ACUTE COMPARTMENT SYNDROME OF EXTREMETIES M. Rustom MRCS ( Eng ) MS Surg-Plastic UM Fellowship in Plastic & Reconstructive Surgery UM

PLASTIC SURGERY VASCULAR SURGERY COMPARTMENT SYNDROME ORTHOPEDIC TRAUMA SURGERY

Contents Definition Aetiology Epidemiology Pathophysiology & Pathogenesis Clinical Presentation Management Sequele & Complications Challenges

DEFINITION

Acute compartment syndrome (ACS) is a condition where osseofascial compartment pressures rise to a point that overcomes capillary perfusion pressure. The lack of tissue perfusion in ACS results in tissue ischemia and necrosis, which can lead to permanent loss of muscle function, nerve damage, limb amputation, and multisystem organ failure. All limbs can be affected, leg, forearm, hands, feet, buttock.

EPIDEMIOLOGY & RISK FACTORS

The incidence of ACS is 3.1/100,000 people annually. Men are ten times more likely to develop ACS. The average age for ACS diagnosis is 32-years-old. High-VELOCITY INJURIES and polytrauma carries higher risk. Open fracture or closed fracture ?

AETIOLOGY

INCREASED COMPARTMENTAL CONTENTS DECREASED COMPARTMENTAL SPACE Crush syndrome Burns (circumferential) Revascularization Muscle hernia repair Infiltrated fluid infusion Casts Arterial puncture Circumferential dressings Gunshot wound Pneumatic antishock garments Snake / venomous bite Lithotomy surgical positioning Nephrotic Syndrome MEDICAL COMORBIDITIES [2] Hematogenous osteomyelitis Diabetes Exercise (chronic compartment syndrome) Coagulopathies

PATHOPHYSIOLOGY & PATHOGENESIS

CLINICAL MANIFESTATION

DIAGNOSIS

High index of clinical suspicion. May require closed repeated assessment if uncertain Head trauma, spinal injury, intoxicated patient & patient undergoing prolong surgery ( diagnosis can be missed ) Measurement of intra compartment pressure Near-InfraRed (NIR) spectroscopy is an imaging technique, based on the same principle as pulse oximetry Biomarkers ( e.g., creatinine phosphokinase & myoglobin ) may be elevated but they are not specific.

MANAGEMENT

Differential Pressure < 30 Differential Pressure 20-30 ACS Suspected Differential Pressure < 30 Differential Pressure 20-30 Differential Pressure > 20 Fasciotomy Observe +/- get expert opinion Unlikely ACS, preventive measures

Diagnosed earlier than 8-12 H ACS Confirmed Diagnosed 12-24 H Diagnosed Later than 24 H Diagnosed earlier than 8-12 H Immediate fasciotomy Controversial, take another opinion, council the patient & family DO NOT DO FACIOTOMY

Adequate hydration and O2 supplementation are important. Position the limb flat ( at the level of the heart ). Remove the external pressure if any ( dressing, splints, traction,....). Do not deprive from analgesia. Check the renal function closely. Upon fasciotomy, all involved compartment needs to be decompressed. Patients must be educated on both the complications of ACS and the potential complications of surgery.

Post fasciotomy wound management Cover with antibiotics. Negative pressure wound therapy is the dressing of choice. Avoid placing tensions sutures. Do debridement as necessary. Delayed primary closure or skin grafting once the oedema subsides.

SEQUELE & COMPLICATIONS

Only 68% of those treated with fasciotomy earlier than 12 H recovers well. Untreated ACS leads to loss of limb function, necrosis & carries high risk of amputation. Delayed fasciotomy increases the risk of infection, amputation & prolongs the hospital stay. Systemic complications includes: renal impairment, sepsis & multi organ failure.

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