Compartment syndrome

  • Introduction

  • Diagnosis

  • Treatment

  • Creating Your Own Pressure Monitor

  • Surgical Approaches

  • Compartments, Muscles & Nerves

  • References

    •

    Introduction

     

    "Raised pressure in a closed osseo/facial compartment"

    "Increasing pressure in a closed compartment compromises circulation"

     

    Absolute pressure greater than 30mmHg (other numbers suggested but most accepted).

    Better still Pressure within 30mmHg of Diastolic pressure (Viz perfusion).

     

    Diagnosis

     

    Clinical

    Forget the 5 P's (Pain, Pallor, Pulselessnes, Parasthesias, Poikilothermy) Very late and variable

    MOST IMPORTANT!

    High index of suspicion

    Increasing pain and pain on passive stretch of muscles in involved compartment.

    Beware can still get compartment syndrome in open fractures if only small hole in fascia.

    Beware depressed level of consciousness patients consider continuous monitoring.

     

    Pressure monitoring

    Multiple methods

    1. Needle manometer (bubble-free column of saline), blockage, false readings

    2. Wick and slit catheters (bubble-free column of saline), suggested improved accuracy

    3. Solid-state transducer intracompartment catheter, level of external transducer

    4. Transducer- tipped probe if correctly positioned probably best pressure monitor

    All potential for false readings if not correctly positioned.

    Variable pressure readings in same compartment depending on site, suggest measure within 5 cm of fracture, but not directly in fracture site.

     

    Remember 4 distinct compartments in lower leg measure all.

    If continuous monitoring to be used, measure all initially and then use highest or anterior compartment for continuous monitoring.

    Concept of pressure pattern and timescale also important with regard to tissue damage, not just single absolute pressure.

     

    Treatment

    Emergency any delay may increase tissue injury.

    Delay of 12 hours catastrophic.

    Within 6 hours potential for full recovery.

    Split dressings to skin/

    Elevate limb (NOT too high as decrease perfusion pressure, at level or just above heart)

    Improve blood pressure, Oxygen

    Definitive treatment Fasciotomy

    Lower leg - all 4 compartments through two separate incisions.

     

    Creating Your Own Pressure Monitor

    Should you find yourself in a position where a commercial monitor  is unavailable, a simple monitor can be rigged up with few items.
    What you need ...
    - A bedside monitor capable of using an arterial line transducer
    - An arterial line transducer and setup
    - A three-way stopcock
    - A 10cc syringe with sterile saline
    - A 20 gauge needle
    What to do ...
    1) Set up the arterial line transducer and tubing as is normally done
    2) Attach the stopcock to the tubing, and attach the needle and syringe to the stopcock
    3) Flush the system with saline from the pressure bag
    4) Zero the monitor
    5) Insert the needle into the desired compartment. Using the stopcock inject 0.1cc saline from the syringe then change the stopcock to the monitor
    6) Record the reading

     

    Surgical Approaches (All approaches click here)

    Compartments, Muscles & Nerves


    Forearm

    • Volar Compartment:

      • FCR, FCU, FDS, FDP, FPL, PL

      • Median, Radial, Ulnar nerves

    • Dorsal Compartment:

      • ECU, EDC, EPL, EIP

    • Mobile Wad:

      • ECRB, ECRL, BR

      • Superficial Radial nerve

    Upper Arm

    Anterior Compartment:
    * Biceps
    Lateral Compartment:
    * Brachialis, BR
    Posterior Compartment:
    * Triceps
    Radial nerve
     

    Thigh

    Anterior Compartment:
    * VL, VMO, VI
    Medial Compartment:
    * Adductors
    Posterior Compartment:
    * ST, SM, Gracilis
     

    Leg

    Anterior Compartment:
    * Tibialis Anterior
    Ant. Tibial nerve
    Lateral Compartment:
    * Peroneals
    Superficial peroneal nerve
    Deep Posterior Compartment:
    * PT, FHL
    Post. Tibial nerve, Common peroneal nerve
    Superficial Posterior Compartment:
    * Gastrocnemius, Soleus
    Sural nerve

    References

     

    Kirsten G. B. Elliott, Alan. J. Johnstone. Diagnosing Acute Compartment Syndrome JBJS- (Br); 2003: (85) 5 Pg 625-632


    TE Whitesides and MM Heckman; Acute Compartment Syndrome: Update on Diagnosis and Treatment; J. Am. Acad. Ortho. Surg., Jul 1996; 4: 209 - 218.


    N Hyder; S. Kessler; A.G. Jennings; P.G. De Boer. Compartment Syndrome in Tibial Shaft Fracture Missed Because of a Local Nerve Block. JBJS -(Br) 1996: (78) 3 Pg 499-500

    Southern Illinois Residents guidebook

    Created by: Lee Van Rensburg
    Last updated 11/09/15