Compartment Syndromes







Additional videos related to the subject of this chapter are available from the Medizinische Hochschule Hannover collection. The following videos are included with this chapter and may be viewed at expertconsult.inkling.com :



  • 16-1.

    Intracompartmental pressure measurements.


  • 16-2.

    Stryker Stic device assembly.


  • 16-3.

    Pressure measurement with Stryker.


  • 16-4.

    Compartment syndrome: diagnosis and operative therapy.




Introduction


Acute compartment syndrome (ACS) can be a devastating injury if diagnosis and treatment are delayed or missed. Physicians evaluating patients with acute, long bone fractures, especially of the tibia, should keep ACS in the forefront of their mind when examining the traumatized patient. While the ability to define ACS has become clearer, still much controversy and confusion remains regarding when ACS exists and when intervention is required. As with many conditions associated with severe loss of function, ACS is a highly litigious topic. Because fasciotomies are not benign procedures, both failing to treat ACS and unnecessary treatment when ACS is not present can lead to significant dysfunction. The goal of this chapter is to provide a review of the pathophysiology of ACS, its diagnosis, and the methods for performing fasciotomy to various areas of the limbs.


In addition, we will provide lessons learned and a military perspective on ACS, which is a disease process that has been defined in war. Due to the sheer volume (density of exposure) of injuries, as well as the severity of injury associated with the recent conflicts throughout the world, much has been learned about the diagnosis, treatment, management, and mismanagement of ACS, but unfortunately much remains to be learned about this condition. This chapter will discuss lessons learned on the management of ACS in both the civilian and military setting, and highlight areas requiring further research and understanding.




History


In 1881, Richard von Volkmann published an article in which he attempted to relate the state of irreversible contractures of flexor muscles of the hand to an ischemic process occurring in the forearm. In 1906, Hildebrand first used the term Volkmann’s ischemic contracture to describe the end point of an untreated compartment syndrome and suggested that elevated tissue pressure may be causally related to the ischemic contracture. In 1914, Murphy was the first to suggest that fasciotomy, if done before the development of the contracture, may prevent the contracture from occurring. After almost 100 years of investigation, advancements have been made in the field of ACS, but still the ability to definitively and objectively diagnose and treat ACS has remained a challenge.


During and after World War II (WW II), high-velocity gunshot wounds and their concomitant soft tissue injuries were identified as causes for residual muscle contractures of both the upper and lower extremities ( Fig. 16-1 ). Although the existence of arterial trauma complicating a fracture was well known, the concomitant need for fasciotomy at the time of arterial repair was not generally appreciated. During the Korean War, the advancements in vascular surgery allowed for the better restoration of blood flow to ischemic limbs, but the insight into reperfusion injuries was limited. Similar observations were made in 1967 during the Vietnam War by Chandler and Knapp, who also suggested that had more fasciotomies been performed after arterial repair to the extremities, the long-term results might have been better.




Figure 16-1


This radiograph shows a comminuted proximal tibia fracture resulting from a gunshot wound. This type of high-energy injury has a high risk of developing acute compartment syndrome (ACS).

(Courtesy of Dr. Michael S. Shuler.)


In 1958, Ellis brought attention to the existence of ACS in the lower extremity by describing a 2% incidence of ACS associated with tibial fractures. In 1966 and 1967, two different reports described the existence of four separate compartments within the lower leg and the need for addressing each injured compartment. After helping describe the compartments of the lower leg, Whitesides and colleagues went on to postulate a perfusion model for ACS as well as guidelines for decompression, which have been the basis for our understanding of ACS for nearly four decades.




Pathophysiology


Compartment syndrome is a condition that involves increased pressure within a confined tissue space, resulting in ischemia. This increased pressure can come through adding volume to the compartment or by decreasing the volume through external forces. There are many causes of compartment syndrome, yet ultimately, all lead to the increased pressure within a closed compartment resulting in ischemia. The excess tissue pressure within the compartment leads to venous obstruction. If the pressure is left untreated, prolonged muscle and nerve ischemia will lead to irreversible damage to the compartment components.


Any condition increasing the content or reducing the volume of a compartment could lead to compartment syndrome, but the most prevalent cause of compartment syndrome is trauma associated with a fracture. In the cases of fracture, energy from the trauma is dissipated into the bone and muscle, inducing intracellular swelling at the site of the trauma. The fracture site is also susceptible to hematoma after the injury, further amplifying the problem by increasing the volume and therefore pressure of the compartment. High-energy tibial fractures are the most common type of injury associated with compartment syndrome, and more specifically, bicondylar plateau fractures and segmental or comminuted tibial shaft fractures ( Figs. 16-2 and 16-3 ). ACS has been reported to complicate tibia fractures in as few as 1% to 9% of all cases and as high as 24% of polytrauma patients. However, it is important to consider that compartment syndrome can also develop secondary to arterial injury, occlusions, reperfusion injury, crush injuries, prolonged malposition, burns, electrocutions, snake venom, stressful athletic activity, contusions, and infiltrations from intravenous (IV) sites. There is also the potential for a compartment syndrome to arise from postresuscitation systemic inflammatory response syndrome after massive blood and fluid resuscitation.




Figure 16-2


This radiograph shows a comminuted bicondylar plateau fracture. This type of high-energy injury has a high risk of developing acute compartment syndrome (ACS).

(Courtesy of Dr. Michael S. Shuler.)



Figure 16-3


This radiograph shows a segmental tibial shaft and fibula fracture. This type of high-energy injury has a high risk of developing acute compartment syndrome (ACS).

(Courtesy of Dr. Michael S. Shuler.)


Compartment syndrome may result as a complication of an arterial injury ( Fig. 16-4 ). When it occurs, it is often observed after restoration of arterial inflow to the compartment termed reperfusion injury . Prior to the restoration of arterial inflow, there is a period of nerve and muscle ischemia. During hypoxia, transudation of fluid through the capillary basement membranes and the capillaries of striated muscle can occur. Once arterial inflow has been reestablished, the fluid continues to leak through the basement membrane into the interstitial space, subsequently raising the pressure because of increased content within the compartment.




Figure 16-4


An arteriogram showing arterial disruption at the site of a fractured femur.

(From Seligson D, editor: Concepts in intramedullary nailing, Orlando, FL, 1985, Grune & Stratton, p 111.)


The pathophysiology of compartment syndrome was poorly understood during the Korean War, and misdiagnosis would often lead to poor outcomes. At the time, the five or six “P’s” (pain, pallor, pulselessness, paralysis, paresthesia, and poikilothermia) were most commonly used to identify compartment syndrome. However, in most cases, all of the “P’s” except pain are signs and symptoms associated with severe ischemia and occur too late in the process to serve as the trigger for optimal intervention and recovery. A series of tourniquet studies by Whitesides in 1971 improved our understanding of the condition. By using a long cuff tourniquet and radioactive xenon imaging, the study evaluated blood reabsorption at different pressures. When the cuff pressure was at or above diastolic pressure, there was no reabsorption of xenon in the calf. However, once the cuff pressure was lowered below the diastolic pressure, xenon reabsorption was recovered. This study established the relevance of perfusion pressure (i.e., perfusion pressure = diastolic blood pressure − intracompartmental pressure) when considering compartment syndrome.


There has been significant controversy over the pressure threshold for the diagnosis of ACS. Two theories have been proposed. One is based on an absolute value of 30 mm Hg for intracompartmental pressure, and the other theory is based on a differential value of pressure also termed perfusion pressure or ΔP. As the body of evidence has grown, the theory of perfusion pressure has been borne out to be the more reliable and diagnostically accurate threshold for determining ACS.


Initially proposed by Whitesides and colleagues, the perfusion pressure theory was based on the fact that decreased blood flow occurs as intracompartmental pressures near the diastolic blood pressure. Dahn showed that flow measured with xenon clearance stops as a cuff pressure reaches diastolic pressure. Clayton and colleagues showed similar findings in a rabbit model using xenon washout.


McQueen and Court-Brown reported on 116 diaphyseal tibia fractures with prospective continual monitoring of the anterior compartment. Within the first 12 hours, 53 patients had absolute intracompartmental pressures higher than 30 mm Hg, 30 patients had pressures higher than 40 mm Hg, and 4 patients had pressures higher than 50 mm Hg. However, only one patient had a perfusion pressure less than 30 mm Hg, and he underwent fasciotomy without complication. Similar elevated absolute pressures were observed over the following 12 hours out to 24 hours after injury with only two patients requiring fasciotomy for perfusion pressures less than 30 mm Hg. No sequelae associated with missed ACS were reported. Previously, this group had shown that continual anterior compartment pressure monitoring leads to earlier diagnosis of ACS (diagnosed on average 16 hours from injury) and substantially less (none in their series), long-term sequelae of ACS compared to a group of patients who were not monitored and who were diagnosed much later (average, 32 hours from injury). These long-term sequelae include weakness, stiffness and contracture, as well as negative effects on bone healing (delayed and increased risk of nonunion). Based on this work, McQueen and Court-Brown recommended a perfusion pressure of less than 30 mm Hg as the threshold for diagnosing ACS in the leg.


White and colleagues compared two groups with continual pressure monitoring. The control group consisted of 60 tibia fractures with absolute intracompartmental pressures that remained below 30 mm Hg. The study group consisted of tibial fractures with pressures greater than 30 mm Hg for at least 6 hours. No fasciotomies were performed, and there were no differences at final follow-up between groups with regard to recovery and strength. The work of these different groups provided a clinical evidence base for the superiority of perfusion pressures over absolute pressures in assessing for ACS; yet, absolute pressure thresholds remain commonly applied and commonly described in texts and articles.


Accepting perfusion pressure as the optimal means for applying information obtained from intracompartmental pressure monitoring, subsequent clinical and basic science research has been aimed at defining the most diagnostically accurate perfusion pressure threshold. Prayson and colleagues continually monitored 19 alert patients with tibial fractures. All remained asymptomatic for ACS and showed no signs of missed ACS. Of patients, 95% had pressures of higher than 30 mm Hg; 84% had pressures that were within 30 mm Hg from diastolic pressure; and 58% had intracompartmental pressures within 20 mm Hg of diastolic. Prayson’s clinical study is consistent with animal studies that suggest the threshold for ischemia and irreversible muscle damage occurs between perfusion pressures of 10 and 20 mm Hg based on diastolic blood pressure. Despite these findings, 30 mm Hg has remained the most commonly recommended perfusion pressure threshold. This more conservative threshold increases sensitivity (i.e., maximizes chance of finding all true positives) in an attempt to ensure that a fasciotomy will be performed prior to permanent muscle and tissue damage. Because pressure measurements are typically performed as a single measurement, the goal in setting the 30 mm Hg threshold was to allow for enough time to perform an appropriate fasciotomy after a critical perfusion pressure has been recorded.


The culmination of ACS research to date was a validation that perfusion pressure is the best means for using intracompartmental pressure data in the diagnosis of ACS. While perfusion pressure seemed to have been a leap forward in our understanding of how best to objectively diagnose ACS, we still have more to learn. The ambiguity in clinical and basic science research findings highlights the fact that pressure monitoring is ultimately an indirect measure or surrogate of the physiologic parameter that is at the source of ACS—perfusion.


At this point, based on the current evidence, the utility of an absolute threshold of 30 mm Hg can be considered historical. While the exact effects of moderately elevated intracompartmental pressures on muscle tissue are unknown, it seems evident that this condition does not result in significant permanent dysfunction consistent with ACS. The necessity of interpreting the intracompartmental pressure in the setting of the patient’s blood pressure is vital. Understanding that blood flow is significantly decreased between 20 and 10 mm Hg perfusion will assist the surgeon in managing a potentially catastrophic disorder. By using the perfusion method in conjunction with available clinical examination, the clinician can attempt to minimize unnecessary fasciotomies while preventing missed compartment syndromes.




Diagnosis: Clinical Assessment


The clinical diagnosis of ACS is not always obvious. Typically, the patient is polytraumatized, and ascertaining which injury is causing pain can be difficult. In many cases, the patient may be obtunded or sedated. Because of these conditions, frequent delays in ACS diagnosis can occur. The subjective nature of this decision process was highlighted by O’Toole and colleagues, who examined the rate of ACS diagnosis associated with tibia fractures at a single, level I trauma center. The rate of ACS, as well as use of intracompartmental pressure measurements, varied based on the surgeon. The attending surgeons were all fellowship-trained faculty at an orthopaedic trauma fellowship program, yet the rate of ACS diagnosis in essentially the same patient population, with the same injury, varied from 2% to 24% between surgeons.


The first feature of the clinical assessment is serial examination. ACS does not occur instantaneously and pressures can increase for up to 48 hours after injury or surgical procedure. Identifying a change in clinical findings over time can be key to the accurate and timely diagnosis of ACS. Outcomes are directly correlated to the prompt diagnosis and treatment of ACS. If treatment is not instituted within 12 hours of symptoms, the clinical outcomes are substantially reduced.


Clinical signs of an impending ACS include pain on palpation of the swollen, tense compartment and reproduction of pain with passive muscle stretch ( Fig. 16-5 ). Later findings include sensory deficit in the territory of the nerves traversing the compartment and muscle weakness ( Fig. 16-6 ). Pallor, pulselessness, paralysis, and poikilothermia (decreased temperature) are all late-stage signs that may or may not be present. If present, these symptoms indicate complete ischemia and should be considered a sign of poor prognosis.




Figure 16-5


Image of a swollen leg with fracture blisters showing signs concerning for acute compartment syndrome (ACS).



Figure 16-6


This image demonstrates how to test light-touch sensation in the first web space innervated by the deep peroneal nerve.


ACS is typically encountered within the first 36 to 72 hours after a traumatic injury. Peak pressures were measured between 24 and 48 hours after injury and initial pressure measurements did not correlate with maximum pressures. ACS is 10 times more common in men than women and has a propensity for younger subjects, with the average age being 30 years in men and 44 years in women. High-energy injuries of the tibia followed by those of the forearm are the fractures most commonly associated with ACS. Bleeding disorders or anticoagulation are also risk factors for ACS.


ACS should be considered in any traumatized patient. While clinical findings are considered the gold standard, these signs cannot always be relied on. Sensitivity (13% to 19%) and positive predictive value (11% to 15%) are quite low in the traumatized patient while specificity (97%) and negative predictive values (98%) are much better. In other words, if the patient has all the clinical signs, you can be fairly certain they have ACS, but the absence of signs does not necessarily imply absence of ACS. Additionally, in many instances, the patient may be obtunded or sedated leaving minimal information to gain from the clinical examination.


The earliest clinical signs associated with ACS are typically a tense compartment or extremity with increasing pain at rest and with passive stretch ( Fig. 16-7 ). The term “pain out of proportion” is commonly used to describe symptoms associated with ACS; however, in advanced ACS, this symptom may be absent. Additionally, it can be difficult to assess what is “out of proportion” for any single individual. A more worrisome pain finding is progressive pain, especially when it is not well controlled by pain medications. Pulses and capillary refill are not reliable signs. They should be examined but not used to determine the existence of an ACS. Shunting can occur through vessels outside of the affected compartment(s) allowing for distal pulses and capillary refill. Further, alteration in pulse, or in the extreme case, pulselessness, is an end-stage sign of ACS, and its presence may indicate a delayed diagnosis.




Figure 16-7


Passive stretch testing can cause pain within the associated compartment when there is decreased blood flow or ischemia.


Any evaluation of an injured extremity, especially penetrating injuries, should include an assessment of the vascular status. Arterial injuries can be confused with or associated with ACS. Johansen and colleagues demonstrated the value of measuring the Doppler-assessed ankle-brachial index (ABI) (the systolic arterial pressure in the injured extremity divided by the arterial pressure in the uninvolved arm). A value less than 0.90 necessitates further arterial investigation; 94% of patients with an index this low have positive arteriographic findings. No major arterial injuries were missed using these criteria (see Fig. 16-4 ).


The presence of an open wound associated with the fracture should not eliminate the possibility of ACS. Between 6% and 9% of open tibial fractures are complicated by compartment syndrome, with the incidence being directly proportional to the severity of the soft tissue injury ( Fig. 16-8 ). Special consideration should be given to patients after fracture stabilization. In most cases, initial fracture stabilization aims to restore alignment for definitive management or for temporary management with permanent stabilization once the soft tissues are ready. It is common for ACS to develop after alignment has been restored in fractured extremities ( Fig. 16-9 ). Intramedullary compartment pressures have been shown to increase with manipulation during intramedullary nailing of a tibia. While this study showed a rapid return to lower levels of pressure, a reduction of overlapping bones will typically elongate the compartment. With elongation (i.e., distraction), a potential decrease in compartment volume can occur placing a limb at risk for ACS.




Figure 16-8


This image demonstrates an open left tibia fracture as well as an open right femur fracture. Despite the fracture being open, there is still a high risk for acute compartment syndrome (ACS).

(Courtesy of Dr. Michael S. Shuler.)



Figure 16-9


This image demonstrates a severely comminuted both-bone forearm fracture. Both-bone forearm fractures and distal radius fractures are the second most common cause of acute compartment syndrome (ACS). Care should be taken postoperatively if increasing pain occurs. Blocks should not be used postoperatively.

(Courtesy of Dr. Michael S. Shuler.)


Postoperative increases in pain medicine should be monitored, and patients, as well as floor staff, should be warned to monitor the injured extremity closely. The use of epidural and regional anesthetic techniques, such as pain catheters, in these patients has been a subject of debate, with case reports of delayed ACS diagnosis following each of these techniques, but systematic review of the literature calls into question the putative role of regional anesthetics in the diagnostic delays. Postoperative blocks and pain pumps should be used with caution in patients for whom ACS may be concerning, specifically, upper extremity injuries such as both-bone forearm fractures. The fear is that regional or epidural anesthetics will decrease the patient’s ability to detect increasing pain associated with ACS. That being said, ischemic pain tends to overcome nerve blockade, and the presence of pain (especially breakthrough pain) over a functional pain catheter should be viewed as very worrisome for ACS. Over the last decade of war, the need to transport combat-injured patients great distances by land and ground transport in the initial 72 hours following injury has progressed the use of regional pain catheters in patients with injury patterns that are considered prone to ACS (like tibial shaft fractures) without an observed increase of ACS diagnosis delay related to this pain modality. Last, a thorough postoperative evaluation or multiple evaluations in the obtunded patient should be performed to detect early signs of ACS.




Crush Syndrome


Crush syndrome is a medical term used specifically to describe a type of injury that can ultimately lead to devastating consequences, including death, if not managed appropriately. Crush injury is typically produced by continuous and prolonged pressure and is most prevalent in the setting of mass casualties such as with earthquakes or military conflict. Crush syndrome is the second most common cause of death in these situations, behind direct injury from the catastrophe. Additionally, this syndrome can occur in persons who are trapped in one position for a prolonged period or who have collapsed or fallen asleep in one position for an excessive period when under the influence of alcohol or drugs. Careful consideration should be made based on the timeline of the injury, as well as the resources available, prior to administering any medical treatments.


The first step in managing the patient is to administer intravascular support. Typically, the patient experiences significant systemic hemodynamic complications such as acute renal failure and cardiac arrhythmias or collapse because of the influx of toxins and myoglobin secondary to large muscle damage. If possible, IV catheters should be begun prior to releasing the compressive force, as once the force is released, the damaged muscle will begin to release cellular metabolites into the bloodstream. It is important to remember that although elevated pressures cause muscle damage in ACS, the elevated pressures in crush syndrome are a result of already damaged muscle resulting in leaky vasculature.


Appropriate management will require an understanding of both the timeline of the injury as well as the medical resources available. Surgical treatment in a crush syndrome should mirror that of an ACS with regard to timelines. Surgical release should be performed if the crush period was less than 6 to 12 hours. After 6 hours but before 12 hours of compression, the benefit of surgical release is controversial as significant muscle damage will have already occurred. Surgical release after 12 hours of compression is considered contraindicated, as irreversible muscle death has already occurred and surgical release only exposes necrotic tissue to the outside environment and increases the likelihood of infection. Additionally, if the compression period was less than 6 to 12 hours but elevated pressures have persisted for extended periods (greater than 6 hours), consideration for nonoperative management should be given. When in doubt and if possible, a discussion with the patient or family members regarding the potential need for revision surgery and amputation if significant necrotic muscle is encountered should take place.


In the case of a mass casualty setting, management from a surgical perspective should again center on the timeline, the time of crush and the availability of continued care and medical resources. Typical humanitarian responses can be delayed by several hours to days. In these settings and when resources are limited for continued management such as wound care and surgical closure of fasciotomies, surgical intervention should not be performed. In the setting of a patient found unresponsive, an attempt at determining an accurate timeline is critical to managing the patient. If compression is alleviated within a 6-hour time frame, release of the affected compartments should be performed in an urgent manner assuming the patient is stable to undergo surgical intervention ( Figs. 16-10 and 16-11 ). Releases after 12 hours of ischemia should be avoided because of the increased risk for infection and amputation.




Figure 16-10


This image depicts an upper arm fasciotomy after the patient was found unconscious after intoxication. Fasciotomy was performed early and muscle necrosis was prevented.

(Courtesy of Dr. Bradley Register.)



Figure 16-11


This image depicts an upper arm fasciotomy after the patient was found unconscious after intoxication. Fasciotomy was performed within the intensive care unit (ICU) because of instability secondary to myoglobinuria.

(Courtesy of Dr. Bradley Register.)


The clinical examination can be very similar to ACS in crush syndrome. The patient usually suffers no pain initially and may have no physical complaints. Initially there is flaccid paralysis of the injured limb and a patchy sensory loss. Over the course of hours, swelling rapidly ensues, often far more dramatically than would be seen in compartment syndrome. The swelling is caused by rapid release of fluid because of the failure of intracellular mechanisms that allow cells to retain water. The result is clinical evidence of muscle damage with darkening of the urine related to myoglobinuria and rapid deterioration of renal function. In summary, the viability of the muscle and the ability to provide follow-up wound care and management should guide surgical intervention when managing crush syndrome.




Compartment Syndrome in Combat


While Volkmann (1881) is credited with the initial description of the aftermath of a missed compartment syndrome (the eponym for which is a Volkmann contracture ), ACS has and will always remain a disease of the military surgeon. Since the Napoleonic era, when Desault and others coined the term “débridement,” which described the “unbridling” of the swollen soft tissues under the nonelastic fascia following severe traumatic injury, compartment syndrome and its diagnosis and management have been a constant bane of combat casualty care. Fast-forward 200 years or more to the conflicts in southwest Asia (Iraq and Afghanistan); military surgeons continue to struggle with the ideal method for diagnosing this condition.


Between September 1, 2011, and March 18, 2013, review of the Joint Theater Trauma Registry (JTTR), which is a prospectively maintained trauma registry that collects data from all echelons of care (i.e., from the battlefield support medical facilities to the major medical centers in the United States), reveals that 31% of soldiers with tibia fractures (65 out of 211) were recorded as having undergone fasciotomy. Ritenour and colleagues found that in the lead up to the “surge” in Operation Iraqi Freedom, 336 soldiers in a similar length of time (January 1, 2005, to August 21, 2006) underwent fasciotomy, with 49% being in the leg. This rate of fasciotomy, a surgery whose only indication is the treatment or prophylaxis of compartment syndrome, is substantially higher than that reported in the civilian level I trauma setting. For example, O’Toole and colleagues reported a rate of 2% to 24% for tibial shaft fractures at a single major trauma center in the United States. There are several explanations for this increase in fasciotomy rate in the combat setting. In some cases, the amount of energy imparted by military wounding mechanisms (i.e., improvised explosive devices [IED] blasts) is simply substantially greater than that seen in the civilian setting ( Fig. 16-12 ). Additionally, two primary reasons for the difference in fasciotomy rates between combat and civilian casualties are the concept of a “completion” fasciotomy and the concern for transit times between echelons of care.




Figure 16-12


This image depicts the type of high-energy blast type injuries encountered in the combat setting.


One of the most likely explanations for the divergence is a semantic one. The most common mechanism of injury in today’s combat setting is blast related, most commonly from an IED. These blast injuries produce devastating lower extremity trauma, yielding highly contaminated, grade IIIB/C fractures with large “out-to-in” open wounds ( Fig. 16-13 ). The blast wave spontaneously rips open the fascia in many cases, at least at the injury zone. In the process of wound care, extension of the wound margins provides ready access to remaining intact fascia proximal and distal to the zone of injury. This intact fascia can act as a tourniquet, and because the wound and wounding mechanism has introduced all of the negative aspects of fasciotomy, the benefit of completing the fascial release for the length of the compartment comes with little increased risk ( Fig. 16-14 ). Thus “completion” fasciotomy is one of the more common types of fasciotomies performed over the last decade of combat surgery.




Figure 16-13


This image demonstrates the extent of soft tissue damage that is typically encountered with combat wounds.



Figure 16-14


As with many combat injuries, fasciotomies are performed as a completion of fasciotomy that is partially performed during the injury.


While direct blast injury is the most common mechanism, there are certainly many other injuries, like gunshot wounds ( Fig. 16-15 ), motor vehicle (land and air) accidents, and direct blows. Likewise, IED blasts that hit armored vehicles produce blunt injuries similar to civilian high-speed motor vehicle collisions. These mechanisms of injury produce long bone fractures and soft tissue responses that are similar to the civilian setting; however, these injuries also receive a higher than expected rate of fasciotomy. In this situation, one of the most cited concerns from combat surgeons is the process of aeromedical evacuation, where surgical access to the patient is lost for about 8 hours in the prime window for the development of ACS (i.e., the first 72 hours after injury). In addition, patients are flown at altitude (cabins are typically pressurized to 8000 feet) and access to the patient to complete detailed compartment assessments is diminished. Cognizant of the theoretical potential for aero-evacuation increasing the risk of missed or delayed diagnosis of ACS and based on the results of a study conducted in the U.S. military, the U.S. Army Surgeon General issued an Al l Ar my Act ivities (ALARACT) message in May 2007 directing combat surgeons to apply “liberal use of complete fasciotomy,” especially for those at highest risk. In addition, delay in evacuation of 24 hours should be considered for patients at high risk, to allow continued serial monitoring. The military retrospective study cited in this ALARACT showed that when complete fasciotomy was delayed until reaching Landstuhl Regional Medical Center, in Germany, the rate of amputation doubled (31% vs. 15%) and the rate of mortality quadrupled (19% vs. 5%), as compared to the cohort of patients who were successfully released in theater. The effect of this ALARACT was the routine and frequent use of prophylactic fasciotomy for many tibial fractures.




Figure 16-15


This image demonstrates the types of wounds experienced with penetrating wounds, such as shrapnel and gunshot wounds.


One of the most telling findings of the Ritenour study was that 17% of patients who underwent fasciotomy in theater, had need for revision fasciotomy to most commonly extend the fascial release (63%) or skin incision (14%). In 41% of these patients, an entire compartment was not released at the index procedure, with the anterior (40%) and deep posterior (37%) being the most commonly missed compartments. Thus, the real message was not the lack of diagnosis and fasciotomy performed on soldiers with ACS; instead, the issue was with the adequacy of surgical technique. Missing a compartment, most commonly in the leg (especially the deep posterior) and forearm, is not unique to the combat setting or surgeon, nor is the several-fold increase in amputation rate when this occurs. The results of this study did prompt the development of a combat extremity surgery course in the U.S. Army that uses didactic and cadaver training to reinforce the proper technique for a double-incision fasciotomy of the leg, as well as fasciotomies of the other extremities, for surgeons preparing to deploy to combat medical treatment facilities.


An important lesson from this pivotal study is that simply making the incisions on the leg or other limb does not ensure that a fasciotomy has been successfully performed. This fact is most important in the setting of prophylactic fasciotomy, where the patient who receives an incomplete fascial release is exposed to all of the risk and morbidity of the procedure without the maximal potential benefit. While the improved training and attention to detail that has emerged as a result of Ritenour’s study has benefited combat casualties, the use of this data to reinforce an exaggerated use of fasciotomy, many of which are prophylactic, is a lasting undesirable effect of this study. Conversely, possibly the most beneficial impact of this study is that it has generated substantial commitment of Department of Defense (DoD) research dollars directed toward finally understanding ACS and developing a gold standard for diagnosis that uses reliable, readily attainable objective information to define the presence or absence of this purely physiologic disease.




Measurement Techniques


Reliable and accurate intracompartmental pressures can be difficult to obtain in the hands of an experienced clinician. Practice and attention to detail during measurements can help avoid errors in measurement. Measurements taken when pressure is erroneously elevated may prompt a surgeon to act inappropriately and perform an unnecessary fasciotomy; therefore, it is critical to obtain accurate measurements.


As described by Heckman and colleagues, the measurement should be performed within 5 cm of the fracture site when evaluating fracture patients. Highest pressures were obtained within 5 cm of the fracture and dissipated as pressures were recorded further away from the fracture site. Additionally, deeper values have been shown to be higher than more superficial values.


At the time of measurement, the position of the foot (in the case of leg ACS) should be maintained in a neutral position without extreme dorsiflexion or plantar flexion. Dorsiflexion will increase posterior compartment pressures, whereas plantar flexion will increase the anterior and lateral compartments. The ideal position is between neutral and the resting position or between 0 and 37 degrees of plantar flexion. Additionally, when measuring the posterior compartments, a rolled sheet or towel should be placed under the heel to remove any pressure associated with the weight of the leg pressing down on the bed ( Fig. 16-16 ). The injured extremity should not be elevated to decrease edema, as this maneuver will increase the intracompartmental pressure in, and decrease perfusion to, the extremity.




Figure 16-16


A towel or sheet can be rolled and placed under the heel to reduce the pressure in the posterior compartments when measuring the pressures. Elevation should be avoided, as this increases the pressure and reduces blood flow in the injured extremity.

(Courtesy of Dr. Michael S. Shuler.)


The injured extremity should have all constrictive or circumferential dressing removed. Garfin and colleagues showed in an animal model that removal of a plaster cast resulted in a 60% reduction in intracompartmental pressures. Cutting the cast, spreading the cast, cutting the cast padding, and ultimately, cast removal all resulted in sequential decreases in intracompartmental pressure.


There have been several studies examining the difference between different pressure measurements. The Stryker Stic and arterial lines have been shown to provide reliable and reproducible readings. Straight needles as well as smaller gauge needles have shown a propensity to overestimate the intracompartmental pressure. Wick catheters and side port needles have shown a more reliable reading when compared to an 18-gauge needle. Regardless of instrument used, once the needle is inserted into the limb, a small amount of fluid (roughly 0.1 to 0.2 mL) should be injected through the needle to clear the needle of any soft tissue that may have been trapped in the needle during insertion. If this maneuver is not performed, erroneously high measurements may be obtained.


Needle Manometer


The first direct attempt at measurement of interstitial compartment pressure was by Landerer in 1884. Subsequently, French and Price reported on the usefulness of the technique in diagnosis of chronic compartment syndrome. Whitesides and colleagues first applied the needle manometer technique to the diagnosis of ACS. In their original description, an 18-gauge needle was connected to a 20-mL syringe by a column of saline and air, and this column was then connected to a standard mercury manometer. After the needle was injected into the compartment, the air pressure within the syringe was raised until the saline-air meniscus was seen to move. The pressure was then read off the mercury manometer ( Fig. 16-17 ). Details of the technique have been well described.




Figure 16-17


The needle injection technique measures compartment pressure by looking for movement of the air-saline meniscus. IV, Intravenous.

(Redrawn from Whitesides TE Jr, Haney TC, Morimoto K, Hirada H: Tissue pressure measurements as a determinant for the need of fasciotomy, Clin Orthop Relat Res 113:46, 1975.)


Arterial Line Catheter


A common means of measuring intracompartmental pressures without specialty devices is through the use of an arterial line. An arterial line is attached to any standard critical care or pressure-sensing monitor. The IV tubing is then connected to an IV bag. The tubing is attached to a stopcock valve and a 10-cc syringe full of saline is attached to the stopcock. A 16-gauge needle is attached to the stopcock needle. The system is then primed and zeroed at the level of the extremity ( Fig. 16-18 ). Care must be taken to have the transducer at the level of the injured extremity as well. Once zeroed, the needle is inserted and a small amount of saline is injected through the needle with the stopcock opened to the syringe. The stopcock is then switched to allow free flow between the needle tip and the IV tubing and transducer (Video 16-1).




Figure 16-18


Pressure measurements can be obtained using an arterial line and a 16-gauge needle as depicted in this image (lateral compartment). The pressure transducer should be at the level of the injured extremity and the line should be flushed and zeroed with the needle ready to insert.

(Courtesy of Dr. Michael S. Shuler.)


Stryker Stic Catheter System


The Stryker Stic catheter system manufactured by Stryker is a handheld device that allows the surgeon to measure intracompartmental pressures quickly and simply ( Fig. 16-19 ). The device is easy to use; it can be carried in the pocket and used in the emergency department without having to search for pieces of equipment. It has been shown to be reliable and accurate.




Figure 16-19


The Stryker Stic unit comes in three pieces that are assembled into a single syringe and needle unit.

(Courtesy of Dr. Michael S. Shuler.)


The method of use is relatively simple, which has led to its increase in popularity. The device needs to be adequately “charged” for accurate use. A disposable syringe preloaded with fluid is connected to the measuring instrument, and a disposable needle-catheter that comes as part of the set is then added to the other end (Video 16-2). After the system is purged with some fluid, the monitor is zeroed at the level of the compartment to be tested and the needle is then inserted through the fascia ( Fig. 16-20 ). The numbers on the monitor screen fall reasonably rapidly, and as the descent levels off, a reading of the compartment pressure can be made. The pressure reading on the monitor may continue to drop slowly with time and some individual variation may occur in determining the pressure at which leveling off has occurred (Video 16-3).




Figure 16-20


This image demonstrates the Stryker Stic device being used to measure the lateral compartment of an injured leg.

(Courtesy of Dr. Michael S. Shuler.)


Microporous Catheter


The catheter system designed by Twin Star Medical has been shown to allow for continuous pressure measurements. A catheter is inserted using a needle and sheath to insert the catheter. The sheath is then peeled away to leave the soft microporous catheter to constantly record pressures ( Fig. 16-21 ). The catheter is then attached to the skin to prevent inadvertent removal. This indwelling catheter allows for continual pressure monitoring without the necessity of continual nursing involvement. It also eliminates the risk of increasing pressures through the continual infusion of fluids required in traditional continual pressure monitoring using an IV catheter. Additionally, this technology allows for tissue ultrafiltration through the catheter. By removing some of the fluid from the compartment, tissue ultrafiltration may allow for prevention of ACS by reducing the volume within the compartment.


Jun 11, 2019 | Posted by in ORTHOPEDIC | Comments Off on Compartment Syndromes
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