compartment syndrome crush injuries
TRANSCRIPT
Foot Compartment Syndrome/ Crush Injuries
Ronald Belczyk, DPM
Fellowship Director: Thomas Zgonis, DPM
Foot Compartment Syndrome• A surgical emergency• Definition:
– Persistent rise in the pressure within a confined fibro osseous compartment that leads to partial or complete infarction and fibrosis of the vital structures of that compartment
• CS reported in forearm, hand, thigh, leg, foot abdomenfoot, abdomen……
• Acute vs. Chronic• Delay in diagnosis is the most important
determinant of poor outcome
4th Annual International External Fixation Symposium
December 11-14, 2008
4 groups: Medial, Lateral, Central, Interossei
1 Adductor•Adductor hallucis
1 Medial•Abductor hallucis
4 Interosseus•Interossei
1 Superficial•Flexor dig. brevis
1 Calcaneal•Quadratus plantae
•Flexor hallucis Brevis1 Lateral
•Abductor digit minimi
•Flexor DM
Calcaneal Compartment
• Always measureAlways measure • Subject to the highest pressures• Calcaneal compartment
communicates with deep compartment of leg
• Contains the lateral plantar l b dlneurovascular bundle
• Long term sequela hammertoes
4th Annual International External Fixation Symposium
December 11-14, 2008
• Increased compartmental contents
Bleeding:
Potential Etiologies• Decreased
compartmental size– Bleeding:
• Major vascular injury, Bleeding disorder, Anticoagulation therapy
– Increased capillary permeability:
• Trauma, Postischemic swelling or reperfusion injury, Burns, Infection, Intra-arterial drugs, Orthopedic surgery, Exercise, Seizures and eclampsia, Snake bite
I d ill
p• Closure of fascial
defects, Tight dressings, Localized external pressure
– Increased capillary pressure• Exercise, Venous obstruction,
Long leg brace and postoperative dressings, Muscular hypertrophy, Infiltrated infusion, Nephrotic syndrome
• Young muscular menAlt d t l t t
“At Risk Patient”
• Altered mental status• Severe local trauma• High energy injury • Severe swelling• Fracture hematoma• Tense tissue bulging• Tense tissue bulging
4th Annual International External Fixation Symposium
December 11-14, 2008
• Foot fractures– Calcaneus (10%)
Associated Injuries
Calcaneus (10%)– Lisfranc Metatarsal fractures
• 41% of crush injuries• Other fractures:
– Lumbar spine– Tibial fracture (pilon, plateau)– Ankle/ Foot fracture– Acetabular fracture
Prolonged limb compression
Direct muscle damage
Muscle Ischemia
Edema
Rising Compartment Pressure
Compartment Tamponade
Muscle Ischemia
Neural Injury
Compartment Syndrome
Volkman’s Contractures
Muscle Infarction
Myoglobinemia Third Space Fluid Loss
Acidosis/ Hyperkalemia
Renal Failure Shock Cardiac Arrhythmia
Crush Syndrome
4th Annual International External Fixation Symposium
December 11-14, 2008
Simulation 1Assessment
Chief Complaint
Check Responsiveness
Chief Complaint
S/P fall 15 feet Pain out of proportionNot relieved by immoblizationRequiring increased narcoticsP th i
Check Circulation
Check Airway/ Breathing
Lower extremity exam
12 Lead EKG
Check Vital Signs
Check Lung Sounds
L b
Paresthesias
Vital Signs
SBP stable
Labs
K+ 3 5 Labs
Radiology
Compartment Pressures
K+ 3.5BUN/ SCRnormal
Compartment Pressures
Calcaneus129 mmHG
Clinical Assessment
• Patient History– Pain
• Severe Unrelieved by analgesiaSevere, Unrelieved by analgesia, Persistent, Progressive, Worsens with passive stretch, Unrelieved by immobilization
• Physical Exam– Hypotension, Pallor, Limb feels tense,
compartments noncompressible, Pain on passive stretch, Reduced sensation, muscle weakness, Absent pulses, Elevated compartment pressures
4th Annual International External Fixation Symposium
December 11-14, 2008
Clinical Assessment• Clinical Suspicion is the main indicator
– Pulses are NOT a useful sign-peripheral vascularity does NOT correlate with compartment status
– Pallor & Paralysis are late findings• Imaging not useful in making
diagnosis of acute compartment syndrome
• ICP can confirm diagnosis• Damage varies with differential and
time
Initial management• Remove all constrictive dressings/ cast
M it t i BP• Monitor systemic BP• Analgesia• Keep extremity at level of heart• Monitor compartment pressure• Intermittent compression for swelling not
recommendedrecommended
4th Annual International External Fixation Symposium
December 11-14, 2008
Pressure Measurements
• Not necessary if clinical situation is ob io s Patient Pressureobvious
• Useful applications– Clinical situation is
uncertain– Baseline value– Comatose patients
Normal Resting
<8 mm Hg
After exercise 19 mm HgNormotensive 30 mm HgHypotensive < 20-30 mm
Hg of diastolic p– Following
revascularization of a limb
– Patients with open/ closed fractures
pressure
Why 30 mm HG?The fluid movement due to filtration across the wall of a capillary is dependent on the balance of hydrostatic pressure gradient and the oncotic pressure gradient across the capillary
The critical value•When fluid pressure exceeds 30 mm Hg the capillary pressure is not sufficient to maintain muscle- capillary blood flow
4th Annual International External Fixation Symposium
December 11-14, 2008
Why not 30 mm HG?
• There is variation amongst Sogpatients in tolerance to increased tissue pressure
• Critical value should reflect tissue pressure
Example 1 • ICP 30• Diastolic BP 100
D lt P i 70
So….•Lower threshold for fasciotomy in patients with hypotensive.•Higher threshold for fasciotomy in patients with hypertension.
• Delta P is 70• No fasciotomy indicatedExample 2• ICP 30• Diastolic BP of 40 • Delta P is 10• Fasciotomy indicated
Degree of Ischemia is Time DependentDamage TimeSensory changes 1/2 hourMuscle 2-4 hoursdysfunctionIrreversible neuromuscular damage
5-6 hours
90 % of muscle fibers show damage after 8 hours of ischemia
Myoglobinuria late
4th Annual International External Fixation Symposium
December 11-14, 2008
Pressure Measurements
• Current Methods– StrykerStryker– Arterial Line Manometer– Whiteside Apparatus
• Experimental– Near Infrared
spectroscopy
Pressure Measurements
• Transducer tips
•Side-port needles and slit catheters are more accurate than straight needles are.•The arterial line manometer is the most accurate device. The Stryker device is also very accurate. •The Whitesides manometer apparatuslacks the precision needed for clinical use.
4th Annual International External Fixation Symposium
December 11-14, 2008
Pressure Measurements• Measuring compartment pressure
– Proper positioning and instrument calibration
– Insert needle or catheter into compartment and take readingcompartment and take reading
– Minimum saline injection– Take measurements from
different sites in the compartment
– Measurements depend on technique and may vary between operators
– Look at the trend if single measurements equivocal
– Can compare with contralateral punaffected limb in unsure
– Multiple sticks necessary to measure the remaining compartments
– Repeat measurements every 1 to 2 hours
– All involved compartments of foot/ leg should be checked
Guidelines for fasciotomyFasciotomies are recognized as proper treatment for impending ischemia and to prevent irreversible damage
•If: • 30 mmHg for 8 hours or unknown period
• 20 mmHg below diastolic pressure
Cli i l i i l• Clinical suspicion plus pressure of 30 mmHg
4th Annual International External Fixation Symposium
December 11-14, 2008
Fasciotomy
• Avoid use of tourniquetsAvoid use of tourniquets• Subcutaneous fasciotomy is inadequate• Muscle debridement is kept to a minimum• Avoid tight bandaging- post ischemic rebound• Close monitoring of wounds• Fracture stability• Monitoring of cardiac arrhythmias myoglobinuria• Monitoring of cardiac arrhythmias, myoglobinuria, sepsis• Sympathetic blocks are not useful in prolonging fasciotomy
Fasciotomy
• Various Approaches– Dorsal– Dorsal– Medial– Plantar– Evacuation of hematoma with large bore needle and serial recordings–Limited incisions
•Disadvantage:–Skin a constrictive envelop– can’t assess muscle viability
4th Annual International External Fixation Symposium
December 11-14, 2008
Fasciotomy• Two dorsal incisions
– Release: Interossei and Adductor compartment
Plantar interosseus fascia
– Plantar compartments blindly approached– Used as an adjunct to medial incision or isolated forefoot CS– Useful for ORIF of fractures of the forefoot and midfoot
Intermuscular septum
• Medial incision– Release: Medial compartment (Superficial, Calcaneal, Lateral)
Medial extension of plantar aponeurosis
Post-fasciotomy
• Stabilize skeletal injuries of the forefoot and midfoot• Do not definitively• Do not definitively stabilize calcaneus fractures at this time if ORIF• Leave wounds open• HBO• Delayed primary closureDelayed primary closure• Skin grafts• Vacuum assisted closure
4th Annual International External Fixation Symposium
December 11-14, 2008
• Delayed DiagnosisE i d Pl t t t
Long Term Sequela
• Salvage– Equinus and Plantar contracture – Pes Cavus– Claw toe deformities– Nerve paresthesia– End result is a painful dysfunctional
extremity characterized by sensory disturbances, stiffness, forefoot contractures, and clawing of the toes
– Few options for poor results–Nonoperative options:
•Shoe modifications, Neurontin
–Operative options•1. Excision of scarred muscle•2. Soft tissue procedures•3. Bony procedures•4. Hammer toe correction•5. Tarsal tunnel•6. Amputation
Prolonged limb compression
Direct muscle damage
Muscle Ischemia
Edema
Rising Compartment Pressure
Compartment Tamponade
Muscle Ischemia
Neural Injury
Compartment Syndrome
Volkman’s Contractures
Muscle Infarction
Myoglobinemia Third Space Fluid Loss
Acidosis/ Hyperkalemia
Renal Failure Shock Cardiac Arrhythmia
Crush Syndrome
4th Annual International External Fixation Symposium
December 11-14, 2008
Simulation 2Assessment
Chief Complaint
Check Responsiveness
Chief Complaint
S/P crush injury from train. Pain out of proportionNot relieved by immoblizationRequiring increased narcoticsParesthesias
Check Circulation
Check Airway/ Breathing
Lower extremity exam
Radiology
Check Vital Signs
Check Lung Sounds
Vital Signs
SBP < 90
Labs
Labs
EKG
Compartment Pressures
>K+>BUN/ SCR
Elevated CK
pH <7.35
Urinalysis:Multiple RBCs
Compartment Pressures
Calcaneus129 mmHG
EKG
Elevated T waves
Crush Injuries• Direct Trauma• Fractures are usually comminuted or transverse
fracture extensive soft tissue damagefracture, extensive soft tissue damage• Zone of injury
– Inflammatory response of the soft tissue of the traumatized lower limb that extends beyond the gross wound & results in perivascular changes, such as increased friability & perivascular scar tissue, in the blood vessels
– Classifications• Tscherne and Gustillo-Anderson
4th Annual International External Fixation Symposium
December 11-14, 2008
• Initial Assessment
Management of Crush Syndrome
• Physical exam– ABC’s– Distal vascular and neurologic function– Distal and proximal joints– Skin
Associated injuries– Associated injuries• Labs• Radiographs/ Advanced imaging modalities• Compartment pressures
Tscherne classification• Grade 0: minimal soft tissue
injury, indirect injuryinjury, indirect injury• Grade 1: Injury from within,
superficial contusion or abrasion
• Grade 2: Direct injury, more direct soft tissue injury with muscle contusion and skin abrasion
• Grade 3: Severe injury to soft tissue, degloving of subcutaneous tissue and muscle, can include a compartment syndrome or vascular injury
4th Annual International External Fixation Symposium
December 11-14, 2008
Gustillo - Anderson Classification
• Type 1: Clean wound < 1cm • A: adequate• Type 1: Clean wound. < 1cm. Little soft tissue damage with no crushing component. Minimal comminution
• Type 2: > 1cm. Moderate contamination. Minimal Comminution
• A: adequate soft tissue coverage
• B: plastics consult
• C: vascular lt• Type 3: > 5cm with extensive soft
tissue damage. Associated with crush and severe comminution. Marked contamination.
consult Increased Amputation rate
Management of Crush Syndrome
• MultidisciplinaryMultidisciplinary approach– Medical
management• Renal failure• Shock• CardiacCardiac
arrythmias
4th Annual International External Fixation Symposium
December 11-14, 2008
• ABC’s
Overall plan- Crush Syndrome
• Consider amputation• Serial Debridements• Antibiotic usage/ tetanus prophylaxis• Soft tissue coverage• Fracture fixation
S d R t ti• Secondary Reconstructive procedures
Recommendations for Tetanus Prophylaxis
Clean, Minor Wound Other Wounds
History of Tetanus toxoid administration
Tetanus Toxoid vaccine
Immunoglobulin Tetanus Toxoid vaccine
Immunoglobulin
Unknown or less than 3 doses
Yes No Yes Yes
More than 3 doses
No, unless > 10 years since last
No No, unless > 5 years since last
Nodoses years since last
doseyears since last dose
4th Annual International External Fixation Symposium
December 11-14, 2008
Common Organisms Found Following Trauma
O f t• Open fractures– S. aureus– S. epidermidis– P. aeruginosa– Streptococcus– Enterobacteriaceae– B. fragilis– Miscellaneous anaerobes
Antibiotics for Open Fractures
T 1 I f ti t i il ith ith t• Type 1: Infection rate similar with or without abx
• Type 2 & 3: Recommended– Should be effective against S. aureus– Duration of treatment controversial– Gram negative coverage for Type 3Gram negative coverage for Type 3– Centers with high incidence of MRSA
substitute Vancomycin• Agricultural injury- coverage of Clostridia
4th Annual International External Fixation Symposium
December 11-14, 2008
• High index of suspicion for CS
SummaryHigh index of suspicion for CS
• ABC’s• Recognize other associated injuries• Pressure measurements are helpful in making
diagnosis• Crush syndrome has systemic comorbidity and
requires multidisciplinary management
Which is a late finding of Compartment Syndrome?
1. Pain out of proportion to injury2. Requiring increased narcotics3. Paresthesias4. Tense, non-compressible compartment5 P i i t t h5. Pain on passive stretch6. Hammertoes
4th Annual International External Fixation Symposium
December 11-14, 2008