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Compartment Syndrome and it’ s Management Dr Minaal Ahmed Malik Trust Doctor Trauma & Orthopeadics, Worthing Hospital# CASE DISCUSSION A 27 year old male presents to A+E after incurring a sports injury while playing Football. He is unable to bear weight on his left leg and walks with a limp. Trauma & Orthopeadics, Worthing Hospital# CASE DISCUSSION XR of the limb shows Trauma & Orthopeadics, Worthing Hospital# CASE DISCUSSION Management • Closed reduction / cast immobilization • FU in Lower Limb Clinic in 1 week Trauma & Orthopeadics, Worthing Hospital# CASE DISCUSSION He presents 6 hours later to the A+E complaining of unmanageable pain and pins and needles in his cast. Trauma & Orthopeadics, Worthing Hospital# CASE DISCUSSION This is a TRUE ORTHOPEADIC EMERGENCY The patient is suffering from Acute Compartment Syndrome Trauma & Orthopeadics, Worthing Hospital• Anatomy • Surrounding the long bones are muscles, tendons, ligaments, lymphatics, vessels and nerves. They are enveloped together by fascia. • Thus forming the osteofascial compartment Trauma & Orthopeadics, Worthing Hospital• Anatomy • We have the following compartments • Compartment of arm • Compartment of wrist • Compartment of thigh • Compartment of leg • Compartment of foot Trauma & Orthopeadics, Worthing Hospital• Compartment Syndrome can have an acute or chronic presentation •Chronic Compartment Syndrome also known as Exertional Compartment Syndrome is NOT a medical emergency • It usually appears in athletes and is a result of chronic overuse. • Pain is felt on exertion and usually settles upon rest. • Symptoms may also include muscle bulging, numbness or even difficulty in movement. • Chronic Compartment Syndrome usually occurs in the leg. Trauma & Orthopeadics, Worthing HospitalAcute Compartment Syndrome • Acute compartment syndrome of a limb is due to raised pressure within a closed fascial compartment causing local tissue ischaemia and hypoxia. • In clinical practice, it is most often seen after tibial and forearm fractures, high-energy wrist fractures and crush injuries. • Early diagnosis and treatment is vital to avoid severe disability. • Pulses are normally present in compartment syndrome. Absent pulses are usually due to systemic hypotension, arterial occlusion or vascular injury. Trauma & Orthopeadics, Worthing HospitalTrauma & Orthopeadics, Worthing Hospital• Why is it an emergency? Trauma & Orthopeadics, Worthing Hospital• Pathophysiology Trauma & Orthopeadics, Worthing Hospital• Pathophysiology Trauma & Orthopeadics, Worthing Hospital• Pathophysiology Trauma & Orthopeadics, Worthing Hospital• Pathophysiology Trauma & Orthopeadics, Worthing Hospital• Pathophysiology Trauma & Orthopeadics, Worthing Hospital• Danger Signs Trauma & Orthopeadics, Worthing HospitalAssessment for compartment syndrome should be part of the routine evaluation of patients • who present with significant limb injuries, • After surgery for limb injuries • Any prolonged surgical procedure which may result in hypoperfusion of a limb. Trauma & Orthopeadics, Worthing HospitalClear documentation should include: • Time and mechanism of injury • Time of evaluation • Level of pain • Level of consciousness • Response to analgesia • Whether a regional anaesthetic has been given. • Limb neurology • Limb perfusion, including capillary refill and distal pulses Trauma & Orthopeadics, Worthing HospitalIn addition, assessments should include • Muscle tenderness • Motor and Neurological function • If fracture is suspected, then radiographs Trauma & Orthopeadics, Worthing HospitalFor High-Risk Patients • These observations should be performed hourly whilst the patient is deemed still to be at risk. • If pain scores are not reducing, then senior clinical review is mandated. • Regional anaesthesia and patient controlled opiates can mask the symptoms of compartment syndrome. While RA should be avoided entirely, the rate and dose of opiates and other analgesics must be taken into consideration and recorded in the medical records. Trauma & Orthopeadics, Worthing HospitalSuspicion of Compartment Syndrome • Provide supplemental O2 • All circumferential dressings released to skin • Limb elevated to heart level. • Measures should be taken to maintain a normal blood pressure • Patients should be re-evaluated within 30 minutes. Trauma & Orthopeadics, Worthing HospitalConfirmation of suspicion • For patients with diagnostic uncertainty and those with risk factors where clinical assessment is not possible (e.g. patients with reduced level of consciousness), hospitals should have a clear, written management policy. Trauma & Orthopeadics, Worthing HospitalTrauma & Orthopeadics, Worthing HospitalTrauma & Orthopeadics, Worthing HospitalConfirmation of suspicion • The pressure sensor should be placed into the compartment(s) suspected of being abnormal or at risk. Trauma & Orthopeadics, Worthing Hospital Whiteside T echnique • Preparation: Sterile saline is drawn into a syringe attached to a three-way stopcock. • Setup: An intravenous extension tube is manometer is attached to measure pressure. • into the muscle compartment to be tested. • increased by depressing the syringe plunger until the saline meniscus in the tube flattens, indicating that the pressure in the system equals the interstitial pressure in the muscle Trauma & Orthopeadics, Worthing HospitalConfirmation of suspicion • Stryker solid-state transducer intercompartment catheter (STIC Trauma & Orthopeadics, Worthing Hospital• Compartment Pressures Trauma & Orthopeadics, Worthing Hospital• Confirmation of suspicion • If the absolute compartment pressure is greater than 40 mmHg, with clinical symptoms, urgent surgical decompression should be considered unless there are other life-threatening conditions that take priority. Trauma & Orthopeadics, Worthing HospitalFasciotomy • Fasciotomy or fasciectomy is a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle. • Fasciotomy is a limb-saving procedure which is commonly used to treat acute and sometimes chronic compartment syndrome. • High success rate. • Most common complication – nerve damage, scarring, stricture, loss of mobility. Trauma & Orthopeadics, Worthing HospitalSurgery should involve immediate open fascial decompression of all involved compartments, taking into account possible reconstructive options. Necrotic muscle should be excised. The compartments decompressed must be documented in the operation record. All patients should undergo re-exploration at approximately 48 hours, or earlier if clinically indicated. Early involvement by a plastic surgeon may be required to achieve appropriate soft tissue coverage. Trauma & Orthopeadics, Worthing Hospital• For lower leg fasciotomies it is recommended to perform a two- incision four-compartment decompression. Trauma & Orthopeadics, Worthing HospitalTrauma & Orthopeadics, Worthing HospitalAn incision from intertrochanteric line to lateral epicondyle. Posterior compartment is released by incising fascia lata and vastus lateralis is retracted medially to expose lateral intermuscular septum, which is incised to decompress posterior compartment Trauma & Orthopeadics, Worthing HospitalAnterior (Flexor) Compartment Fasciotomy: Make a longitudinal incision along the medial aspect of the arm, starting from the distal third of the humerus and extending to the medial epicondyle. This incision should run over the biceps brachii muscle. Incise the deep fascia over the biceps brachii and brachialis muscles, carefully avoiding the brachial artery and median nerve, which lie within this compartment. Posterior (Extensor) Compartment Fasciotomy: Incision: Make a longitudinal incision along the lateral aspect of the arm, starting from the distal third of the humerus and extending to the lateral epicondyle, along the line of the triceps brachii muscle. Incise the fascia over the triceps brachii muscle to decompress the posterior compartment. Trauma & Orthopeadics, Worthing HospitalTrauma & Orthopeadics, Worthing HospitalTrauma & Orthopeadics, Worthing Hospital• There is no consensus for the management of foot compartment syndrome. • Patients with late presentation or diagnosis (greater than 12 hours) have a high risk of complications with surgery. • Decision-making is difficult and should involve two consultants. Non- operative management is an option. Trauma & Orthopeadics, Worthing HospitalComplications Trauma & Orthopeadics, Worthing HospitalConclusion • In conclusion, compartment syndrome is a critical condition that demands early recognition and swift intervention to prevent irreversible damage. Understanding the signs, symptoms, and appropriate diagnostic techniques is essential for timely diagnosis. Effective management, primarily through fasciotomy, can significantly improve patient outcomes and reduce the risk of long-term complications. As healthcare providers, staying vigilant and informed about compartment syndrome is crucial in delivering the best possible care to our patients. Trauma & Orthopeadics, Worthing Hospital• Thank you Trauma & Orthopeadics, Worthing Hospital