AAOS Clinical Practice Guideline - Management of Acute Compartment Syndrome
At a Glance
Section titled āAt a Glanceā| Metadata | Details |
|---|---|
| Publication Date | 2020-11-12 |
| Journal | Journal of the American Academy of Orthopaedic Surgeons |
| Authors | Marcus P. Coe, Colonel Patrick M. Osborn, Andrew H. Schmidt |
| Institutions | DartmouthāHitchcock Medical Center, Military Health System |
| Citations | 15 |
Abstract
Section titled āAbstractāAcute compartment syndrome (ACS)āincreased intracompartmental pressure in a closed fascial space resulting in tissue ischemiaācan be encountered after orthopaedic trauma and has serious sequelae if misdiagnosed or mistreated. The diagnosis and treatment of ACS remain a challenge because the patient history and presentation varies, a benchmark for diagnosis is lacking, and the distracting injuries that often accompany ACS can cloud a complex clinical picture. The American Academy of Orthopaedic Surgeons Clinical Practice Guideline (CPG) for the Management of ACS1 attempts to synthesize the best available literature and provide guidance for orthopaedic surgeons and other healthcare providers in the civilian and military sector. The following case presentations are designed to demonstrate how this CPG can be used in a clinical setting to help determine treatment. Case #1 A 32-year-old man is involved in a high-speed motor vehicle accident. He was a restrained driver and was extricated from the vehicle and transferred via ambulance to a tertiary care facility. There he was found to have a painful, deformed right proximal tibia. His vital signs are stable. He is first evaluated by the trauma surgery team, who do not identify other life-threatening injuries. Radiographs reveal a Schatzker VI tibial plateau fracture (Figure 1, A and B). The treating orthopaedic surgeon is asked to evaluate the patient.Figure 1: (A and B): radiographs of the patientās initial injury in case #1.On initial evaluation, the patient is awake, alert, and conversant. He has a history of greater than 2 years of narcotic use for a back injury but has not taken opioids in over 3 months. He rates his pain as 5/10, but shifting position causes him to wince. He received intravenous pain medication in the ambulance and again on his arrival in the hospital. Examination of the right leg reveals a swollen lower leg with intact ankle dorsiflexion, toe dorsiflexion, and ankle plantar flexion. He has a palpable dorsalis pedis and posterior tibial pulse. Sensation is intact in the deep peroneal, superficial peroneal, and tibial nerve distributions. Passive stretch of his great toe causes some pain, but he is able to maintain a conversation while the orthopaedic surgeon performs the maneuver. Given the clinical examination, the orthopaedic surgeon elects to monitor the patient clinically. This is consistent with the recommendation of the ACS CPG that serial clinical examinations can assist in ruling in ACS (limited evidence). Given the unstable nature of the patientās fracture, the orthopaedic surgeon does elect to schedule the patient for urgent external fixation of his fracture with a knee-spanning construct. The orthopaedic surgeon is told that it will be a few hours before the operating room is ready because the driver of the other vehicle involved in this collision is undergoing an emergent exploratory laparotomy. The orthopaedic surgeon places the patient in a knee immobilizer and attends to other patients with plans to reevaluate the patient. Two hours later, the orthopaedic surgeon returns to see the patient. The patient is visibly uncomfortable, shifting in bed, and rating his pain as 9/10. Palpation of his lower leg compartments reveals no notable change in skin tension or fullness, but the patient has more discomfort with ankle dorsiflexion and plantar flexion. He still endorses full sensation to light touch in his foot but says it feels āweird.ā The orthopaedic surgeon checks the chart and sees that over the last 2 hours, the patient has received three doses of intravenous pain medications. The orthopaedic surgeon is now concerned for compartment syndrome, but given the patientās history, he elects to check intracompartmental pressure readings, consistent with the ACS CPGās recommendation that compartment pressure monitoring can assist, but is not always necessary, in diagnosing ACS (moderate evidence). The patientās blood pressure before compartment checks is 145/70 mm Hg. The orthopaedic surgeon uses a handheld syringe-based pressure monitor and measures pressures of 30 mm Hg in the superficial posterior compartment, 35 mm Hg in the deep posterior compartment, 55 mm Hg in the anterior compartment, and 50 mm Hg in the lateral compartment. Given these findings, when combined with the increase in narcotic use and pain, the orthopaedic surgeon diagnoses him with ACS and calls the operating room to increase the urgency of his case. This diagnosis is consistent with the ACS CPGās recommendation that a difference between the patientās diastolic pressure and the intracompartmental pressure of 30 mm Hg can be used as a threshold for diagnosing ACS and performing fasciotomy (moderate evidence). A second anesthesia team is brought in, and the patient is in the operating room in less than an hour. The orthopaedic surgeon performs two incision, four compartment fasciotomy with care to make sure that he is visualizing and releasing all compartments while keeping in mind his plan for definitive fixation in placing these incisions. Herniating, viable, contractile muscle is found in the anterior and lateral compartments after release. The superficial and deep posterior compartments also contain viable muscle, although it does not herniate after being released. The orthopaedic surgeon then places a diamond-shaped external fixator spanning pins placed in the anterior lateral femur and anterior tibia. Treatment with fasciotomy and external fixation of the fracture are both in keeping the ACS CPGās consensus statements on treatment modalities. The skin and fascia are left open and dressed with negative pressure wound dressings in accordance with the recommendation of the ACS CPG that negative pressure wound dressings may reduce time to wound closure and the need for skin grafting (Limited Evidence). The patient is taken back to the operating room every 2 to 3 days to change his negative pressure dressings, and after 7 days, the skin overlying both fasciotomies is closed. Two and a half weeks after his initial injury, the patient undergoes open reduction and internal fixation (Figure 2, A and B).Figure 2: (A and B): ragiographs after delayed fixation of the patient in case #1.Case #2 A 53-year-old man is found down outside his home with a ladder near by. He was found by a neighbor who called 911. The patient was lying on his side with his right arm underneath him and had been in this position for an unknown amount of time. The weather was temperate, but he was not hypothermic, so it is considered unlikely he was unconscious for >24 hours. When he presented to the hospital, he was found to have an epidural bleed, right-sided rib fractures, and a pneumothorax. Orthopaedics is consulted to evaluate the patient in the intensive care unit, where he is intubated and sedated, to assess his right arm for swelling. On physical examiantion, the orthopaedic surgeon finds the patient to have a diffusely swollen right forearm, predominantly between the elbow and wrist. Radiographs reveal no fractures of the shoulder girdle, humerus, elbow, forearm, wrist, or hand. He has a palpable radial pulse. The patient will withdraw from painful stimuli but is otherwise unable to follow commands. The patientās blood pressure has been 110-140/65-85 over the past 6 hours. The patient has myoglobinuria and an elevated creatine phosphokinase (CPK). Based on the ACS CPGās recommendation, the orthopaedic surgeon knows that myoglobinuria may assist in diagnosing ACS (limited evidence). Given the clinical concern that this obtunded patient has impending or established ACS, the orthopaedic surgeon elects to check intracompartmental pressures in the forearm with a handheld syringe-based pressure monitor, consistent with the ACS CPGās consensus statement that obtunded patients can be monitored with serial compartment pressure checks (moderate evidence). The dorsal compartment of the forearm measures 20 mm Hg, the volar compartment 25 mm Hg, and the mobile was 15 mm Hg. The orthopaedic surgeon determines that ACS does not exist currently but initiates serial examinations and pressure readings every 2 hours for the next 12 hours because the patient is still at risk for developing ACS. At no point does the clinical appearance of the arm change nor does the differential between the diastolic blood pressure and the intracompartmental pressure reading reach <30 mm Hg. After 12 hours, the patient is extubated and can follow commands. He has full motor function in his hand, wrist, and elbow and full sensation. No further deterioration exists in his status with clinical monitoring over the course of his intensive care unit stay and transfer to the floor. Case #3 A 24-year-old woman was found unresponsive after an unknown amount of time by her roommates, who last saw her approximately 36 hours ago in the living room of their shared house. She actively uses intravenous heroin. She was stabilized at an outside hospital and then transferred to a tertiary care facility. She is breathing on her own with a facemask and intermittently able to answer questions but is unable to recount the events leading up to her admission. When she is at her most lucid state, she has notable, uncontrollable pain requiring intravenous opioids and a ketamine drip. The orthopaedic surgeon is asked to evaluate the patient because of rhabdomyolysis, a tense right buttocks and thigh, and concern for ACS. When the orthopaedic surgron examines the patient in the intensive care unit, she is able to answer simple questions but cannot give a full history. She can follow commands by dorsiflexing and plantar flexing her left ankle but not her right ankle. She shakes her head ānoā when asked if she can feel light touch on the plantar and dorsal aspect of her foot. Her right buttocks and right lateral thigh are tense, but her medial thigh is soft and compressible. She has a palpable dorsalis pedis and posterior tibial pulse. Her CPK is elevated at 8,500 U/L (normal < 180), decreased from 9,000 at the outside hospital. She has myoglobinuria with deteriorating renal function, and the intensive care unit team is planning on starting dialysis. The orthopaedic surgeon is concerned that this represents a late-presenting compartment syndrome, and although her CPK is elevated and downtrending, he knows that, consistent with the consensus statement of the ACS CPG, there is not enough evidence to support using biomarkers to assist in clinical decision-making in this scenario. Given the timeline of events and the fact that the patient has signs of irreversible neuromuscular damage (no motor function in the foot), the orthopaedic surgeon declines to check intracompartmental pressures, consistent with the ACS CPGās consensus statement that compartment pressure monitoring does not provide useful information in late-presenting compartment syndrome. Based on the ACS CPGās consensus recommendations, the orthopaedic surgeon does not seek additional laboratory or investigative testing. The orthopaedic surgeon is aware of the ACS CPGās consensus statement that fasciotomy is not indicated in an adult with signs of irreversible intracompartmental damage and a late-presenting compartment syndrome, but given the uncertainty of the timeline, he does have a conversation with the patientās mother and father about the possibility of fasciotomy because the patient is now unreliable in her ability to engage in a conversation. The orthopaedic surgeon thoroughly documents the substance and conclusions of this discussion in the medical record. During the conversation, the orthopaedic surgron stresses the point that the damage from ACS seems to be irrevocable and that a fasciotomy of the buttocks and thigh in this scenario carries a high risk of infection and the need for serial procedures without an improvement in function. He does let them know that despite his opinion, the data on this scenario are limited, and there is still some degree of uncertainty about the timeline leading up to the patientās presentation. Based on their conversation together, the family decides not to pursue fasciotomy.
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Section titled āReferencesā- 2020 - Management of acute compartment syndrome [Crossref]