Marc Hirner


Incidence:

Men

Women
7.3/100,000
0.7/100,000

69% due to trauma


36% fx tibia
9.8% distal radius

23% soft tissue injury without fx

10% on anticoagulants


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


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


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

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


History

Clinical exam: the Ps

Compartment pressures

Laboratory tests

CPK

Urine myoglobin


The six ‘Ps’:

Pressure

Pain

Paresthesia

Paralysis

Pallor

Pulselessness


Early finding

Only objective finding

Refers to palpation of compartment and its tension or firmness

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


Early sign

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

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


Rarely present

Indicates direct damage to vessels rather than compartment syndrome

Vascular injury more of contributing factor to syndrome rather than result

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


Easy to use

Can check multiple compartments

Different areas in one compartment

Distance From Fracture Effects
Pressure


>30 mm Hg as absolute number (Roraback)


Lower leg to level of the heart

Remove cast

Split all dressings down to skin

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

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

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