Acute Compartment Syndrome of the Lower Extremity PDF

Acute Compartment syndrome of the lower extremity MATHE W J OHNSTONE DPM, FACFAS, DABPM, FFPM RCPS( GL ASG) ASSI STANT PROFE SSOR COL L E GE OF PODI ATRI C ME DI CI NE AND SURGE RY, DE S MOI NE S UNI VE RSI T Y Copyright Notice: This presentation may contain copyrighted material used for educati...

Acute Compartment syndrome of the lower extremity MATHE W J OHNSTONE DPM, FACFAS, DABPM, FFPM RCPS( GL ASG) ASSI STANT PROFE SSOR COL L E GE OF PODI ATRI C ME DI CI NE AND SURGE RY, DE S MOI NE S UNI VE RSI T Y Copyright Notice: This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws.”  Demonstrate knowledge of Recognize the pathophysiology of compartmental anatomy of the ACS to the underlying etiology. lower leg and foot. Learning objectives Demonstrate knowledge of diagnosing and managing ACS of the lower leg and foot. Brief historical aside 1881- “Die ischämischen Muskellähmungen und Kontracturen”- Dr. Richard Von Volkmann-head of the department of surgery at the university of Halle, Germany “Volkmann’s contractures” described in this work Previously: Surgeon-General of the Prussian army and one of the most famous physicians of his time. He was once consulted by Pope Pius IX for a foot ailment in 1885 Acute compartment syndrome -A complication of trauma (particularly crush injuries), or other factors -Injury Swelling Interruption of blood flow Tissue necrosis -ACS is a Surgical emergency : prompt diagnosis is key to preserving function -Thorough understanding of the anatomy of the lower leg is critical to successful treatment of ACS Etiology Exertional Major vascular Injury Trauma* Surgical closure Hemorrhage External pressure Burns Snake bites Infiltration Infection Frostbite Pathophysiology 1. INJURY 2. Bleeding and interstitial edema 3. Increased pressure 4. Reduced arterial-venous flow gradient 5. Collapse of capillary blood flow 6. Death of tissue, nerve damage, muscle death etc. Positive feedback loop of ACS Untreated can lead to death At the cellular level Intercompartmental pressure approaches or exceeds capillary hydrostatic pressure. ◦ interrupts the blood flow to the tissues ◦ causes an oxygen debt in the muscle tissue. Skeletal Muscle switches to anerobic metabolism Oxygen debt continues to grow ◦ causing increased capillary permeability ◦ Increased inflammation Compartmental anatomy of the lower limb Compartments of the lower leg Anterior Lateral Deep Posterior Superficial Posterior Septa Compartments of the leg are divided into 4 parts by the Anterior intermuscular septum Interosseous membrane Posterior intermuscular septum Transverse intermuscular septum Compartments of the foot 2 main classifications for compartments of the foot Myerson-4 compartments (1988 injection study) Manoli and Weber 9 Compartments (1990 anatomical/ injection study) Myserson and Manoli would later collaborate on a 1992 study strongly recommending evaluation for compartment syndrome following calcaneal fractures as up to 10% can develop this syndrome Myerson study Central compartment: ◦ flexor dig brevis, lumbrical, quadratus plantae and adductor hallucis muscles; flexor dig longus, peroneal and posterior tibial tendons. Medial compartment: ◦ abductor hallucis and flexor hallucis brevis muscles; flexor hallucis longus, peroneus longus and posterior tibial tendons Interosseus compartment: ◦ Interossei muscles Lateral compartment: ◦ Abductor digiti minimi and flexor digiti minimi muscles 9-compartment modern model 1990: a series of three patients developed unilateral claw toes after calcaneal fractures of the same foot. ◦ A deep, previously un-described compartment was proposed 17 fresh cadaver limbs were with dyed with gelatin, the limbs were then frozen Nine compartments were identified ◦ including a deep separate “calcaneal compartment” which contains the quadratus plantae muscle ◦ Manoli and weber recommended a release of this compartment  3 compartments span the length of the foot Medial: 5 Forefoot Compartments ◦ Flexor Hallucis, abductor hallucis Lateral: Interosseous x4: (interosseous muscles) ◦ Abductor digiti quinti, flexor digiti minimi Adductor: (adductor hallucis) Superficial: ◦ flexor digitorum brevis, lumbricals, flexor digitorum longus tendons, medial Plantar nerve One compartment confined to the hindfoot Calcaneal: (contains the quadratus plantae, posterior tibial nerve, lateral plantar nerve and possible medial plantar nerve as well.) (see circled N/V bundle) Diagnosing ACS HPI (NLDOCAT) ◦ Nature: Injury (primary cause) usually a high energy or crush injury ◦ Location: ask for any other locations of pain/ abnormal feeling as well ◦ Duration: How long has it been since the injury? ◦ Onset: Sudden appearance vs gradual increase in pain ◦ Characteristics: what does pain feel like, any other symptoms ◦ Aggravating factors: does anything make it worse? (elevation) ◦ Treatments: Previously attempted treatments ROS ◦ General is patient conscious? ◦ Vision: flashes? Spots? ◦ Head and neck: Pain? Stiffness? ◦ Pulmonary: Shortness of breath? ◦ Cardio: Palpitations? ◦ Gastro-intestinal: Nausea? Vomiting? ◦ Genito-urinary- pain?, burning with urination? ◦ Hematology/oncology: hx of cancer or bleeding dx ◦ OB/Gyn (female patient only): is patient pregnant? Trying? ◦ Neuro: peripheral sensation? Feeling in injured limb? ◦ Endocrine: is patient diabetic? On steroids? ◦ Infectious diseases: Chronic conditions like HIV ◦ MSK: Pain? Loss of function? ◦ Mental health: is patient cooperative? Alert? ◦ Skin: Redness? Is the foot cold to the touch?  Skin Sensory deficit PAIN discoloration (Paresthesia) (Pallor) Temperature difference Pulselessness Paralysis (Poikilothermia) Exam findings: The (6 P’s)  Focused examination of the feet and legs (Don’t forget the other leg!) ◦ Vascular exam ◦ Pulses (may need Doppler) ◦ Skin Color/texture/ temperature ◦ Capillary fill time ◦ Musculoskeletal exam ◦ Location Physical ◦ Pain ◦ Gross anatomical deformity examination ◦ Neurological exam ◦ Semmes-Weinstein Monofilament ◦ Light touch/ sharp vs dull ◦ Two-point discrimination ◦ Dermatological exam ◦ Describe the Skin ◦ Color ◦ Temperature ◦ Wounds?/Blisters? Example 46-year-old Male construction worker He was standing in a deep post-hole at the build-site when the backhoe operator accidentally began to fill the hole with dirt while he was standing inside He yells for help and is rescued by his teammates who dig him out by hand and bring him to the ED. He is in “astounding pain” Clinical picture is on the right Patient workup HPI–WHEN did this happen, how many hours have passed. Is there any other injury that hasn’t been mentioned (check for back/ neck pain for high impact trauma like a car accident or fall from a height). Is pain increasing? When did patient last eat anything? (may need to go to OR emergently) Medical history: pertinent to know any bleeding disorders or medications which may increase bleeding Surgical history: any previous injury. Surgery to the affected side? Social and Family hx: patient has given his occupation. A functional recovery will be most important for him in order to return to work. Check for family hx of bleeding disorder while waiting for tests. Physical examination Focused to the injured limb: Vascular: You are unable to localize any pedal pulses by palpation, handheld RF doppler is also not picking up any signal from the DP or PT. The skin is cold to the touch (in contrast to the right foot which is warm) MSK: patient has intense pain with obvious dislocation clinically he is unable to move his toes at all Neuro: patient is unable to feel light touch on the distal foot (although he was fully able to feel this area before the injury) Skin: there is a bright red color to the foot and ankle save for the great toe which is white there are no open wounds, however.  Pain Poikilothermia Pallor Paresthesia Pulselessness Paralysis Diagnostic tests Diagnosis is based on strong clinical suspicion as well as intra-compartmental pressure measurement. Intra-compartmental pressures can be read using a wick- catheter system ◦ The wick-catheter system has been in use since at least 1968 (Scholander et al) X-ray/CT also useful in identifying associated fractures and severity of injury Measurement devices Top: Schematic of Whiteside's catheter 1973 Bottom: Modern Stryker-brand compartment pressure measurement tool Side-port The side-ported needle shown If forced to use a traditional hypodermic needle, ensure that needle above is usually included in the set for modern devices the device is not plugged with tissue or pressed against the bone These will result in false positives Measurement techniques (leg) Each compartment is measured at the junction between the upper and middle 1/3 of the leg. Anterior compartment: 1cm lateral to the anterior tibial border to a depth of 1-3cm Deep Posterior: insert needle just posterior to the medial tibial border and directed towards the posterior border of the fibula to a depth of 2-4cm Lateral: just anterior to the posterior border of the fibula to a depth of 1-1.5cm Superficial Posterior insert needle on either side of the anatomic midline at the posterior leg to a depth of 1-1.5cm Placement for measurement of medial (1-1/5cm) and Placement of superficial and deep central Placement for lateral and interosseous compartments calcaneal (2.4cm deep) compartments compartments Measurement techniques (foot)  Measurement values/ significance Muscle perfusion pressure Absolute Measurement Treatment *typically, anterior leg compartment = (intra-compartmental recommendation (Diastolic pressure) – (intra-compartmental pressure pressure reading) 0-8mmHg Normal resting pressure Muscle perfusion Treatment 30-40mmHg Monitoring zone pressure 40mmHG + clinical Fasciotomy Above 30mmHg monitor symptoms Below 30mmHg Fasciotomy Example: patient has a preoperative B/p of 100/70, intra-compartmental pressure readings are 50mmHg Diastolic pressure 70-50=20mmHg, Perform surgery Additional Labs/ Diagnostics ECG Bloodwork ◦ CBC/diff (sickle cell correlation) ◦ Electrolytes ◦ Bun/Creatinine ◦ ALT/Creatinine Kinase (Rhabdomyolysis) Urinalysis Routine Myoglobin Surgical technique (lower leg) 2- Incision Approach Lateral incision allows access to the ◦ Anterior compartment ◦ Lateral compartment 2 incision technique Medial incision allows access to ◦ Superficial posterior compartment ◦ Deep Posterior compartment Surgical technique Proper placement of lateral incision one finger-breadth anterior to the fibula, leads to easier identification of the anterior intermuscular septum, and release of both anterior and lateral compartments Release of deep posterior compartment requires separation of both gastric and soleus from the tibia (Identification of N/v bundle confirms location) Surgical approach diagram Lateral incision and fasciotomy Medial incision and fasciotomy  Let's do: a four- Medial incision begins 2cm posterior to postero- medial tibial border compartment lower Extends from proximal tibia to gastroc-soleus extremity release (leg) junction at the achilles Medial incision Superficial fascia is released with dissection scissors. This release is carried out in-line with the skin incision Take care to protect the saphenous vein and nerve. Deep compartment release The soleus is elevated from the poserior-medial tibia, releasing the deep compartment May need to extend incision for adequate release.  DISSECTION PLANE IS Dissection CARRIED BEHIND THE TIBIA TO ACCE SS THE D E E P P O S T E R I O R C O M P A R T M E N T.  M U ST B E AB L E TO Soleus elevated VISUALIZE THE DEEP P O ST E R I O R C O M PA R T M E N T TO E N SU R E R E L E ASE IS A D E Q U AT E  B O T H C O M PA R T M E N T S ACCESS THROUGH A SINGLE Lateral and anterior release L AT E R A L I N C I S I O N P L A C E D 2CM AN TE R IO R TO THE FIBULA Dissection DEEPEN THROUGH THE S U P E R F I C I A L FA S C I A Identify Release anterior compartment After raising an anterior flap (subcutaneous) incise the anterior fascia (be careful to preserve the superficial peroneal nerve) Lateral compartment T H E L AT E R A L C O M PA R T M E N T I S RELEASED ALONG THE release POSTERIOR BORDER OF THE FIBULA Immediate postop care  Closure options Primary Closure? Packed open Negative-pressure VAC “Shoelace Technique” Elevate extremity after surgery (-requires strict compliance) SPLINT! (prevent equinus contracture) Delayed primary closure Vs Skin graft Shoelace tecnique Silicone vessel loops tied into a large knot which is stapled to the skin at the apex of the incision  VESSEL LOOPS ARE THEN Vessel loop closure “L ACE D ” BY CO N TIN U IN G TO S TA P L E C R O S S E D V E S S E L L O O P S AT T H E S K I N E D G E S Vessel loop closure Vessel loop closure M A I N TA I N T E N S I O N O N T H E VESSEL LOOPS, PLACE T H E S E A B O U T 2 C M A PA R T Anatomical correlation The intermuscular septa are the dividing lines between muscular compartments of the leg, which will need to be opened by the surgeon in order to relieve the pressure in each compartment, inadequate decompression, or missed decompression of a compartment can lead to severe consequences. Lateral incision too far posterior can lead to Accidentally developing a plane between the mistaking the posterior intermuscular septum for gastrocnemius and soleus missing the deep the anterior intermuscular septum posterior compartment Surgical technique (foot) Classic three incision approach Two dorsal incisions access the forefoot compartments One medial incision allows access to medial, calcaneal, superficial and lateral compartments. Forefoot decompression DEEP DISSECTION OF THE F I R S T I N T E R S PA C E A L L O W S ACCESS AN D RELEASE O F T H E M E D I A L C O M PA R T M E N T AS WELL Rearfoot Decompression Single-incision approach Dissection continues dorsal and plantar to the abductor hallucis muscle belly. Five incision approach Note that the calcaneal compartment is not released by this approach  Check your work you can recheck the compartment pressures intraoperatively ◦ Try to normalize BP first ◦ Anesthesia often lowers diastolic BP, must use preop measures for determination Patients are generally admitted to the hospital floor for close monitoring of vitals and symptoms Recheck all postoperatively if pain (and other 6 P’s) continues/ increases Manage Complications Unfortunately ACS carries a high incidence of morbidity following injury even with expedited care, neurological deficits (such as clawtoes, cavo-varus foot and drop-foot) as well as wound healing complications/scarring can persist. Volkmann’s contracture refers to the ischemic contracture of the muscles of the forearm Conclusions -Include ACS in your differential diagnosis for high energy injuries of the leg and foot, especially crushing forces -Consider intra-compartmental pressure measurement for patient’s displaying clinical symptoms of ACS following injury. -Develop your expert knowledge of the anatomical structures of the foot and leg in order to appropriately release compartments and treat ACS. Lecture review Understand the positive feedback loop of ACS and how this leads to increasing oxygen debt to the tissue/cell death. Recognize some of the key injuries which should raise suspicion for ACS (crush injuries, multiple fractures, high energy) Recognize clinical symptoms associated with ACS the “6 P’s” Identify the anatomical compartments of the foot and leg, as well as intramuscular septae. How many compartments are in the foot? The leg? And how would one access each for decompression? Identify the proper locations for compartment pressure measurements. Relate intercompartment pressures to surgical decision making absolute and muscle perfusion pressures. Identify complications associated with acute compartment syndrome Questions? Practice question 1 You are consulted on an 18-year-old female patient with a calcaneal fracture and suspected compartment syndrome. Her blood pressure is 110/75. She has intense pain, a cold insensate foot, and pale discolorations. You cannot feel her pulses. You obtain an intra-compartment pressure reading of 40mmgHg from her foot. What is the best course of action? A: Monitor the patient and recheck her blood pressure B: Monitor the patient and recheck her intercompartmental pressure C: Perform an emergency Fasciotomy of the foot D: Schedule an elective Fasciotomy for the next 24 hours, if symptoms persist E: Perform an emergency fasciotomy of the foot and leg  Practice question 2 Following an acute crush-injury of the foot a patient was diagnosed with acute compartment syndrome and undergoes a 5-incision forefoot fasciotomy. The patient presents to clinic after one year with unilateral claw toe deformity, and numbness of their lateral foot. An MRI reveals severe atrophy of the quatratus plantae muscle. Which pedal compartment was not released, leading to these complications? A: Deep posterior compartment B: Interosseous compartment C: Central compartment D: Lateral Compartment E: Calcaneal Compartment  Practice question 1 (answered) You are consulted on an 18-year-old female patient with a calcaneal fracture and suspected compartment syndrome. Her blood pressure is 110/75. She has intense pain, a cold insensate foot, and pale discolorations. You cannot feel her pulses. You obtain an intra-compartment pressure reading of 40mmgHg from her foot. What is the best course of action? A: Monitor the patient and recheck her blood pressure B: Monitor the patient and recheck her intercompartmental pressure C: Perform an emergency Fasciotomy of the foot D: Schedule an elective Fasciotomy for the next 24 hours, if symptoms persist E: Perform an emergency fasciotomy of the foot and leg Rationale: The 40mmHg reading satisfies both the absolute and muscle perfusion scales for emergency fasciotomy of the foot (details on slide 31) in the presence of clinical symptoms (5 of the six P’s here) this patient emergently requires the fasciotomy... and time is of the essence.  Practice question 2 (answered) Following an acute crush-injury of the foot a patient was diagnosed with acute compartment syndrome and undergoes a 5-incision forefoot fasciotomy. The patient presents to clinic after one year with unilateral claw toe deformity, and numbness of their lateral foot. An MRI reveals severe atrophy of the quatratus plantae muscle. Which pedal compartment was not released, leading to these complications? A: Superficial posterior compartment B: Interosseous compartment C: Central compartment D: Lateral Compartment E: Calcaneal Compartment Rationale: The five incisions seen here will address the intermetatarsal septa (left image) as well as the medial and lateral compartments (right images) and superficial central compartment (center image) as the deep calcaneal compartment is in the posterior foot, this would be omitted by this approach. The superficial posterior compartment is also not located in the foot, however this would not necessarily cause ischemia of the quadratus plantae muscle, and given its position in the leg was not involved in this stated injury.  Clin Orthop Relat Res. 2008 Feb; 466(2): 500–506. Published online 2008 Jan 10. doi: 10.1007/s11999-007-0007-4 Krause F. Zur Erinnerung an Richard von Volkmann [To the memoriam of Richard von Volkmann]. 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