Compartment syndrome

Diagnostic difficulties & future developments

Henrik Grnborg, 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

 Bayes theorem

JOT
2002

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

S
SP
SL

JBJS
2005

A-line manometer
with:
side-port needle
or
slit catheter

Available at ICUs !

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 CSs

JBJS
1996

fracture complexity
delay to diagnosis

=> UP
=> 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 =>
compartment pressure
BUT
BP in elevated limb
53% in perfusion pressure

NO

Wiger & Styf, J Orthop Trauma. 1998

Cut & spread plaster

Cut webril
Remove cast

YES

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