PHTH1110 004 Compartment Syndrome - Wright.pdf

DR DEAN EVERETT WRIGHT COMPARTMENT SYNDROME IDENTIFICATION and MANAGEMENT OF PATIENTS STORY 1 37 YO MAN ADMITTED TO HOSPITAL --- GSW to buttock Transcervical fracture Left hip Fixation Day 6 Discharge 4th postop day 3 MONTHS SEVERE LEFT GROIN PAIN -- f f Xray Failed ixation Bone scan Osteonecrosis f...

DR DEAN EVERETT WRIGHT COMPARTMENT SYNDROME IDENTIFICATION and MANAGEMENT OF PATIENTS STORY 1 37 YO MAN ADMITTED TO HOSPITAL --- GSW to buttock Transcervical fracture Left hip Fixation Day 6 Discharge 4th postop day 3 MONTHS SEVERE LEFT GROIN PAIN -- f f Xray Failed ixation Bone scan Osteonecrosis femur Neck Decision for Vascularised ibular graft SURGERY --- Position Right tilted supine Complicated/ 9+ hours GENERAL ANAESTHESIA Core decompression Fibular strut POST OP NURSED --- Position supine to semiFowler Narcotic and other analgesia 8 hours post-op Mild left buttock op site pain SEVERE RIGHT buttock pain CLINICAL --- Remained afebrile HR 120/min Normotensive No Respiratory Distress CLINICAL -- WORSE RIGHT buttock Pain Complicated/ PARAESTHESIA RIGHT LEG/ FOOT - SWOLLEN TENSE RIGHT BUTTOCK - ACTIVE RT HIP MOTION esp. lexion ↑ ↑ ↑ buttock Pain PASSIVE RT HIP lexion ↑ ↑ ↑ buttock Pain Ankle and knee movements were NORMAL STILL f f CLINICAL CLINICAL -- NO VASCULAR DEFICIT OBJECTIVE SENSORY DEFICIT: dorsal foot was hypo aesthetic Haemoglobin level (gram/ decilitre) (pre-operative Hb 15) LABS 10.6 White cell count 9 (×10 /ml) 16 Platelet count 9 (×10 /ml) 222 PT/PTT Urea and electrolytes (including serum potassium) normal normal. LABS INDICES OF RHABDOMYOLYSIS CPK Urine Myoglobin UNAVAILABLE AT 3AM DIAGNOSIS ? WHY GLUTEAL COMPARTMENT SYNDROME MANAGEMENT INDICATED ? EMERGENCY FASCIOTOMY SURGERY: 11 HOURS POSTOP --- Position: PRONE GENERAL ANAESTHESIA Kocher-Langenback incision GLUTEAL FASCIOTOMY Oedematous but viable gluteus medius and Maximus released Skin closure PROGRESS: 48 - 72 HOURS POSTOP --- Buttock pain subsided Paraesthesia/ hypoaesthesia leg and foot resolved Normal gluteal muscle function Fasciotomy incision healed well (Wound infection original op site) PROGRESS: 48 - 72 HOURS POSTOP --- Buttock pain subsided Paraesthesia/ hypoaesthesia leg and foot resolved Normal gluteal muscle function Fasciotomy incision healed well (Wound infection original op site) DR DEAN EVERETT WRIGHT. ACKNOWLEDGE. DR MAXIM CHRISTMAS COMPARTMENT SYNDROME IDENTIFICATION and MANAGEMENT OF PATIENTS DEFINITIONS - An increased pressure within an enclosed osteofascial space that reduces capillary perfusion below levels necessary for tissue viability Elevation of intracompartmental pressure to a level and for a duration that without decompression will cause tissue ischemia and necrosis - PATHOPHYSIOLOGY --- Increased compartment pressures lead to - increased volume within space - decreased space for contents - combination of both increased venous pressure which decreases A-V gradient resulting in NERVE and MUSCLE ischemia EPIDEMIOLOGY ----- Incidence: Men>women Men 7.3/100,000 Women 0.7/100,000 69% due to trauma 36% fracture tibia 9.8% distal radius 23% soft tissue injury without fracture 10% on anticoagulants High energy > low energy incidence (esp in tibial fractures) May occur in open injuries 9.1% -------- f Fractures Soft-tissue trauma CRUSH injury Arterial injury REPERFUSION INJURY Limb compression during altered consciousness Burns Intravenous luid extravasation Anticoagulants/bleeding diasthases Trauma with bleeding/swelling Tight wraps Traction Surgical positioning Snake bite DIAGNOSIS --- HISTORY CLINICAL EXAM Measure Compartment pressure LAB tests HIGH SUSPICION 🧐🤔👁👀 HISTORY / EXAM --- Injury / Energy absorbed Pain* (sensitivity 19% speci icity 97%) Swelling (subjective) Passive stretch f Pallor, paresthesia, pulselessness, paralysis, poikilothermia. LATE PAIN --- speci ic compartment Activity. To. REST passive lengthening of the muscle Passive stretch distal referred pain related to the course of a nerve - f OUT OF KEEPING WITH ISSUE NERVE DYSFUNCTION --- numbness tingling weakness paralysis SWELLING -- Firmness tenseness Muscle herniation VERY IMPORTANT - Resolution of pain without the recovery of nerve or muscle function may signal the loss of muscle viability -- DIAGNOSIS clinical criteria dif icult (eg. children, concomitant neurological injury, critically ill, prolonged general anaesthesia, Neuraxial analgesia and anaesthesia EARLY DIAGNOSIS to EARLY INTERVENTION avoids complications f - COMPARTMENT PRESSURE MONITORING - an adjunct to clinical examination Raised tissue pressure is the primary event △ intra-compartmental pressures precedes clinical symptoms and signs COMPARTMENT PRESSURE ----- Most common Leg Forearm Other compartments Hand Foot Thigh Finger Gluteal COMPARTMENT PRESSURE WHEN? --f Con irm clinical exam Obtunded patient with tight compartments Regional anesthetic Vascular injury Persistent pain despite analgesia COMPARTMENT PRESSURE HOW? --- Needle manometer method Wick catheter Slit catheter Whiteside infusion Stic technique: side port needle CRITICAL PRESSURE? -- >30 mm Hg as absolute number (Roraback) >45 mm Hg as absolute number (Matsen) ACS Presence of muscle contraction -> proximal nerve injury However, PARALYSIS is a late sign of ACS TREATMENT --- Lower leg to level of the heart Remove cast Split all dressings down to skin Correct hypotension if present Oxygen therapy f TREATMENT - Fasciotomy if continued clinical indings and/or elevated compartment pressure - Stabilization of associated fractures after fasciotomy Delayed closure +/- skin grafting FASCIOTOMY -- Full and adequate decompression Skin incisions must be made along the full length of affected compartment No role for limited or subcutaneous fasciotomy Visualize all contained muscles in their entirety Debride necrotic muscle WOUND CARE ---- Soft tissue coverage by 5-7 days if all muscle groups are viable ?second look procedure by 48hrs Delayed closure Vascular loop ‘lace technique’ Primary Vacuum Assisted closure (VAC) Split thickness skin graft Flaps or free tissue transfer MISSED COMPARTMENT SYNDROMES - Early Late - ---- Myonecrosis Myoglobenemia ->Renal concerns Deformities from contracture of necrotic muscle Muscle weakness Infection Non-unions Amputations Nerve Injury Ulcerations Sensory loss -- MYOGLOBINAEMIA ----- Released in high levels at reperfusion Toxic to glomeruli Metabolic acidosis & hyperkalemia Together lead to: Renal failure Cardiac arrhythmia & failure Hypothermia Shock CONCLUSION -- Early diagnosis of ACS is important However, clinical assessment is still the diagnostic cornerstone & requires: Detailed exam Vigilant examiner Cooperative patient Serum marker of muscle damage Measurement of compartmental perfusion and ischaemia ---