Acute compartment syndrome

Definition

Recognizing signs and symptoms

High index of suspicious

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Definition

A condition resulting from increasing pressure in a confined body space, especially of the leg or forearm, leading to reduce in blood flow, which prevent nourishment and oxygen from reaching the tissue.

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Recognizing signs and symptoms

The tell-tale sign of acute compartment syndrome is ‘pain disproportionate to the injury’. Look for the 5P’s for condition highly suspicious for acute compartment syndrome.

Pain

Pallor

Pulse

Paraesthesia

Paralysis

**poikilothermia (additional)

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High index of suspicious

Acute compartment syndrome is best to be avoided rather than treated. It is a limb-threatening condition, if patient already diagnosed with acute compartment syndrome, most likely its already to late, the limb might not be able to be saved, or become functionless.

Diabetic charcot neuroarthropathy : Management

When diabetic charcot neuroarthropathy is diagnosed, we may want to determine the stage as the treatment option will depend on the stage of the disease. Staging is usually done by using Eichenholtz classification.See also Eichenholtz classification at Diabetic charcot neuroarthropathy : classification.

This is example of management guideline based on Eichenholtz classification.

Example of management guideline based on Eichenholtz classification

A guide to treatment options in Charcot neuroarthropathy

Diabetic charcot neuroarthropathy : Classification

Multiple classification systems have been created for charcot neuroarthropathy. These classification systems have been made wether based on natural history of the disease, anatomical patterns, association with ulceration or infection, or in combination. These classification systems are made for the use of management and/or to predict prognosis of the disease.

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Modified Eichenholtz classification

Modified Eichenholtz classification - may help to serve as a guide for management of Charcot foot

The Eichenholtz classification system was initially developed in 1966 to stage the progression of Charcot neuroarthropathy and recommend treatment based on corresponding clinical and radiographic patterns. Initially there are only 3 stages ( 1 - 3). The newer modified Eichenholtz classification was developed later, which includes also stage 0. Stage 0 and stage I constitute the acute phase of the disease. Stage II and stage III constitute the chronic phase of the disease. 

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Sanders and Frykberg classification

Sanders and Frykberg classification

Pattern I involves the forefoot joints and common radiographic changes include osteopenia, osteolysis, juxta-articular cortical bone defects, subluxation and destruction. 

Pattern II involves the tarsometatarsal joints including the metatarsal bases, cuneiforms and cuboid. Involvement at this location may present as subluxation or fracture/ dislocation, and it frequently results in the classic rocker bottom foot deformity.

Pattern III involves Chopart’s joint or the naviculocuneiform joints. Radiographic changes typically show osteolysis of naviculocuneiform joints with fragmentation and osseous debris dorsally and plantarly. 

Pattern IV involves the ankle with or without subtalar joint involvement. Radiographs reveal erosion of bone and cartilage with extensive destructive of the joint, which may result in complete collapse of the joint and dislocation. Typically, this pattern of involvement results in a severe unstable deformity. 

Pattern V is isolated to the calcaneus and usually results from an avulsion of the Achilles tendon off the posterior tubercle. 

The authors reported the midfoot (patterns II and III) to be the most common area of involvement and these patterns are often associated with plantar ulceration at the apex of the deformity.

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Modified Brodsky and Rouse classification

Modified Brodsky and Rouse classification

Brodsky and Rouse initially described four distinct anatomical areas of the foot and ankle that are most commonly affected by Charcot arthropathy.Type 1 often leads to a rocker bottom foot with symptomatic bony prominences and often results in skin breakdown plantarly at the apex of the deformity. Type 2 and type 3 (A and B) involvements are most likely to result in instability. As this classification system fails to include multiple regions of involvement, and the forefoot, therefore it has been modified to include Type 4 (multiple regions) and Type 5 (forefoot).

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Rogers and Bevilacqua classification

Rogers and Bevilacqua classification may help to predict outcomes of the charcot foot

This classification system considers deformity, ulceration and osteomyelitis, and may be helpful in predicting amputation. This is a two- axis system (XY) . The X- axis marks the anatomic location of involvement and the foot and ankle are divided into three regions: forefoot, midfoot and rearfoot/ankle. The Y- axis describes the degree of complication in the Charcot joint. A is acute Charcot with no deformity, B is Charcot foot with deformity, C is Charcot foot with deformity and ulceration, and D includes osteomyelitis. Therefore, one moves across the X- axis (anatomic involvement) and/or down the Y- axis (complicating factors) as the Charcot foot becomes “more complicated” and is accordingly at greater risk for amputation. A 1A Charcot foot (acute Charcot arthropathy localized to the forefoot) is relatively simple and at lower risk for amputation in comparison to a 3D Charcot foot (rearfoot and/or ankle involvement with underlying osteomyelitis). 

Diabetic foot infection : Classification

Foot infections may be described in terms of severity, extent of involvement, clinical appearance, location, and etiology. Any system for classifying these infections should also serve to facilitate management and predict outcomes. One well accepted method simply provides three categories: non-limb-threatening, limb-threatening and life- threatening infections. This scheme implies severity of infection and, accordingly, directs subsequent management while also portending a general prognosis for outcome.

Example of classification system used to classify diabetic foot infection

See also ( Diabetic foot infection : Antibiotic )

Diabetic foot ulcer (DFU) - Classification / Grading / Staging

Many staging methods for DFU are known but the Wagner method and The University of Texas method are commonly used. Staging of DFU guides therapy and harmonizes communicating with other health professionals with respect to the condition of DFU. The Wagner staging method is simple to use. In the Wagner system, foot lesions are divided into six grades based on the depth of the wound and extent of tissue necrosis. However, these grades fail to consider the important roles of infection and ischemia. On the other hand, The University of Texas classification of diabetic foot wounds is becoming increasingly popular for easy of clinical use. The system associates lesion depth with both ischemia and infection. This system has been validated and is generally predictive of outcome, since increasing grade and stage of wounds are less likely to heal without revascularization or amputation .

Wagner classification system for DFU

University of Texas classification system for DFU

Wagner classification and University of Texas classification system

Diabetic foot infection : Antibiotics

Example of antibiotic guideline in management of diabetic foot infection

External fixation

A device placed outside the skin that stabilizes bone fragments with pins or wires connected to bars

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Outline 

Indications

Open fracture

Closed fracture with soft tissue compromised

Periarticular fracture

Pediatric fracture

Damage control

Pelvic ring injury

Malunion/nonunion

Infected fracture

Limb deformity / length inequality

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Indication

1.Open fracture

This is to allow for wound inspection and proper wound care until the soft tissue heal.

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2.Close fracture with soft tissue compromised

This is to allow for wound inspection and proper wound care until the soft tissue heal.

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3.Periarticular fracture

Fracture with extension or involvement of joint is usually unstable, in which by using external fixation this type of fracture can be held out to length until healing commence. Furthermore, placement of internal fixation in this type of fracture can be difficult technically as it involving bone end.

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4.Pediatric fracture

External fixation is favored in children fracture, compare to internal fixation for example in femur fracture. This is because in children the bone is still growing, therefore, we want to avoid from causing damage to the growth plate, which is likely to occur if internal fixation is used.

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5.Damage control

In polytrauma patient, in which there are multiple fracture, external fixation is commonly used, if not definitive, as temporary measure, as it can be applied quickly. Early stabilization of fracture in polytrauma case can reduce risk of severe complication.

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6.Pelvic ring injury

External fixation is indicated in pelvic fracture when it can not be stabilized quickly by other method.

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7.Nonunion

Certain parts of bone (e.g excess bone in malunion, sclerotic bone ends in nonunion) is usually excised(osteotomy) and the remaining ends is brought together in the external fixator, and sometimes this is combined with lengthening of bone, as the parts of bone being excised (bone loss) can be quite significant, to cause shortening.

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8.Infected fracture

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9.Limb deformity (deformity correction) /length inequality (limb lengthening)

By using external fixation, the limb lengthening and deformity correction process work on the principle of distraction osteogenesis.  In this process, a bone that has been cut during surgery (osteotomy) can be gradually distracted (pulled apart), in proper alignment, leading to new bone formation (osteogenesis) at the site of the lengthening. In this way, bone segments can be lengthened by 15 to 100 percent of their original length.

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Frame adjustment
(frame adjustment is done few times perday following a schedule for gradual distraction of the bone)

Limb lengthening