al.8 and McQueen and Court-Brown21) Normal resting muscle tissue pressure is up to 4 mm Hg and 8 to 10 mm Hg with exertion. Exercise-induced compartment syndrome may have a resting baseline of 10 to 15 mm Hg. Many studies utilizing clinical evaluations and animal models by Whitesides et al.8, Mubarak et al.20, Matsen3, Heckman et al.22, Heppenstall et al.23, and Matava et al.24 have helped to establish a better understanding of the pathophysiology and thresholds of ischemia. Two schools of thought prevail: (1) the absolute pressure theory of Mubarak et al.20, who suggested surgical decompression in compartment syndrome with pressures that reach or exceed these thresholds; and (2) the perfusion theory of Whitesides et al.8, who demonstrated in animal models and human subjects the relationship of tissue perfusion and diastolic blood pressure. Whitesides et al.8 recommended surgical decompression when the tissue pressure is within 20 mm Hg of the diastolic blood pressure. McQueen and Court-Brown21 suggested a differential of <30 mm Hg of the diastolic pressure and the intramuscular pressure as a threshold for release as being more reliable. Mean arterial pressure can also serve as a benchmark with a release suggested when intramuscular pressure is within 45 mm Hg. Caution must be exercised in traumatized tissue and especially in hypotensive patients.

12 Compartment Syndrome: A Clinical Diagnosis
Pain out of proportion Palpably tense compartment Pain with passive stretch Paresthesia or hypoesthesia Paralysis Pulselessness or pallor These physical findings have been described as the clinical hallmarks of compartment syndrome. They are not very sensitive, and if seen in the later stages, it may be too late to change the underlying pathology. Compartment syndrome may be present with good pulses, and no pallor and loss of pulses rarely occur unless arterial damage is present. Pain out of proportion and pain with the passive stretch of a muscle in the compartment in question may be the most sensitive clinical finding before the onset of ischemic dysfunction of the nerves and muscles. These findings are useful only in a conscious cooperative patient and once paresthesia begins, the pain may decrease. One important point to make is that if compartment syndrome is a possibility, then regional anesthesia, continuous epidurals, and intravenous, opiate patient-controlled analgesia should be avoided because they may mask the symptoms of compartment syndrome. Otherwise, monitoring of the tissue pressure is warranted. Some reports have shown missed compartment syndrome in patients with tibial fracture and in other surgical patients at risk managed postoperatively with these techniques; therefore, in general, patients at risk of developing compartment syndrome should have their pain managed by techniques other than regional, spinal, or epidural anesthesia to prevent delayed diagnosis.

13 Beware Epidurals Regional blocks Unconscious Insensate

14 Medical Management Make sure that the patient is normotensive. Hypotension reduces perfusion pressure and facilitates further tissue injury. Remove the circumferential bandages and cast. Maintain the limb at the level of the heart as elevation reduces the arterial inflow and the arteriovenous pressure gradient on which perfusion depends. Administer supplemental oxygen.

15 Compartment Syndrome Pressure Measurements
Suspected compartment syndrome Equivocal or unreliable examination Clinical adjunct ONLY after discussing it with the attending physician Many times, compartment syndrome can be made by pulmonary embolism without tissue pressure measurements. Pressure measurements can help the treating surgeon in his clinical decision-making process in these situations but alone do not make the diagnosis of compartment syndrome. If a compartment syndrome is clinically evident, do not waste valuable time trying to locate the equipment or set up for the pressure measurement; perform the indicated surgical decompression as soon as possible.

16 When NOT to check pressures
Compartment syndrome is diagnosed on a clinical basis.

17 Threshold for Decompression
30 mm Hg: close to capillary blood pressure20,25 40 mm Hg13,26 50 mm Hg in tibia fixation and normotensive27 <10 to 30 mm Hg: difference between diastolic and tissue pressure (delta P)8 Difference between mean arterial pressure and tissue pressure of <30 mm Hg in normal muscle or <40 mm Hg in traumatized muscle22-24,28

18 Fasciotomy Principles
Make an early diagnosis. Make long extensile incisions. Release all fascial compartments. Preserve neurovascular structures. Debride necrotic tissues. Provide coverage within seven to ten days.

19 Compartment Syndrome Lower Leg
Four compartments Lateral: peroneus longus and peroneus brevis (PB) Anterior: extensor hallucis longus, extensor digitorum longus (EDL), tibialis anterior (TA), peroneus tertius Superficial posterior: gastrocnemius (G), soleus (S) Deep posterior: tibialis posterior (TP), flexor hallucis (FH) longus, flexor digitorum longus The four compartments of the leg contain these named muscles and corresponding arteries and nerves. The complete release of all four compartments is mandatory. A physical examination based on sensory loss may be useful in exercise-induced compartment syndrome. The nerves are the most sensitive to ischemic changes.

20 Compartment Syndrome Forearm
Three anatomical compartments Mobile wad: brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis Volar: superficial and deep flexors Dorsal: extensors The pronator quadratus is described as a separate compartment.

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