compartment syndrome crush injuries

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



• 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



• 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



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


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



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



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



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




• Current Methods– StrykerStryker– Arterial Line Manometer– Whiteside Apparatus

• Experimental– Near Infrared

spectroscopy


• 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.



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



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



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



• 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



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


>K+>BUN/ SCR

Elevated CK

pH <7.35

Urinalysis:Multiple RBCs


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



• 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



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



• 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



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



• 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



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