1. Acute Compartment Syndrome
Marc Hirner

2. Demographics Incidence: 69% due to trauma 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

4. Case 1
Patient with ? Trivial knee injury Seen in ED and admitted Registrar to ward , pulseless limb Was in fact a knee dislocation that reduced spontaneously End result popliteal artery repair , fasciotomy , ligament reconstruction and eventual BKA

5. Case 2
Simple fibula fracture Referred to White Cross several days after injury with tight swollen calf Diagnosed acute compartment syndrome 5 days late Fasciotomy of no use as muscles necrotic

6. Case 3
Child required IV access so the tibia was used for rapid infusion Fluid into the calf Acute compartment syndrome Orthopaedics notified late Fasciotomy no use as muscles necrotic

7. Etiology

8. Pathophysiology Increased compartment pressure
Increased venous pressure
Decrease A-V gradient resulting in muscle and nerve ischemia.

9. Diagnosis History Clinical exam: the Ps Compartment pressures
Laboratory tests
CPK
Urine myoglobin

10. Clinical Diagnosis The six ‘Ps’: Pressure Pain Paresthesia Paralysis
Pallor
Pulselessness

11. Pressure Early finding Only objective finding
Refers to palpation of compartment and its tension or firmness

12. Pain Out of portion to injury Exaggerated with passive stretch
Earliest symptom but inconsistent
Not available in obtunded patient

13. Paresthesia Early sign Difficult to interpret
Peripheral nerve tissue is more sensitive than muscle to ischemia
Permanent damage may occur in 75 minutes
Difficult to interpret
Will progress to anesthesia if pressure not relieved

14. Paralysis Very late finding Paresis may be present early
Irreversible nerve and muscle damage present
Paresis may be present early
Difficult to evaluate because of pain

15. Pallor & Pulselessness
Rarely present
Indicates direct damage to vessels rather than compartment syndrome
Vascular injury more of contributing factor to syndrome rather than result

16. Compartment Pressure When Technique Confirm clinical exam
Obtunded patient with tight compartments
Regional anesthetic
Vascular injury
Technique
Whiteside infusion
Stic technique: side port needle
Wick catheter
Slit catheter

17. Stryker Stic System Easy to use Can check multiple compartments
Different areas in one compartment

18. Distance From Fracture Effects Pressure

19. What is Critical Pressure?
>30 mm Hg as absolute number (Roraback)

20. Treatment Lower leg to level of the heart Remove cast
Split all dressings down to skin

21. Treatment If concerned refer these patients early
Fasciotomy if continued clinical findings and/or elevated compartment pressure

22. Treatment

23. Wound Care Soft tissue coverage by 5-7 days Delayed closure
Vascular loop ‘lace technique’
Split thickness skin graft
Flaps or free tissue transfer

24. NO ONE EVER BLAMES US FOR DOING A FASCIOTOMY BUT MISSING COMPARTMENT SYDROME IS A DISASTER