UNE ANZJSurg.com Clinical practice guidelines for the management of acute limb compartment syndrome following trauma Christopher J. Wall,* Joan Lynch,t lan A. Harris,¢ Martin D. Richardson,* Caroline Brand,S Adrian J. Lowe and Michael Sugruet *Dopariment of Surgery, Royal Meboure Hospital Victos ‘Trauma Department, Lwerpe! Host, Liverpool, NSW ‘tuners of New Sout Wes, South West Syney Circa Scho}, Lverpoot Hospital, Luerpol, NSW and Sclnical Epidemiology & Heath Seviees Evaluation Unit, Royal Melbourne Hospital, Victoria, Ausvala Key words {2m injuries, compartment syndromes, lg Abstract Background: Acute compartenat syndrome isa serious and not vncommon comgli- Cation of limb trauma, The condition is surgical emergency, and is associated with significant morbidity if not managed appropriately. There is variation in management (of acute Himb compartment syndrome in Auslia ‘Methods: Clinical prscice guidelines for the management of acute limb compart: ‘ment syndrome following trauma were developed in accordance with Australian National Health and Medical Research Council recommendations. The guidelines ‘wore based on citically apprised literature evidence and the consensus opinion of & ‘muligisciplina'y team involved in trouma menagement who met in a nomial panel proces Results: Recommendations were developed for key decison nodes inthe patent care ‘pathway, including methods of diagnosis in alert and unconscious patients, appropriate ‘assessment of compartment pressure, timing and technique offasciotomy, fasciotomy ‘wound management, and prevention of compartment syndrome in patiets with mb No financial support was received from say commeccat injures. The recommendations were largely consensus based inthe absence of well boda forte reoaerch presented in tha pope. ‘designed clinical tial evidence, “This papor was presented asa re paper presentation Conelusions: Clinical practice guidelines forthe management of acute limb com at he Royal Ausialasan Cotoge of Surgeons Consiot partment syndrome following trauma have been developed that will support consis- ‘Annual Scenic Congress in Hong Kong, in Mey 2008. tency in managoment and optimize patient health outcomes, Correspondence ‘Assocata Professor Martin Richardson, Departnent of Surgery, Royal Melbourne Hospital, Pale VIC 2080, ‘usa, Ema orhowe@bigpand.com J. Wall MBBS, BtodSc, J. Lynch RN, MPS, LA Harrie MBS, MModtGin Eid, PHD, FRACSION, FAOWh4, M.D. Richardson MBBS, M5, FRACSIO“N, FAOMhA, C. Brand MBBS, BA, MPH, FRACP. A. J {Lowa B8SelHons|, MPH, PND, M, Sugtuo MBECH, BAO, MD, FRCSI, FRACS, The corespondig author is nat arecipiont of 2 research schol, econo for puiation 27 September 2008, lok 10.1119, 1446-2107-2010 05218. Introduction ALCS is most commonly caused by trmumatic injury, and is teported to occur in 19% to 10% of tibial fractures? Despite the frequency with which AILCS occurs, and its associated mosbidity, ‘there are cutreally no management guidelines available forthe con Compartment syadeomse is ‘a condition in which increased pressure ‘within a limited space compromises the circulation and funetion of the tissues within that space” "The condition most commonly occurs {nthe muscular compartevets of the limbs, and in paticular those of the leg? ‘Acute limb compartment syndrome (ALCS) is a surgical emergency associated with significant mombidity if not iagnosed promplly and treated effectively. The sequelae of a mismanaged case include Votkmann’s ischaemic contractre, neurological deficit, limb amputation and crush syndrome. (© 2010 The Authors Journal compton © 2010 Royal Austlsion Cotege of Sugeons tion. A recent survey revealed variation in the management of ALCS in Ausra * ‘The aim ofthis project was to develop clinical practice guidlines (CPG) for the management of ALCS following tuma. Methods Staff from the Liverpool (Sydney) and Royal Melbourne Hospitals in Australia undertook a colaborative projet to develop CPG forthe ANE J Sug 80 (2010) 151-188152 ‘management of taumatic ALCS. The CPG were developed based on the Australian National Health and Medical Research Council (NHMRC) recommendations for CPG development? Key stakeholders in the management of ALCS were identied, and mltidisciplinary team of health-care professionals Was estab- Tished (0 provide expert input into the development of the CPG, ‘using a nominal panel process. This team included thee ochopaedic surgeons, three trauena surgeons, a plastic surgeon, an emergency ‘department physician, an intensivst, an anaesthetist, a trauma coor nator, atheate nurse, an orthopaedic ward nurse, a goneral want nurse, an orthopaedic research nurse, and a physician with expertise in CPG development, implementation and evaluation. The panel met ‘on two oceasions co develop key decision nodes (key points in ‘management decision making), to evaluate the Fiteratue wview and ‘contribute to the formulation of recommendations. “The lterture review was conducted by two of the authors (CW and JL) The Medline database was searched from 1966 to 10 August 2007 using the exploded Medical Subjet Heading, ‘Compactenent Syndromes’. Ailes related to chronic compartment syndrome, abdominal compartment syndrome, or acute compartment syndrome with a non-traumatic eause were excluded, as wore cas reports Evidence to underpin best practice recommendations was identi- fied and graded according to the NHMRC Evidence Hiearchy.® ‘Where titerature evidence was lacking, recommendations were made based on the consensus opinion of the muidiscipinary tam. Results “The Medline scarch yielded 2872 articles, which were scxeenel by Ue and abstact. 114 articles were read in thei enti, of which «ight reported evidence directly related tothe management of rau- sae ALCS, ‘The multidisciptnary eam identified nine key decision nodes in| the management of ALCS. Recoumendations fr each ae presented below with associate level of evidence and discussion. A manage- ‘ment lowehart was also designed (ig. 1). | Which trauma patients should be assessed for ALCS? LA. All patients with limb injuries should be assessed for ALCS (Consensus) 1.2. A paticulary high index of suspicion is necessary forthe following patient groups: 1.2.1. Males aged <35 years with fracture of the tibia nar the radius? 1-2) 1.22. High-energy injries (open fractures and/or severe soft tissue injuries} (2) 1.23. Sof tissue injuries in males aged <35 years with a beding discwer oe receiving anticoagulants? a2) 1.2.4, Crush injures (Consensus) 1.2.5. Prolonged limb compression (Forexample, Fallow ing dtug overdose) (Consensus) 1.3. High-tisk patients should be assessed for ALCS atleast every 4h fora minimum of 24h ater the precipitating injury (Consensus) wa Sinoe the development of ALCS is unpredictable, even oocurring alter telatively minor trauma, itis recommended that al patients ‘with limb injuries be assessed for the condition when they are iniially examined, In conscious patients, clinical assessment for ALCS is recommended, whereas in unconscious patents compet- tment pressure measurement i recommended (See 3 and). ‘Compartinent pressures have been shown to ise for atleast 24h postinjory. and hence itis recommended that high-risk paticats ‘be monitored during this period, A numberof authors have repoted that patents with high-grade injuries are at ineease sk of deve- ‘ping compartment syndrome 274%" McQueen and colleagues also ‘denied young males with frearm or ubia ractues and young sales with limb injuries anda high likelihood of bleeding as being at igh sk It is recommended tha patients having sustained erush injuries o prolonged lib compression be included in this high-risk category ‘Tho 4h monitoring routine i recommended to fit in with normal nursing obsevaton rounds andto ensue that a developing compat- iment syndtome is diagnosed within the eicat6- to 8-h threshold for muscle death (se 7). 2, How does one best prevent ALCS in a patient with a limb injury? 2.1. In patients at high ik of developing ALCS, the following, measures should be taken: 2.1.1. Circumferential bandages should be removed and plaster casts should be spit! (I-2 and 1 respectively) 2.12, Affected limb(6) should be positioned at heart level" (U2) + 2.13, Ite leg is affected, the ankle should be main- tained inthe neutral position (17) 214..The patient should be Kept normotensive (Consensus) 2.15. High flow oxygen should be administered if ‘oxygen saturation is subopeimal (Consensus) 2.2. If these measures fail to prevent the development of ALCS, a fasciotomy should be performed as soon as possible (08 7) (Consensus) ‘Todt there is no proven method for preventing ALCS. However, itis recommended thatthe above measures be taken ( minimize the risk ofthe condition developing in high-k patients. Recommendations 2.1.1 to 2.1.3 are based on the findings of ‘experimental studies in humans and annals with aiiilly raised ‘compartment presure."*" Recommendations 2.1.4 and 2.1.5 were included to optimize petfsion pressure and oxygen supply to tssues within affected compartments. If these measures fll to prevent the development of ALCS, the patient should be managed as discussed Further. 3. How does one diagnose ALCS in an alert patient? 3.1. In alest patients with limb injuries, ALCS should be diag nosed in tho presence of clinical sigas of the condition: (Consensus) 3.11, Palpabletenseness or swelling ofthe compartment 3.1.2. Pain out of proportion tothe injury (© 2010 The Authors oven eompiaon © 2010 Royal Australasian Cotege of SugoonsCompartment syndrome management guidelines 189, “na ‘aad ‘tt es | nn A st sos ano sa Tee = cS Po —=— ——" i= a aap ue = Timi on ‘a ag tec eat a mefiSetlian >30 mang, or 7.13. Pectusion pressure (Giastotic blood pressure: — compartment pressure) <30 mnFlg 71.2. AA fascitomy should be performed as soon as possible, proferably within 6 h and definitely within 12h Gif tall possible), once the diagnosis of ALCS has been con firmed by a surgeon (Consensus) Fasciotomy is nearly universally considered to be the definitive Lucatment for ALCS, however there are differing views i te litera- ‘tue as to when the operation is incated. Some authors recommend ‘sing clinical sign asthe diagnostic exter for fsciotomy, others recommend an absolve pressure threshold, whereas others advocate 4 differential (delt’) pressure. Absolute pressure thiesholds of 30/2 402" 45 mmHg? 50, and 70 ong”, and differeatial © 2010 The Authors -Jovrra complaton © 2010 Royal Australasian Coleg of SurgoansCompartment syndrome management guidelines pressure thresholds of 20 and 30 mmifg"" have been proposed in the Titerarore. In a prospective clinical study of routine compartment pressure ‘monitoring in 95 patients with bia fractures, Janzing and Broos did not find a pressure threshold with an acceptable sensitivity and specificity for dtagnosing acute compartment syndrom. In light ofthis, i is recommended thatthe ulticsate decision to petform a fasciotomy be based on a surgeon's disretion. Therefore, it is recommended that a surgeon be contacted immediately for urgent consideration of fasciotomy inthe presence of clinical signs ‘of the condition, an absolute pressure greater than 30 ming, or a ‘itfereatil pressure Less than 30 mm, as these ere the most con- Servet figures advocated in the literate and maximal sensitivity is required (0 ensore that no eases are missed ‘There is « paucity of evidence to suggest the optimal imesiame within which to perform 2 fasciotomy. A number of animal studies Ihave shown that ixeversible muscle damage oocurs ater 6-8 bof ‘moderately raised compartment presse2" In humans, two case sotes have reported a much greater incidence of adverse outcomes {in pions who had a faciotomy beyond 12 of the onset of the condition compared with those who had a fasciotomy within that time period." In light ofthis, itis recommended that fesciotomy be performed as soon as feasibly possible once the diagnosis has ‘bean made. 8, What isthe optimal fasciotomy technique? 8.1 In ALCS of the leg, all four compartments should be ecompressed, and in ALCS of the forearm, both com- ‘parents should be decomprested (Consensus) 82, In the Teg, @ double incision, four compartment f4s- ciotomy should be performed (Consensus) ‘83. In the foreerm, a curvilinear volar incision and a sight dorsal incision should be performed to decompress both ‘compartments (Consensus) 84. For adequate decompression, long. skin. incisions ‘and fulliength fasciotomies should be performed (Consensus) Routine decompression ofall compartments in the vicinity ofthe injury is recommended to avoid missing an affected compartment. For ALCS of the leg, the davble incision, four-ecmpartment fas- ciotomy technique described by Mubarak is recommended, \whereds for ALCS ofthe forearm, Gelberman’s technique involving 4 corviliear volar incision and a staight dorsal incision, is recommended ‘Skin has been shown to act asa limiting boundary even after @ fasciotomy has been performed, with th porentil of perpetuating a ‘compartment syndrome.» Long skin incisions are recommended to Prevent this occuring. 9. How are fascotomy wounds best managed? 9.1. 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