Breaking the Boundaries of the Lower Limb:

1

• Breaking the Boundaries of the Lower Limb
• Compartment Syndrome
• Mary Anne Barry

2
What is Compartment Syndrome?

• An increase in volume or reduction of the size of
  a enclosed compartment or space causing increased
  pressure which then compresses the nerves and
  blood vessels contained therein leading to
  impaired blood flow with muscle and nerve damage
  which, if not relieved will ultimately threaten
  the viability of the tissues it compresses.

3
Where does can it occur?

• Anywhere there is an enclosed space typically
  restricted by fascia
  
• Upper Arm
• Forearm
• Hand
• Thigh
• Abdomen
• Raised ICP of the brain
• In this case presentation focus on the lower
  limb

4
Compartments of the Lower Limb
5
Compartments of the Lower Limb
Tibia
Fibula
Fascia
6
Causes of Compartment Syndrome

• Fracture of the long bones eg Tibia
• Crush injuries
• Burns Eschar
• Lithotomy position
• Pneumatic tourniquet
• High Injury Trauma
• Ischaemia/Reperfusion
• Penetrating injuries

7
CS Mechanism of Action
As pressure rises VR causing P
8
Pathophysiology

• Tissue Ischaemia Tissue Reperfusion / Tissue
  Injury
  
• Anterior Compartment is more susceptible to
  ischaemia
  
• Stronger fascia - lower compliance
• (c v/ p )
• More slow type 1 muscle fibres rely on
  oxidative metabolism. Other compartments have
  more fast type 2 which can access their increased
  glycogen stores more via anaerobic metabolism

9
Clinical Diagnoses

• Symptoms Signs
• Deep aching Pain out of proportion to the injury
• Incredible pain on passive movement of leg due
  to stretched ischaemic muscles
  
• As arterial supply cut off - Pulselessness
• Parasthesia - distally
• Pallor
• Perishing Cold
• Paralysis
• Tight tense swollen limb
• Redness, mottling, blisters
• 6Ps may or may not be present cannot exclude
  condition based on their absence
  
• Support Clinical Suspicions
• Manometer to calculate pressure
• Doppler to measure blood flow

10
What are its consequences?

• If not recognised and not treated myoneural
  necrosis occurs due to ? tissue pH as a result of
  lactic acidosis from anaerobic metabolism and a
  release of K
• Myoglobin is released leading to rhabdomyolysis-
  the products of this lead to acute tubular
  necrosis (ATN) - acute renal failure (ARF)
  
• sepsis and death can result
• So it is important to act swiftly once the
  diagnosis is suspected

11
Why is it so serious

• Capillary pressure 30 mmHg

prevents perfusion of tissues

• ischaemia and ultimately death of tissue.

12
Tissue Threshold to Ischaemia

• Muscle 4 hrs
• Nerve 8 hrs
• Fat 12 hrs
• Skin 24 hrs
• Bone 72-96 hrs
• Therefore for a viable functional limb the upper
  threshold is about 6 hrs
  
• "Amputation is one of the meanest yet one of the
  greatest operations in surgery Sir William
  Fergusson
  
• (glycogenolysis -ischaemia lack of O2 reduced
  removal of metabolites glycogen 1-3 of muscle
  mass)
  

13
Case Presentation

• P/C 58 yrs gentleman referred to CUH from GP
  after complaining of a painful swollen left calf
  for 2 days on a background of DVT and PE
  
• Note ? Another DVT, injury, infection

14
Case Presentation

• HOPC The pain started slow and indulating on the
  first day which he put down to limb strain.
  
• Woke up on the second day with the worse pain
  ever radiating from his foot into his calf,
  rated 10/10 and constant with parasthesia of the
  medial 4 digits, forefoot and ankle of his left
  leg which also felt colder to touch with a
  reduction in movement.
• He felt his leg was progressively getting worse.

15
Case Presentation

• PMEDHx of relevance to case
• Left lower limb DVT and PE in January 2005
• HTN
• No Hx of AFib/MI/known blood disorders
• On no anticoagulants or thrombolytics at time of
  admission discontinued warfarin in april
  
• No aspirin, No clopidogrel
• Past Surgery Bilateral inguinal hernia repair 4
  years ago
  

16
Case Presentation

• FHx of relevance to case
• Parents alive and well
• 1 sister had a stroke
• No Family History of DVT/PE
• SHX
• Sedentary lifestyle
• Ex-smoker past 5 years (36 pack years)
• Ex-drinker several year (40 units per week)

17
On Examination

• General Appearance Distressed and in pain
  unwilling to move left limb, inability to stand
  on leg without causing intense pain.
  
• Vital signs
• HR 76 sinus rhythm - RR 14
• Apyrexial - BP 131/81mmHg

18
Examination

• Inspection of left lower limb
• Mottled pale appearance
• Swollen
• Palpation of left lower limb
• Increasingly cold from thigh down and in
  comparision to right lower limb
  
• Absent pulse dorsalis pedis
• Paraesthesia from mid lower leg down
• Extreme Pain on passive movement of leg and foot
• Capillary refill about 4s in left leg should be
  
  

-
-
19
Investigations

• Haematology
• FBC (infection), UE (dehydration), D Dimers
  (produced during polymerisation of fibrinogen as
  it forms fibrin, detect presence of DIC and other
  coagulation disorders raised in DIC,DVT and PE)
• Group and hold A Rh D ve
• ECG
• Arteriogram
• Ultrasound Abdomen

20

• A Femoral angiogram (cannula and dye) revealed a
  Left Popliteal Artery Thrombus stretching to both
  the anterior tibial and posterior tibial
  arteries
• Virchows Triad - vessel wall, blood
  constituents or flow
  
• Following this had U/S of Abdominal Aorta to
  check for stenosis or aneurysm NAD

Popliteal Artery
Posterior Tibial
Anterior Tibial
21
Diagnosis

• Acutely Ischaemic Limb
• ? 2o to Deep Vein Thrombosis
• (otherwise leg would have emptied full leg
  pressure - compartment syndrome. DVT prevented
  VR - oedema and pooling of blood in the venous
  side and slowed blood flow from the arterial side
  - stasis and thrombosis)
• Compartment Syndrome

22
Embelectomy

• The Fogarty Balloon Embolectomy Catheter. It is
  comprised of a hollow tube with a small
  inflatable balloon attached at the tip. It is
  inserted through an incision into a blood vessel,
  and pressed through a blood clot the balloon is
  inflated, so it can displace the clot as it is
  extracted from the vessel.

23
Fasciotomy

• Decompression surgically of all four compartments
  of the lower limb
  
• Lateral -Anterior Lateral
• Medial - Superfical Deep posterior
• Reperfusion of tissues occur
• Debride any necrotic muscle

24
Lateral MedialFasciotomy

• Initally muscles appear pale and lifeless wait
  15-20 minutes should pink up muscle twitch to
  touch
  
• Surgical incision from the medial and lateral
  patella to ankle
  
• Jelonet dressing keep moist
• If black/grey or jelly bad sign of viability
• IV Heparin

25
Wound Managment

• Close by secondary intention, split skin graft,
  gradual tension (needle and hook)
  
• Keep systolic blood pressure 100mmHg
• Leg not to be elevated (decrease in arterial
  perfusion)
  
• Test capillary refill should be
• Use doppler to assess blood flow
• Check colour of leg and wound and temperature of
  leg
  
• Check sensation and motor function
• Sterile jelonet dressings risk infection

26
Cause of Arterial Thrombosis

• No positive thrombophilic screen
• factor V Leiden APC fine
• Anti thrombin 3 present natural anticoagulant
• D-dimers
• Protein S and C normal range lack of these
  predispose to thrombus formation
  
• No positive tumor markers
• Carcinoembryonic antigen (CEA) Ca colon,
  bronchial ca, IBD, heavy smokers
  
• Carbohydrate antigen (CA 19-9) pancreatic ca,
  cholelithiasis, chronic pancreatisis etc
  
• Alphafetoprotein Hepatocellular carcinoma
• Prostate specific antigen (PSA)
• No positive autoimmune markers
• Urine and Serum myoglobin if urinalysis is ve
  for blood but negative for RBC on microscopy
  -rhabdomyolysis watch for development of ARF

27
Therapeutics

• Heparin was administered during the embolectomy
  and Fasciotomy
  
• Therapeutic levels of warfarin if first clot
  6mths warfarin 2nd one warfarin for life. Keep
  INR high.

28

• Felt burning pain after fasciotomy (nerve
  dysfunction) since operation
  
• Sensory loss over left ankle and medial aspect of
  metatarsal heads
  
• Slight Motor weakness of extensors and flexors
• Physiotherapy mobilisation and weight bearing
  as tolerated
  

29

• Special thanks to Emmet OBrien, Mr Fultons
  Intern, CUH
  
• http//catalog.nucleusinc.com/enlargeexhibit.php?I
  D325
  
• www.hughston.com/hha/b_17_2_1c.jpg
• http//web.mit.edu/invent/www/ima/video/fogarty_hb
  .rm
  
• www.szote.u-szeged.hu/.../vasc/femang.jpg
• http//www.mdevidence.com/imagesthumbs/3478T.jpg
• Netters Interactive Atlas of Anatomy version 3
• Emedicine.com