Patient with compartment syndrome of the lower extremity☆☆☆★★★
Article Outline
Abstract
J Vasc Nurs 2003;21:24-9.
Case situation
A 54-year-old man was admitted to our hospital for treatment of compartment syndrome of the left lower extremity. He gave a history of sustaining a puncture wound from an injection of equine steroid to his left medial thigh. He immediately felt pain and noted pallor in the left lower leg, and the extremity soon became edematous. He went to his local emergency department, was treated with an oral steroid dosepak, and was released. The pain and edema increased during the next 2 days, and the patient came to our emergency department with mottling of the left lower leg, severe pain, edema, and numbness of his toes.
The patient's dorsalis pedis and posterior tibial pulses were not palpable but were audible with a Doppler. The Doppler ultrasound showed no deep venous thrombosis or arterial injury but did show compression of the popliteal and tibial veins because of severe swelling of the left calf. The arterial component of the Doppler ultrasound was not completed because of severe leg pain. The anterior lateral compartment pressure was 100 mm Hg, and the medial compartment pressure was 99 mm Hg. Pressures from 40 to 80 mm Hg sustained for 12 hours or more can cause significant muscle necrosis and permanent neurologic changes.1 The patient's serum glutamate oxaloacetate transaminase level was 1386 (normal, 0-37), his serum glutamate pyruvate transaminase level was 590 (normal, 0-40), and his white blood cell count was 21,160 (normal, 3.5-11,000). The patient was given cefazolin (Kefzol), 1 gm intravenously every 8 hours for 6 doses, and intravenous morphine sulfate for pain management.
Phillips1 defined the pathophysiology of compartment syndrome as an insult to normal local tissue homeostasis that results in increased tissue pressure, decreased capillary blood flow, and local tissue necrosis caused by oxygen deprivation. Physical signs of acute compartment syndrome are extreme pain out of proportion to the injury, pallor of the extremity, and paresthesia. Passive stretch of the muscle causes increased pain. Muscle weakness, paralysis, and an absent extremity pulse are late findings. When compartmental pressures are greater than 30 mm Hg in the presence of clinical findings, the recommended treatment is to perform a fasciotomy to decompress the leg compartments. The prognosis is good when a fasciotomy is performed 25 to 30 hours after onset. After the third or fourth day, a fasciotomy may be contraindicated because severe infections can occur in the necrotic muscle.1
The patient underwent medial and lateral fasciotomies of the left lower extremity and debridement of necrotic tissue. The orthopedic surgeon ordered that the wounds be packed with dressings moistened with 0.25% Dakin's solution. The dressings were changed at least every 4 hours because of copious amounts of serosanguineous drainage. The patient's bed linens were often saturated. The dressing changes were painful, and each change took 30 minutes. Foot drop was already present, and a splint was used for treatment. A plastic surgeon and the WOC nurse were consulted for wound care recommendations.
Linda Wessel, BSN, RN, CWOCN
Following debridement by the plastic surgeon, the medial and lateral wounds measured 32 cm and 30 cm in length and 8 cm in width. Extensive ecchymosis was present in the periwound tissue, and tendons were exposed in both wounds (Figures 1 and 2).
Fig. 1.
Medial left calf fasclotomy wound prior to VAC application.
Fig. 2.
Lateral left calf fasclotomy wound prior to VAC application.
The VAC system uses a sterile foam dressing connected to a suction pump that applies negative pressure to the wound. The negative pressure removes wound debris, fluid, and bacteria. It increases tissue perfusion, thus promoting granulation of the tissue.2 The foam dressing is placed in the wound and secured with an occlusive film dressing that decreases bacterial contamination.3 Figure 3 shows the medial calf wound with the VAC dressing in place.
Fig. 3.
Medial left calf wound with VAC dressing in place.
Pain medication was administered prior to the VAC dressing change if needed. Supplies listed in the Box were used. Universal precautions were followed. The dressing tubing was clamped and disconnected from the canister tubing. Allkare Adhesive Removal Wipes (ConvaTec, Princeton, NJ) were used to help loosen the film dressing. Sterile normal saline solution was instilled through the tubing port to aid in removal of the foam dressing. The wound was flushed copiously with sterile normal saline solution with use of a 50-mL syringe and an 18-gauge angiocath.4 The periwound skin was dried and Allkare Skin Protective Wipes were applied to protect the skin from maceration. During the first VAC dressing application, Duoderm CGF (ConvaTec) was used to cover the ruptured blisters distal to the wounds to help obtain an occlusive seal. For subsequent dressing changes, Duoderm Extra Thin strips (ConvaTec) were applied to the periwound skin to protect it from the suction should any of the foam dressing overlap the skin. The foam dressing was cut to fit the size of the wound. One person held the foam dressing in place while another applied the film dressing. The film dressing was applied in overlapping strips to prevent puckering of the dressing.
The suction tubing was inserted into slits made in the film dressing and foam dressing. The exit site and tubing were sandwiched between 2 pieces of the film dressing to occlude it. The wounds were dressed separately, using care not to circumferentially wrap the extremity with the film dressing. The ends of the 2 dressing tubes were cut and inserted into a Y adaptor, which was then connected to the canister tubing. The pump was turned on and the dressing checked for occlusiveness and vacuum. Pain was initially experienced when the foam compressed, but the pain soon subsided. During the first 24 hours of VAC therapy, 1200 mL of serosanguineous fluid was removed. The canister was changed as needed or at least weekly.
After the first dressing change, I modified the procedure and placed an Adaptic Non-Adhering Dressing (Kendall, Mansfield, Mass) on the wound bed prior to the foam dressing application. This additional dressing decreased the patient's pain when the foam dressing was removed. Dressings were changed on Mondays, Wednesdays, and Fridays and took about 1 hour. Wound measurements, calf circumference, and photographs were done at that time. The wound size decreased, edema and ecchymosis of the leg improved, and granulation tissue filled in much of the wound defect after 12 days of VAC therapy (Figure 4).
Fig. 4.
Medial left calf wound after 12 days of VAC therapy: note that granulation tissue has filled in much of the wound defect.
After 2 weeks of VAC therapy, split-thickness skin grafts were performed. The VAC system was again used. Adaptic dressings were placed over the new grafts to prevent adherence of the foam dressings. The patient was discharged 4 days after the skin graft procedure with daily dressing changes of Adaptic and Kerlix gauze (Kendall). He had a slight residual foot drop as a result of nerve compression. A physical therapist applied an ankle foot orthosis splint (Restorative Care of America, Inc, Clearwater, Fla) and worked with the patient on ambulation. The patient returned to the clinic 6 weeks later, and photos were taken. The grafts had healed (Figure 5) and the patient was able to return to work.
Fig. 5.
Medial left calf wound 6 weeks after split-thickness skin graft.
The patient received a significant benefit from the VAC system. The VAC therapy saved nursing time, as well as dressings and linen supplies. The wound drainage was contained and accurately measured. The chance of wound contamination and infection was reduced, the wound healing process accelerated, and the wound bed prepared for skin grafting.
Bonnie Cunningham, MS, RN, CWOCN, CS
Acute compartment syndrome can occur as a result of extremity fracture, crushing injuries, prolonged tourniquet use under anesthesia, restriction from casts, dressings, burn eschar, injury from exercise, bleeding from trauma or anticoagulation therapy, or a multitude of other reasons.5 It is most common in the calf or forearm but can also occur in the hand, foot, or upper portions of the limbs. As stated in the case discussion, prompt recognition and treatment of acute compartment syndrome is critical to the prevention of long-term complications and disability.6 Complications such as infection, contracture, and amputation are caused by a delay in diagnosis and are the result of tissue ischemia, which leads to nerve and muscle necrosis.7 Rapid diagnosis can be established with use of an intracompartmental pressure monitor such as the Stryker monitor (Kalamazoo, Mich), which provides immediate information. High intracompartmental pressures are associated with tissue compression and are an ominous sign with regard to long-term outcomes. The definitive treatment for acute compartment syndrome is fasciotomy, which involves an incision through the skin, subcutaneous tissue, and fascia of the compartment to relieve pressure and allow tissue perfusion.8 Depending on the limb involved, single or double incisions along the limb axis may be needed to expose the fascia.5 Fasciotomy wounds are typically left open and dressings applied. Depending on the severity of the injury, the wound may be closed primarily within days of surgery, or in severe cases, split-thickness grafting may be required. When a fasciotomy is performed within hours of the injury, outcomes are improved and potential complications are reduced.
In this particular case, there was at least a 48-hour delay from time of initial injury, pain and edema, and the time of surgery. Intracompartmental pressures were significantly elevated. Medial and lateral fasciotomies were performed and tissue necrosis was identified. Additional debridement procedures and application of Dakin's solution, which is commonly used to liquefy necrotic tissue, were implemented. Wound care was managed by the orthopedic surgeon and then by the plastic surgeon. The WOC nurse initiated and monitored VAC application, evaluated patient progress, and followed up with the patient until healing was complete. Approximately 2 months elapsed from the time of the injury until the patient returned to work.
VAC therapy is one option for managing full-thickness wounds. It uses controlled negative pressure to accelerate wound healing by evacuating wound fluid, stimulating granulation tissue, and reducing bacterial counts in the wound.9 Generally, wounds created as a result of compartment syndrome are heavily exudative initially, which makes this type of therapy a feasible option for wound healing. Additional management options exist that could be explored prior to selection of a plan of care.
This patient was 54 years old, but his age did not guarantee that he was in a physiological state of health to support the healing of two full-thickness wounds of this size and magnitude. Several assessments are needed to determine a definitive wound care protocol. These assessments include a thorough health history, specifically evaluating any comorbidities such as diabetes mellitus, immune system diseases, and other factors that could impede wound healing. A comprehensive review of medication use is indicated, because the use of steroids and other drugs can have a negative influence on wound healing. In a case such as this, in which there was significant loss of serosanguineous fluid from the wound, it is also important to assess for the administration of anticoagulation therapy or other medications that could lead to bleeding within the wound or surrounding tissues. A nutritional assessment and an evaluation of the patient's personal stressors, family support system, type of employment, and financial situation are important because of the impact of a potentially lengthy recovery period. The type and specifics of insurance coverage, projected length of hospital stay, and anticipated recovery period also require consideration. The care setting will have an impact on wound care decisions. If care will be provided in the home prior to complete wound closure, then it must be determined if there is adequate caregiver support and insurance coverage for home health care, wound therapy, and/or supplies. Each potential wound care option should be researched for reimbursement parameters prior to implementation of a plan of care. The patient and his or her family, if available, should be involved in the final decision-making process.
Because of the numerous factors involved in decision making, a team approach is important in selecting a final plan of care. Realistic goals need to be individualized and agreed upon by the entire health care team and should include the patient and his or her family. Members of a multidisciplinary team relevant to this patient, in addition to his surgeon(s), would most likely be a physical therapist, because of identified ambulation deficits; a nutritionist, because of the significant loss of tissue fluid and hypermetabolic state that exists after multiple surgical procedures; a case manager, to identify specific needs as he progresses through the continuum of care; and staff nurses and possibly pain management experts in the initial postoperative period. The WOC nurse should serve as team leader to facilitate the decision-making process because the WOC nurse will most likely follow up with this patient through all phases of care and be able to provide current knowledge of wound healing and wound management modalities. Ultimate decision making should be done in collaboration with the patient and family, because compliance with the plan of care is essential for wound healing to progress in an orderly fashion.
Selection of a wound management option should be based on the following principles of wound management: (1) control or eliminate causative factors, (2) provide systemic support to reduce existing and potential cofactors, and (3) maintain a physiologic local wound environment.9 VAC therapy has already been described as one option for use with fasciotomy wounds, and this therapy was chosen for this patient. VAC therapy can be used until the patient has complete wound healing or can be used during the initial phase of therapy for exudate management and edema control. The VAC can then be replaced by another treatment modality if that is deemed appropriate. Other options to be considered include hyperbaric oxygen therapy (HBO), a wound management protocol for full-thickness wounds based on moist wound healing principles, and delayed primary closure of fasciotomies.
HBO can be used as an adjunctive therapy for trauma patients who have experienced crush injury, compartment syndrome, and acute traumatic peripheral ischemia.10 The rationale for the use of HBO is based on increasing the amount of oxygen dissolved in plasma as a result of breathing 100% oxygen in an environment of increased atmospheric pressure. Thus, this state of “hyper-oxygenation” counteracts trauma-related tissue hypoxia and edema, improves microcirculation, and promotes cellular function.10 Based on these criteria, HBO would be another feasible option in this situation, especially because there was extensive tissue ischemia after the injury, which leads to necrosis and muscle/nerve damage. Although this treatment modality is costly, it has been associated with fewer surgeries, improved healing rates, and improved clinical responses in older patients.10 It would be critically important to investigate insurance coverage for cost of treatment if this option was considered. Use of HBO therapy can be limited because of the lack of availability and the need for additional clinical evidence to support its use.
A wound management protocol based on the principle of moist wound healing is a modality widely used by WOC nurses for healing full-thickness wounds and is readily available in most practice settings. In this situation, initial postoperative care requires the selection of dressings that not only promote debridement but also are able to manage large volumes of exudate and assist with pain control. Prior to VAC application, it was noted that extreme pain was experienced during dressing changes, which took 30 minutes several times daily. Whenever acute pain is experienced during dressing changes, it is important to evaluate dressing technique to ensure that the care provider or the type of dressing selected is not traumatizing the wound. Pain control prior to dressing changes is important. Patient-controlled analgesia has been successful in diminishing discomfort.
In my clinical experience with postfasciotomy wounds, I have found that the use of a hydrofiber or alginate as the primary dressing and an absorbent foam or another highly absorbent dressing as the secondary dressing is an effective exudate management system. This dressing is held in place with an absorbent gauze wrap and secured with an elastic net dressing, being careful not to compress the extremity. Initially, a skin sealant or skin barrier spray may be needed to protect the periwound skin from contact with excess fluids. The extremity should be elevated. Initially, when edema and exudate is maximal, dressing changes need to be performed several times daily. As the edema subsides, the frequency of dressing changes will decrease until once daily, then every other day. In my experience, this usually occurs after the first 48 to 72 hours after surgery.
If pain continues in spite of pain control interventions, a contact layer that allows the passage of wound exudate and avoids trauma to the wound bed during dressing changes may be added.9 Examples would be Mepitel (SCA Molnlycke, Sweden) or Tegapore (3M Health Care, St Paul, Minn). This layer is not used until debridement is complete, but typically it stays in contact with the wound surface for a period of about 1 week and allows trauma-free changes of the absorbent dressing.
Once the wound is stabilized, reassessment will dictate changes in the dressing protocol. It is essential that a secure yet nonconstrictive dressing be in place when the patient is ready for physical therapy. It is important to consider a management system that will not interfere with ambulation and also one that can be implemented at home if discharge from acute care is an option. In this case, care was provided in the acute care setting for a minimum of 20 days. The patient was discharged after skin grafting was complete. This may not be the case in all situations. It may be that the patient is initially stabilized with intravenous antibiotics, surgical debridement, and wound management but is then discharged to the home or an alternate care setting for subsequent care until scheduled for grafting on an outpatient basis. This decision will be based on wound evaluation and team discussion and related to individual patient needs.
A final option for consideration is that of delayed primary wound closure. A technique modified by Harrah and his colleagues at the Marshall University School of Medicine in Huntington, West Virginia, is described in the literature. It uses a simple approach for gradual reapproximation of wound margins using daily reapplication of Steri-strips (3M Health Care).8 This method allows final closure of fasciotomy wounds with simple suture in 5 to 8 days without infection, necrosis of wound margins, scar contracture, or significant pain. It can be done in any care setting and could potentially reduce the cost of care in treating patients who have undergone a fasciotomy. Although I have not personally used this technique, I find it intriguing and worth investigating in future cases. For this case discussion, delayed primary closure would not be an option initially. A combination of therapies may be useful, beginning with VAC application postoperatively until wound size and exudate decreases. Then perhaps a technique similar to this could be added to the plan of care.
In summary, a thorough assessment and team approach is critical for successful wound management. Communication among care providers and the patient and family is also important. Decision making must be collaborative throughout the postoperative course of treatment. Several options are available for wound management, each of which should be based on clinical evidence. It is important to note that wound management modalities must be reevaluated at regular intervals and modified according to wound progression.
References
- . Traumatic disorders. In: 8th ed. Crenshaw AH, Daugherty K, Campbell WC editor. Campbell's operative orthopaedics. St. Louis: Mosby; 1992;p. 1895–1900
- . The clinical and cost effectiveness of externally applied negative pressure wound therapy in the treatment of wounds in home healthcare medicare patients. Ostomy Wound Manage. 1999;45:41–50
- . Vacuum-assisted closure: a new method for wound closure and treatment: clinical experience. Ann Plast Surg. 1997;6:563–576
- . Cleansing the traumatic wound by high pressure syringe irrigation. JACEP. 1976;5:17–21
- . Preventing the sequelae of compartment syndrome. Hosp Pract. 1999;1:105–107
- . Acute compartment syndrome. J Bone Joint Surg Br. 2000;82-B:200–203
- . Soft tissue complications of orthopedic emergencies. Emerg Med Clin North Am. 2000;18:115–139
- . A simpler, less expensive technique for delayed primary closure of fasciotomies. Am J Surg. 2000;180:55–57
- . Acute and chronic wounds nursing management. St. Louis: Mosby; 2000;
- . Hyperbarlc oxygen therapy for trauma: crush injury, compartment syndrome, and other acute traumatic peripheral ischemias. Int Anesthesiol Clin. 2000;38:139–151
☆ Bonnie L. Cunningham, MS, RN, CWOCN, CS, is a Certified Clinical Nurse Specialist and Director, Wound Care Services/Diabetes Management, at Beebe Longneck Health Center, Millsboro, Delaware.
☆☆ Address reprint requests to Linda C. Wessel, BSN, RN, CWOCN, Southeast Missouri Hospital, 1701 Lacey St. Cape Girardeau, MO 63701.
★ Article reprinted with permission from the Journal of Wound, Ostomy and Continence Nursing 2002;29:210-5.
★★ 1062-0303/2003/$30.00 + 0
PII: S1062-0303(02)74512-3
doi:10.1067/mvn.2003.12
© 2003 Society for Vascular Nursing, Inc. Published by Elsevier Inc. All rights reserved.
