Compartment syndrome

Diagnostic difficulties & future developments

Henrik Grønborg, co-director

Rigshospitalet Trauma Center
Copenhagen
• The past

• The present (difficulties)

– Symptoms
– Diagnosis

• The future ?
 History
• Volkmann's ischaemic contracture
• Permanent flexion contracture
• Claw-like deformity of the
hand and fingers

1830 - 1889
 Development of acute CS
In an enclosed muscle (osteofascial) compartment:

Increase in volume of contents

and/or
Reduction in size of compartment

↓
increased pressure within the compartment
↓
compression of muscles, nerves & vessels
↓
impaired blood flow
↓
ischemia & necrosis
 Numerous etiologies
• Fracture (also open #’s)
• Blunt trauma
• Cast/dressing
• Arterial injury
• Post-ischemic
hyperperfusion
• Burns/electrical injuries
• Distorsion (ankle)
• Tumour
• Lithotomy position
• IM nailing (reaming)
• Exertional states
• Closure of fascial
defects
• GSW / stabbings
• IV & A-lines
• Hemophil./coag.disorder
• Intraosseous infusion
• Snake bite
……….and more
 Symptoms
• Pain out of proportion
• Pain on passive stretch
• Paraesthesia
• Paresis
• Pulses present
• Palpatory pain

• ACS is a surgical emergency !

2008 2004
Patient characteristics

JBJS
1996
Patient characteristics

CJEM
2003
 Injury
2006

• 17% of consultant anaesthetists

• 9% of nonconsultant anaesthetists
had seen CS masked by regional anaesthesia !
Diagnostic delay

CJEM
2003
 JOT
2002

The clinical findings

 JOT
2002
• Bayes’ theorem
– Estimating the probability of a diagnosis based
on a series of clinical findings

– The likelihood ratio that compartment

syndrome exists in a patient with a tibial shaft #
• based on pain, paresthesia, PPS, paresis:
 Clinical features of ACS of the lower leg are:

• more useful by their absence in excluding ACS JOT

• than they are when present in confirming ACS 2002
JOT
2002
 Measurement of
intracompartmental
pressure
 Pressure monitoring
Kodiag

Whiteside
technique

Stryker
AJEM
2003
JBJS
2005

SP

SL
 JBJS
2005

• A-line manometer
with:
– side-port needle
or
– slit catheter
• Available at ICU’s !
Heckman
JBJS-A, 1994

Pressure measurements
should be performed in:

1. both the anterior and the deep

posterior compartments

2. at the level of the fracture

+
3. at locations proximal and distal
to the fracture zone
 Arch Orthop
Trauma Surg
1998

• A pressure threshold of 30 mmHg seems

to give an unacceptably high rate of
fasciotomies
– ”Even if the absolute pressure limit had been
increased to 40 or 50 mmHg, we would have
19% or 14%, respectively”
 JBJS
1996

– 116 patients with tibial #’s

– Continuous monitoring of anterior tibial
compartment for 24 hrs
– UP=30 mmHg threshold for fasciotomy
• 3 patients (2.6%) fasc.
• no missed cases
– If P=30mmHg
• 50 patients (43%) fasc.
– If P=40mmHg
• 27 patients (23%) fasc.
 Injury
2001

95 patients with 97 tibial #’s

• ICP > 30mmHg
or
• PP = UP = (DBP – ICP) <30 mmHg
– acceptable sensitivity
but
– poor specificity too many fasciotomies

• PP = UP = (MAP – ICP) <30 mmHg, used in combination

with clinical symptoms or a second measurement after 1hr
– excellent specificity
but
– low sensitivity too many missed CS’s
 JBJS
1996

• ↑ fracture complexity => ↓ UP

• ↑ delay to diagnosis => ↓ UP

• Open vs. closed # => ns diff. in UP

• IM nail vs. Ex-Fix => ns diff. in UP

 JBJS
1996

• CCPM is
– invasive
– requires hourly nursing attention
– regular in-service training of nursing staff
• not cost effective

• CCPM is not indicated in alert patients

who are adequately observed
Management of acute compartment
syndrome - how do we do it ?

Injury
1998

ANZ J.Surg
2007
 Injury
1998

• 100 questionaires to consultants at

different centres
• 78 answers
– 36/78 had equipment for pressure monitoring
• 12/36 used equipmet routinely
• 24/36 used it selectively or not at all
Injury
1998
 ANZ J.Surg
2007

• 264 valid responses

– (29% of all eligible respondents).

• 78% of respondents regularly measured

compartment pressure
– 33% used an absolute P threshold
– 28% used a UP threshold
– 39% took both into consideration
ANZ J.Surg
2007
ANZ J.Surg
2007
ANZ J.Surg
2007
 Immediate actions
• Limb elevation => • Cut & spread plaster
↓ compartment pressure • Cut webril
BUT
• Remove cast
• BP ↓ in elevated limb
• 53% ↓ in perfusion pressure
YES
NO

Wiger & Styf, J Orthop Trauma. 1998

 Surgery
1997

• Fasciotomy most efficacious when performed early

• However, when performed late
– similar rates of limb salvage as compared to early fasc
– but increased risk of infection

• Results support aggressive use of fasciotomy

regardless of time of diagnosis
 JOT
1996

• 5 patients
• Average delay 56 hrs (35-96 hrs)
• 9 fasciotomies in lower limbs
– 1 death of septicaemia and MOF
– 4 required amputations

• If CP in a closed lower limb injury > 8 to 10 hours:

– ICP recordings after an 8-hour period is not useful
– Treatment of potential acute renal failure must be considered
– Viable skin left intact; no exposure of necrotic muscle to infection
– Late reconstructive procedures to correct muscle contractures
The future ?
JBJS
1999
Physiol Meas
2004
J Orthop
Trauma
2006
 Identifying the patient at risk
• Unconsciousness
• Intoxication
• Concomitant nerve injury
• Multiple injuries
• Young children
• Individual patients with equivocal
symptoms and signs
• Epidural anaesthesia
”seek, and ye shall find”
Matthew (ch. VII, v. 7-8)
Trauma
2007
 Take home message
• ACS is a surgical emergency
• High level of suspicion (”seek, and ye shall find”)
• Classic clinical symptoms have:
– low sensitivity & pos+ predictive value
– high specificity & neg- predictive value
• ICP easily measured with A-line manometer
• UP=30 mmHg useful threshold for fasciotomy
• Screening protocols for patients at risk
• Non-invasive pressure monitoring is coming
This lecture is available at:

www.flims.dk