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) IM nailing (reaming)
Blunt trauma Exertional states
Cast/dressing Closure of fascial
Arterial injury defects
Post-ischemic GSW / stabbings
hyperperfusion IV & A-lines
Burns/electrical injuries Hemophil./coag.disorder
Distorsion (ankle) Intraosseous infusion
Tumour Snake bite
Lithotomy position
.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

 JOT
2002
Bayes theorem
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

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 => UP

delay to diagnosis => 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 => Cut & spread plaster
compartment pressure Cut webril
BUT
Remove cast
BP in elevated limb
53% in perfusion pressure
YES
NO

Wiger & Styf, J Orthop Trauma. 1998

 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