Gluteal Compartment Syndrome and Other Common Compartment Syndromes

5/21/2017

Gluteal Compartment Syndrome AND other common compartment syndromes

Erlanger Trauma Symposium June 1, 2017 Hunter Rooks, MD Philip W. Smith, MD Nicholas Ballay, MD; John Huggins, MD; Timothy Stevens, MD; Brandon Boyd, MD

Trauma Symposium June 1, 2017 Speaker with no conflicts to report • It is our duty to each learner to honor your right to expect that your continuing medical education experience includes content and a learning environment that is free of commercial influence and conflicts of interest. To this end, UTCOMC requires program planners, speakers, and staff to disclose and resolve any relevant financial relationships with companies whose products may be discussed during the activity or who may support this program. For information on how any conflicts listed below were resolved, please contact the Surgery CME coordinator at 423-778-7695. • Hunter Rooks, MD, reports having no financial relationships with commercial interests relevant to this presentation.

1 5/21/2017

Outline

• Case Presentation • Anatomical Considerations • Presentation • Diagnostics • Treatment

Case

• Level III Trauma Activation • Chief Complaint: Right Hip Pain • HPI: 45 y/o male 24 hr history of intoxication, assault, and subsequent prolonged immobilization. Presented to ED ~24 hours later with R hip pain, LLE lack of sensation & paralysis • PMHx: HTN, Snakebite, MVC • SHx: burr holes • Medications & Allergies: none • SoHx: Tobacco 1 PPD, EtOH 6 pack every other day, History of IV drug use

2 5/21/2017

Physical Exam

• Vitals: T: 97.8°F, BP: 140/103, HR: 124, RR 20, O2: 93% (RA) • Labs 57 • Urine: Hb +, myoglobin + • Serum myoglobin: 13500 (Normal <223) • CPK: 43600 (normal <5000) • CKMB: 300 (normal <6) • GCS 15 • Pulses 2+ Bilateral Radial & Pedal • RLE Hip Ecchymosis • LLE • Buttock tense, ecchymotic, shiny skin • Insensate Sciatic distribution • Extremity Paralysis • Pain with Passive ROM Hip adduction, extension

Physical Exam

Compartment Measurements • Arterial line • Stryker needle • Gluteus maximus compartment: 50 mmHg • Gluteus medius & minimus Compartment: 70 mmHg • Diastolic BP 100, ∆P=30

3 5/21/2017

Imaging

• MRI • Mild Spinal Stenosis L4-S1

• CT Abdomen Pelvis • Significant Edema in Left Buttock • Enlargement of Gluteus Maximus, medius, minimus

Diagnosis

Gluteal Compartment Syndrome Plan: Emergent Gluteal Fasciotomy

4 5/21/2017

Anatomy

• What is a Compartment? • Compartment Syndrome • “Compartment syndrome is the excessive swelling of tissue within a closed space, to the degree that the pressure exceeds the capillary bed perfusion pressure and effective blood flow is cut off.” –Cameron’s Current Surgical Therapy

Known Locations

Common Uncommon • Lower Extremity • Thigh • Upper Extremity • Hand • Abdomen • Foot • Gluteal • Eye • Chest

5 5/21/2017

Causes

• Trauma • Crush injuries • Bleeding • Insect/snake bites • Constrictive dressings • Prolonged immobilization • Reperfusion • Burns

Pathophysiology • Local swelling • Blood flow decreases as compartment pressure approaches diastolic pressure • Early: venous outflow • Late: arterial inflow • Tissue hypoperfusion, ischemia, and necrosis • Worsening edema

6 5/21/2017

Diagnosis

Subjective Objective • Early • Compartment Pressure > 30 mmHg • Pain with Passive stretch • ∆P < 30 • Pain out of proportion • ∆P = Diastolic Pressure – Measured Pressure • “ 6 Ps” • Laboratory Abnormalities • Pain • CPK: > 1000-5000 • Pallor • Renal function • Poilkilothermia • Urine myoglobin • Pulseless • Paresthesias • Potassium • Paralysis • Lactic acid

Treatment

• Fasciotomy • Delayed Presentation (>48 hrs) • Full thickness incision through skin and deep fascia confining muscle • Increased infective risk with fasciotomy • Unlikely functional recovery • Viability Assessment • “ 4 Cs” • Color: (red vs dusky) • Supportive Management • Contractility • Rhabdomyolysis • Consistency (intact vs friable) • Renal injury • Capacity to bleed • Myonecrosis • Debridement • 2nd Look • Delayed Primary Closure vs Grafting

7 5/21/2017

Contraindications

• Non-viable extremity • Crush injury

Upper Extremity Compartments • Forearm • 2nd most common location • Crush injury, fracture • 3 Compartments • Volar, Dorsal, Mobile Wad • Fasciotomy Ulnar Approach • Release of deep flexors • Carpal tunnel, Guyon canal release • Extensors • Upper Arm • Uncommon Dorsal • Anterior, Posterior, Deltoid • Anterior & Posterior or Single lateral incision

8 5/21/2017

Hand

• 10 Compartments • Cause • Crush injuries • Fractures • Presentation

• Swollen • IP flexion, MCP extension • Increased pain with passive stretch of intrinsic muscles

Lower Extremity

• Lower Leg • Most common location • Treatment • 4 compartment fasciotomy

Double Incision Single Incision

9 5/21/2017

Thigh

• Uncommon • Anterior, Medial, Posterior • Anterior compartment most common • Femur, vascular trauma • Iatrogenic: post intramedullary nailing

Foot

• Uncommon • Fractures • Calcaneus, Lisfranc • Crush injuries, trauma • Clinical Diagnosis • +/- elevated ICP

10 5/21/2017

Gluteal Compartment Syndrome

• Common Etiology • Prolonged Immobility • Intoxication • Local Trauma • Pain out of proportion • Sciatic nerve distribution deficits • Dx: ∆P < 30

Gluteal Compartment Syndrome

Treatment • Gluteal Fasciotomy • Kocher-Langenbeck • Modified Gibson

11 5/21/2017

Literature Reviewed

• Documented Causes: • Associations • Trauma • Alcohol & drug use • Hip arthroplasty • Immobilization • Iatrogenic vascular injury • Pelvic fractures • Lateral decubitus or lithotomy positioning in the operating room • Overuse or exertion • Epidural analgesic infusion • Anticoagulation • Bone marrow biopsy

Our Treatment

• Day 1 • Modified Gibson Fasciotomy • Color: Dusky • Contractility: minimal at inferior aspect • Consistency: non-friable • Capacity to bleed: none • Packed wet • Day 3 • Wound check • Day 4 • Able to flex LLE at knee • No movement/sensation distally

12 5/21/2017

Our Treatment

• Day 5 • Wound check

• Day 7 • Ambulating • Operation: Primary Closure • Discharged Home

Compartment Syndrome vs Crush Injury Crush Injury Compartment Syndrome • Continuous or prolonged pressure • Compartment syndrome • Natural disasters • Elevated pressure  muscle damage • Prolonged immobilization under the influence • Crush Syndrome • Examination • Muscle damage  elevated pressure • Initial paralysis • Rapidly ensuing swelling • Treatment • Supportive care • Surgical release < 6-12 hrs

13 5/21/2017

Compartment Syndrome Triaging • Mechanism • Physical Exam • Trauma • Tense Compartments • Crush injuries • Early • Bleeding • Pain with Passive stretch • Prolonged immobility • Pain out of proportion • Burns • “ 6 Ps” • Pain • Pallor • Poilkilothermia • Pulseless • Paresthesias • Paralysis

Compartment Syndrome Triaging

• Pre-Hospital • Hospital Period • IV Fluids • Changes in clinical exam • Communication • Lab abnormalities • Elevated Creatinine • Hyperkalemia • Elevated CPK • UA positive for hemoglobin/myoglobin

14 5/21/2017

References • Cameron, J. Current Surgical Therapy,12th Edition. 2017. Pg. 1286-1290, access via clinical key. • Chung, J., Modrall, G. Rutherford’s Vascular Surgery, 8th Edition. Compartment Syndrome. 2014, access via clinical key. • Shuler, M, et al. Compartment Syndrome. Skeletal Trauma: Basic Science, Management, and Reconstruction. 2015. access via clinical key. • Garner, M. Compartment Syndrome: Diagnosis, Management, and Unique Concerns in the Twenty-First Century. HSS J. 2014 Jul; 10(2): 143– 152. • Published online 2014 Jun 7. doi: 10.1007/s11420-014-9386-8 • Kong, G, et al. Compartment Syndrome of the Gluteus Medius Occurred without Bleeding or Trauma: A Case Report. Hip Pelvis. 2015 Dec; 27(4): 278–282. Published online 2015 Dec 30. doi: 10.5371/hp.2015.27.4.278 • Smith, A, et al. Acute gluteal compartment syndrome: superior gluteal artery rupture following a low energy injury. BMJ Case Rep. 2012; 2012: bcr2012007710. • Published online 2012 Dec 17. doi: 10.1136/bcr-2012-007710. • Rasul, A., Acute Compartment Syndrome workup. Jan 2017. http://emedicine.medscape.com/article/307668-workup • http://kingsleyphysio.com/common-conditions/chronic-compartment-syndrome/ • CPT Brendan Masini, MD, http://www.wheelessonline.com/ortho/12797 • Yadav, Umesh. https://www.slideshare.net/umeshyadav5682/approach-to-hip-joint • Compartment Syndrome Of The Gluteal Region - Everything You Need To Know - Dr. Nabil Ebraheim, https://www.youtube.com/watch?v=qQuZnxySxOA • https://www2.aofoundation.org/wps/portal/surgerymobile?showPage=redfix&bone=Tibia&segment=Shaft&classification=42- Special%20considerations&treatment=&method=Special%20considerations&implantstype=Complications&approach=&redfix_url=13413190 36277

Thank You