Topic 4: Fractures and External Fixation Acute Compartment Syndrome Prof. Dr. Andreas Platz Stadtspital Triemli, Zürich
Demographics Incidence: Men 7.3/100,000 Women 0.7/100,000 69% due to trauma 36% fx tibia 9.8% distal radius 23% soft tissue injury without fx 10% on anticoagulants
Pathophysiology Increasing volume in a closed compartment Pressure increased in compartment Decreasing arteriovenous difference Hypoxia : Muscle necrosis
Pathophysiology Increased compartment pressure: ICP > 30mm Hg (>40mm Hg) Delta Pressure: P diast - P comp < 30 mm Hg Related to diastolic blood pressure Worse in shock
6 P
Clinical Picture 6Ps Pain: Pain out of proportion of expectation Increased pressure / burst sensation Pain with passive motion / stretch Paresthesia Paralysis Pallor TREAT Pressure Pulselessness (very late sign or arterial injury!) è too late, >8h
Lower leg compartments Anterior Dorsiflexion Lateral Eversion Superficial posterior Plantarflexion Deep posterior just behind tibia Toe flexion
Extrinsic factors Burns circumferential Tight casts Tight dressings Compression devices malfunction
Intrinsic factors Fractures most common cause Tibia-/ fibula fx: 36%; supracondylar; radius/ulna Patients on coumadin with trauma IV drug abuse IV infiltration, IO infil: IM injection; arterial injection Attempts at cannulation veins in patients on anticoagulation Lithotomy position ORIF, then post op hemorrhage
Intrinsic factors Comatose patient, not moving Buttock; extremities; high pressures Vigorous exercise Hemorrhage from large injury Rhabdomyolysis Gastrocnemius / baker cyst ruptures Revascularisation and reperfusion Crush and direct blow to compartement
Pathophysiology N=0-4 mm Hg Compartment pressure > 30 mm Hg Venous outflow Venous pressure Gradient A.V pressure Arterial perfusion Capillary permeability Ischemia, tissue necrosis, edema
Should leg be elevated? Elevation of limb is contraindicated, it decreases arterial blood flow & narrows A-V gradient Immobilize lower leg with ankle in slight plantar flexion to decrease deep posterior compartement pressure
Compartment Syndrome of the lower leg Single Incision or double Incision? Complications? PD Dr. Andreas Platz Stadtspital Triemli, Zürich
Dermatofasziotomy (Single Incision)
Dermatofasziotomy (Single Incision) Release of the anterior compartment
Dermatofasziotomy (Single Incision) Release of the lateral compartment
Dermatofasziotomy (Single Incision) Release of the superficial posterior compartment
Dermatofasziotomy (Single Incision) Release of the deep posterior compartment
Dermatofasziotomy (Double Incision)
Single Incision vs double Incsion Single: Only one wound Needs more experience Double: Better overview Large wounds, problems with skin bridge Results:... The fasciotomy technique used did not show a significant correlation with outcome.
Dermatofasziotomie forearm Complete dissection of th Lig.carpi transversum!!!
This is NOT a fasciotomy This is a disaster!!
Dermatofasziotomy This is a fasciotomy!!
Compartment Syndrome of the Foot PD Dr. Andreas Platz Stadtspital Triemli, Zürich
Fascial Anatomy of the Foot
Etiology crush injury, fracture reperfusion injury surgical procedures occlusive dressing
Clinical Presentation History of injury / energy absorbed Swelling Pain Passive stretch Pallor, paresthesia, pulselessness, paralysis
Investigations 1 sample vs continuous monitoring Measure all four compartments (lower leg, foot) Don t delay getting measurements if diagnosis is obvious
Investigations Compartmental pressure measurements Whiteside technique Arterial line setup Commercially available monitors
Stryker: Pressure device
The syringe is filled with fluid
and then zeroed
Investigations: Technique Interosseus compartment Lateral compartment
Investigations: Technique Central compartment Medial compartment
Treatment Remove dressings Do not elevate the foot Max. level of the heart Analgesia Have low threshold to proceed surgically
Treatment Emergency fascial release 3 incisions 1 medial, 2 dorsal
Treatment Emergency fascial release 3 incisions 1 medial, 2 dorsal
Treatment Blunt and finger dissection Divide fascia Delayed closure +/- skin grafting Prophylactic releases
Treatment Two incisions Accident Delayed closure
Summary 5 (6) P s of pain, pressure, pulselessness, paralysis, paresthesia and pallor are more indicative of arterial injury or occlusion Hypotensive develop compartment syndrome earlier Lower compartement pressure threshold for fasciotomy in hypotense patient
Summary Lower leg: Single vs double incsions Foot: 4 main compartments Be aggressive to prevent long term sequelae