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Compartment Syndrome

Vascular Seminar October 17th, 2009

John C. Kedora, M.D

Objectives

· Define compartment syndrome. · Review the history, frequency, and etiology of

compartment syndrome.

· Understand the pathophysiology and clinical presentation of

compartment syndrome.

· Discuss the diagnosis and treatment of compartment

syndrome.

What is Compartment Syndrome?

· Increased pressure

within a fascial compartment

· Muscle is enclosed in

compartments bound by relatively rigid walls of bone and fascia.

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What is Compartment Syndrome?

· Two Types

Acute ­ usually due to trauma » Long bone fractures » Vascular injury » Crush injury Chronic ­ due to repetitive microtrauma from physical activity. (chronic exertional compartment syndrome)

A Little Background...

· First medical reference

was by Volkmann in 1872 and the upper extremity contracture resulting from excessive pressure was named after him.

· In 1926, Paul Jepson

described prompt surgical decompression for prevention of contracture.

Etiology of Compartment Syndromes

· Internal Increase in

Compartment Volume

Hemorrhage Hemophilia Fractures Gunshot Wounds Massive IV fluid infusion Compartment fluid injection Crush Injuries Gastrocnemius Muscle Tear Ruptured Baker's cyst Knee Arthroscopy

· External Restriction of

Compartments

Splints, Casts, Dressings Burns (Eschar) Military Antishock Trousers Tight Ski Boots

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Frequency of Compartment Syndrome

· The incidence varies depending on the inciting

event 6% in patients with open tibial fractures. 1.2% 1 2% in patients with closed tibial fractures fractures.

· Prevelance higher in vascular injuries

Reported 19-30% in vascular trauma.

· Incidence in chronic compartment syndrome has

not been determined

Pathophysiology

Postulated that increased compartment pressure obstructs venous outflow and leads to reduced A-V gradient and a decrease in local blood flow resulting in ischemia of both muscles and nerves. Fluid accumulation leads to increased pressure in confined space. Viscous cycle of ischemia and swelling then ensues.

Increased Pressure Leads to Ischemia

· pressure in confined space

decreases blood flow and leads to ischemia

· Intra-compartmental pressures

greater than 30 mm Hg lead to symptoms of compartment syndrome

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Clinical Presentation

· Physical Signs

Pain or burning, followed by decrease in strength. Severe pain at rest or with any movement should raise suspicion. Pain with passive stretching of the muscles is the earliest clinical indicator.

Clinical Presentation

· Determine if neural

compromise exists · Sensory Loss · Motor Loss

· Limb may feel tense or

hard as the compartment swells with fluid

Know Your Anatomy

It is the key to understanding symptoms

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A high index of suspicion and familiarity with this condition should lead the clinician to get pressure measurements. Failure to do so, can lead to permanent paralysis and/or amputation · Measure Intracompartmental

Pressures (ICP)-gold standard Stryker Pressure Tonometer Direct measurements of pressure by inserting a needle into the compartment It measures the pressure that is necessary to inject a small quantity of fluid. Currently recommended thresholds for fasciotomy: persistent pressure >30 mmHg

Diagnosis

Diagnostic Modalities

· Methoxy Isonitrile MRI (MIBI MRI) · Phophate Nuclear MRI

MRI-not sensitive or specific enough so far

· T h iti Technitium Sestamibi S t ibi · Xenon Scanning · Laser Doppler Flowmetry and Scintigraphy · None of these methods have been shown to be

as useful as direct compartment measurement or clinical exam.

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Other Workup

· Creatine Phosphokinase (CPK)

Released into blood with muscle damage/ischemia Helpful for dx of rhabdomyolysis (In absence of clinical signs, elev. could indicate unsuspected CS. Not helpful for early dx.) Complete blood count, PT/INR Hemoglobin (anemia worsens ischemia) Pt. predisposed to bleeding? Renal Panel BUN/Cr, K+

·

·

Treatment of Compartment Syndrome

"I learned a long time ago that minor surgery is when they do the operation on someone else, not you." Bill Walton

Treatment

· Surgical Fasciotomy

(compartment release) · Often combined with orthopedic reduction or stabilization and vascular repair if needed. · Goal is to restore muscle perfusion within 6 hours.

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Fasciotomy

Kashuk et al. Patient Safety in Surgery 2009

Lateral Incision

Photographs courtesy of DG Smith, MD, Harborview Hospital, Seattle, WA

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Medial Incision

Photographs courtesy of DG Smith, MD, Harborview Hospital, Seattle, WA

Fasciotomy

· After fasciotomy,

wet to dry dressing changes are performed. · May require further debridement in OR · Return to OR in 1-3 days to close the fasciotomy incisions.

Fasciotomy

· Sometimes partial

closure can only be done. done

· Skin Grafting may

be required.

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Fasciotomy

Complications of Compartment Syndrome

· Post-Operative Motor Deficits

Foot Drop: treated with appropriate orthotic device Function usually improves within 1 year ·N b Numbness or Painful Neuropathy P i f lN th May resolve slowly with time Medication (Neurontin) may help symptoms · Systemic Complications Renal Failure from rhabdomyolysis ARDS

Conclusion

· Compartment syndrome is cause by increased pressure

within muscular compartments that can compromise blood flow leading to tissue ischemia.

· The clinician most have a high suspicion to that prompt

treatment can be implemented to halt tissue ischemia.

· Fasciotomy is the treatment of acute compartment

syndrome and sometimes for chronic compartment syndrome.

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References

· Jepson PN. Ischaemic Contracture: experimental study. · Matsen FA et al. Monitoring of intramuscular pressure. · Bong, M., Chronic Exertional Compartment Syndrome,

Injury, 35, 1221-1227, 2004. Surgery. Jun 1976; 79(6):702-9. Bulletin-Hospital for Joint Diseases, Vol. 62, No. 3, 4, 2005. Ann Surg. 1926:84:785-95.

· Kostler, W., Acute Compartment Syndrome of the Limb, · Bhattacharya, K., Acute compartment Syndrome of the ·

Lower L L Leg, L Lower E t Extremity Wounds, 2(4) 2003, pp. 240it W d 2(4): 2003 240 242. Van de Brand, J. The Diagnostic Value of Intracompartmental Pressure Measurement, Magnetic Resonance Imaging, and Near-Infrared Spectroscopy in Chronic Exertional Compartment Syndrome, The American Journal of Sports Medicine, Vol. 33, No. 5, 2005.

References, cont'd.

· Brown, David, Lower Leg Syndromes. · Pritchard, M., Chronic Compartment Syndrome, an

Important Cause of Work Related Upper Limb Disorder, Rheumatology, 2005.

· Webber, M., Rhabdomyolysis and Compartment Syndrome · Liem, N., Acute Exertional compartment Syndrome in the · Steinberg, B., Evaluation of Limb Compartments with

Increased Interstitial Pressure, Journal of Biomechanics, 38, pp. 1629-35, 2005. Muscle Caused by compartment Syndrome, The Journal of Bone and Joint Surgery, 86-B, pp. 906-11, 2004. with Coadministration of risperidone and simvastatin, Journal of Psychopharmacy, 18(3), 2004. Setting of Anabolic Steroids: an Unusual Cause of Bilateral Footdrop, Muscle & Nerve, July 2005.

· Kearns, S., Oral Vitamin C Reduces the Injury to Skeletal

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