Trauma and Critical Care—Extremity
Compartment Syndrome
Concept
Elevated pressure in a closed compartment that leads to ischemia damage to muscle and nerve that may lead to limb loss and myoglobinuria with resulting renal failure.
Most commonly in the extremities as the result of crush injuries, vascular injuries, reperfusion after prolonged ischemia, compression by cast, or burns. Key is high index of suspicion.
Way Question May Be Asked?
“You have just finished repairing a GSW to the femoral artery and vein and you notice that it took you about 6 h to perform. The nurse wants to know if there is anything else you would like to do.” Rarely would the question be so leading, but remember in any case of vascular trauma, orthopedic trauma, or vascular repair. Also, consider in patients with deep burns to the extremity.
How to Answer?
History
Mechanism of injury
Pain out of proportion to injury Pain distal from site of injury Tingling/numbness in extremity
Physical Exam
Tense, swollen extremity
Pain with passive range of motion Sensory deficit
Absence of pulses is late finding In leg, examine:
(1) Sensation in first web space (deep peroneal nerve. = anterior compartment)
(2) Sensation of dorsum of foot (superficial peroneal nerve = lateral compartment) (3) Sensation of plantar surface (tibial nerve =
deep posterior compartment)
(4) Pain with passive dorsiflexion and plantar flexion of great toe
Diagnostic Tests
Measuring compartment pressures
(1) Use specific device such as Stic catheter (2) Attach 16 g needle to A-line setup with three
way stop cock and sterile saline, zero monitor and inject 1cc into compartment
Should measure all compartments at risk
Repeat exam at intervals if suspicions remains high especially during resuscitation
Surgical Treatment
Decompression for:
Strong clinical suspicion
Compartment pressure > 40 mmHg
Compartment pressure within 30 mmHg of dias- tolic BP
Bivalve any cast OR for fasciotomy:
In leg:
Two incisions
First incision from knee to ankle and centered between anterior and lateral compartments Divide fascia 1 cm above and below intermuscular
septum to free anterior and lateral compart- ments respectively
Careful to avoid superficial peroneal nerve in lateral compartment
Second incision also from knee to ankle and is 2 cm posterior to posteromedial border of tibia
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Avoid saphenous vein
Divide fascia overlying gastrocnemius and soleus muscles (medial compartment)
Detach soleus from posterior tibia to reach fascia of deep compartment and incise
Apply loose dressings
Keep extremity at heart level (don’t raise!)
Return to OR q36 h to debride necrotic tissue/dressing changes
Keep pt well hydrated to avoid renal failure STSG if can’t close after 7 days
Common Curveballs
Pt will have altered sensorium/be intubated and you won’t be able to obtain H+P
Compartment pressure will be 30 mmHg
Compartment pressure will change on repeated record- ings
Asked to describe how to perform fasciotomy
Pt will have necrotic muscle after fasciotomy and asked if you debride (no, wait and return to OR, necrotic tissue may improve)
Pt will develop myoglobinuria and renal failure
Strikeouts
Not correctly diagnosing compartment syndrome Only performing escharotomies when fasciotomy indi-
cated
Not being able to describe fasciotomy
Waiting until extremity is pulseless before performing fasciotomy
Trying to describe one incision quadruple fasciotomy for the leg
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