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Compartment Syndrome

Compartment Syndrome. Compartment Syndrome Definition. Elevated tissue pressure within a closed fascial space Reduces tissue perfusion - ischemia Results in cell death - necrosis True Orthopaedic Emergency. Acute Compartment Syndrome Of The Upper Arm. Compartment Syndrome.

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Compartment Syndrome

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  1. Compartment Syndrome

  2. Compartment SyndromeDefinition • Elevated tissue pressure within a closed fascial space • Reduces tissue perfusion - ischemia • Results in cell death - necrosis • True Orthopaedic Emergency

  3. Acute Compartment Syndrome Of The Upper Arm

  4. Compartment Syndrome A condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space.

  5. Compartment Syndrome • when pressure within a closed muscle compartment exceeds the perfusion pressure it will results in muscle and nerve ischemia.

  6. Compartment SyndromeEtiology Compartment Size • tight dressing; Bandage/Cast • localised external pressure; lying on limb • Closure of fascial defects Compartment Content • Bleeding; Fx, vas injuries, bleeding disorders • Capillary Permeability; • Ischemia / Trauma / Burns / Exercise / Snake Bite / Drug Injection / IVF

  7. Compartment SyndromeEtiology • Fractures-closed and open • Blunt trauma • Temp vascular occlusion • Cast/dressing • Closure of fascial defects • Burns/electrical • Exertional states • GSW • IV/A-lines • Hemophiliac/coag • Intraosseous IV(infant) • Snake bite • Arterial injury

  8. Compartment syndrome of upper arm • Rare • Trauma • Burns • Infection • Fracture neck of Humerous • Triceps avulsion • Thrombolytic therapy • Prolonged pressure on the arm during sleep or unconsciousness as a result of alcohol or other drugs(binge drinking)

  9. Fracture • The most common causes • Incidence of accompanying compartment syndrome of 9.1% • The incidence is directly proportional to the degree of injury to soft tissue and bone Blick et al JBJS 1986

  10. Blunt Trauma • 2nd most common cause • About 23% of CS • 25% due to direct blow McQueen et al; JBJS Br 2000

  11. Compartment SyndromeTissue Survival • Muscle • 3-4 hours - reversible changes • 6 hours - variable damage • 8 hours - irreversible changes • Nerve • 2 hours - looses nerve conduction • 4 hours - neuropraxia • 8 hours - irreversible changes

  12. Compartment SyndromeDiagnosis • Pain out of proportion • Palpably tense compartment • Pain with passive stretch • Paresthesia/hypoesthesia • Paralysis • Pulselessness/pallor

  13. Clinical Evaluation • Beware of epidural analgesia • Beware long acting nerve blocks • Beware controlled intravenous opiate analgesia

  14. Management • Check pressure :10-30 mmHg higher than diastolic needs fasciotomyimmediately • Abnormal Nerve function after 1/2 hour • Functional impairment after 2-4 hours • Irreversible function loss after 4-12 hours • Acute Renal Failure : Rhabdomyolysis

  15. Compartment SyndromePressure Measurements • Measurements must be made in all compartments • Anterior and deep posterior are usually highest • Measurement made within 5 cm of fx • Marginal readings must be followed with repeat physical exam and repeat compartment pressure measurement

  16. Compartment SyndromeEmergent Treatment • Remove cast or dressing • Place at level of heart (DO NOT ELEVATE to optimize perfusion) • Alert OR and Anesthesia • Bedside procedure • Medical treatment

  17. Compartment SyndromeDifferential Diagnosis • Arterial occlusion • Peripheral nerve injury • Muscle rupture

  18. SUSPECTED COMPARTMENT SYNDROME (Pressure = DBP – ICP) Unequivocal + Findings FASCIOTOMY Pt. not alert/polytrauma/inconc. Comp. pressure measurement < 30 mm Hg >30 mm Hg of DBP Serial exams FASCIOTOMY

  19. Medical Management • Ensure patient is normotensive ,as hypotension reduces prefusion pressure and facilitates further tissue injury. • Remove cicumferential bandages and cast • Maintain the limb at level of the heart as elevation reduces the arterial inflow and the arterio-venous pressure gradient on which perfusion depends. • Perfusion pressure = Arterial P (30-35mmHg) – Venous P (10-15mmHg) • Supplemental oxygen administration.

  20. Medical Management • Compartmental pressure falls by 30% when cast is split on one side • Falls by 65% when the cast is spread after splitting. • Splitting the padding reduces it by a further 10% and complete removal of cast by another 15% • Total of 85-90% reduction by just taking off the plaster! Garfin, Mubarak JBJS 1981

  21. Surgical Treatment • Fasciotomy, Fasciotomy, Fasciotomy, • All compartments !!!

  22. Fasciotomy Principles • Make early diagnosis • Long extensile incisions • Release all fascial compartments • Preserve neurovascular structures • Debride necrotic tissues • Coverage within 7-10 days

  23. Surgical incision for decompression of upper arm compartment

  24. Surgical incision extending to forearm for decompression

  25. Compartment SyndromeSurgical Treatment • Fasciotomy - prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma. • Fracture care – stabilization • Ex-fix • IM Nail

  26. Compartment SyndromeIndications for Fasciotomy • Unequivocal clinical findings • Rising tissue pressure • Significant tissue injury or high risk patient • Injury at high risk of compartment syndrome • CONTRAINDICATION - Missed compartment syndrome (>24-48 hrs)

  27. Use a Generous Incision • Lengthening the skin incisions to an average of 16 cm decreases intracompartmental pressures significantly. • The skin envelope is a contributing factor in acute compartment syndromes of the leg and The use of generous skin incisions is supported

  28. Compartment SyndromeLower Leg • 4 compartments • Lateral: Peroneus longus and brevis • Anterior: EHL, EDC, Tibialis anterior, Peroneus tertius • Supeficial posterior-Gastrocnemius, Soleus • Deep posterior-Tibialis posterior, FHL, FDL • .

  29. Compartment SyndromeHand • non specific aching of the hand • disproportionate pain • loss of digital motion & continued swelling • MP extension and PIP flexion • difficult to measure tissue pressure

  30. Single Incision • Perifibular Fasciotomy • Matsen et al (1980) • Single incision just posterior to fibula • Common peroneal nerve

  31. Double Incision • In most instances it affords better exposure of the four compartments • 2 vertical incisions separated by minimum 8 cm • One incision over anterior and lateral compartments • Superficial peroneal nerve • One incision located 1-2 cm behind postero-medial aspect of tibia • Saphenous nerve and vein Mubarak et al JBJS 1977

  32. Forearm Fasciotomy • Volar-Henry approach • Include a carpal tunnel release • Release lacertus fibrosus and fascia • Protect median nerve, brachial artery and tendons after release

  33. Forearm Fasciotomy • Protect median nerve, brachial artery and tendons after release

  34. Interim Coverage Techniques • Simple absorbent dressing • Semipermeable skin-like membrane

  35. Fasciotomy: Medial Leg Gastroc-soleus Flexor digitorum longus

  36. Fasciotomy: Lateral Leg Intermuscular septum Superficial peroneal nerve

  37. Complications related to CS • Late Sequelae • Volkmann's contracture • Weak dorsiflexors • Claw toes • Sensory loss • Chronic pain • Amputation

  38. Volkmann's contracture

  39. Wound Management • Wound is not closed at initial surgery • Second look debridement with consideration for coverage after 48-72 hrs • Limb should not be at risk for further swelling • Pt should be adequately stabilized • Usually requires skin graft • DPC possible if residual swelling is minimal • Flap coverage needed if nerves, vessels, or bone exposed • Goal is to obtain definitive coverage within 7-10 days

  40. Wound Management • After the fasciotomy, a bulky compression dressing and a splint are applied. • “VAC” (Vacuum Assisted Closure) can be used • Foot should be placed in neutral to prevent equinus contracture. • Incision for the fasciotomy usually can be closed after three to five days

  41. Wound Closure • STSG • Delayed primary closure with relaxing incisions

  42. Split thickness skin graft

  43. Complications Related to Fasciotomies • Altered sensation within the margins of the wound (77%) • Dry, scaly skin (40%) • Pruritus (33%) • Discolored wounds (30%) • Swollen limbs (25%) • Tethered scars (26%) • Recurrent ulceration (13%) • Muscle herniation (13%) • Pain related to the wound (10%) • Tethered tendons (7%)

  44. Summary • Keep a high index of suspicion • Treat as soon as you suspect CS • If clinically evident, do not measure pressures • Fasciotomy • Reliable, safe, and effective • The only treatment for compartment syndrome, when performed in time

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