2. HISTORY Volkmann 1881
Richard von Volkmann published an article in which
he attempted to describe the condition of irreversible
contractures of the flexor muscles of the hand to
ischemic processes occurring in the forearm
3. Hildebrand 1906
First used the term Volkmann ischemic contracture to
describe the final result of any untreated compartment
syndrome, and was the first to suggest that elevated
tissue pressure may be related to ischemic contracture.
4. Thomas 1909
Reviewed the 112 published cases of Volkmann ischemic
contracture and found fractures to be the predominant
cause. Also, noted that tight bandages, an arterial
embolus, or arterial insufficiency could also lead to the
problem
5. Murphy 1914
First to suggest that fasciotomy might prevent the
contracture. Also, suggested that tissue pressure and
fasciotomy were related to the development of
contracture
6. What is a compartment?
Closed area of muscles
group, nerves & blood
vessels surrounded by
fascia
Pressure: 5-15 mmhg
7. DEFINITION
Increase in interstitial fluid presuure within an
osseofascial compartment of significant magn
itude to cause compromise in microcirculation
and myoneuralnecrosis
8. What is a compartment
syndrome?
intra comp. pressure
(35-40 mmhg)
capillaries collapse
Blood flow to muscles
and nerves
Bl.Vs collapse
12. Why is it dangerous?
Nerves:
neuropraxia: will
regenerate
Ischemia: cell death
Muscles: contracture
(Volkmann's ischemic
contracture)
Gangrene
13. Normal tissue pressure
0-4 mm Hg
8-10 with exertion
Absolute pressure theory
30 mm Hg - Mubarak
45 mm Hg - Matsen
Pressure gradient theory
< 20 mm Hg of diastolic
pressure – Whitesides
McQueen, et al
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
14. Compartment Syndrome- CAUSES
Causes
Fractures
Contusions
Surgery
Post Ischemic swelling after arterial occlusion
Major vascular trauma
Crush injuries
Burns
Prolonged limb compression
15. Causes
Fracture of a long bone
(Supracondylar humerus,
forearm, hand,tibia and
foot)
24. SYMPTOMS
Burning of the affected limb
Tight muscle(rigid)tightness feeling
Numbness: bad sign
25. SIGNS & DIAGNOSIS
Passive stretching of fingers or toes (muscle stretch)will
lead to severe pain (diagnostic sign)
Never wait for signs of ischemia (5 Ps):irreversible
damage
26. STRECH TEST
It is possible to strech the
affected muscles by
passively moving the
joints in direction
opposite to that of the
damaged muscles,s action
(( e.g. ::: passive
extension of fingers
produces pain in flexor
compartment of forearm
33. •management
Surgical management:
(FASCIOTOMY)
Open skin and fascia
down to a compartment
It is a surgical procedure
where the fascia is cut to
relieve tension or
pressure commonly to
treat the resulting loss of
circulation to the tissue
34. Fasciotomy Principles
Make early diagnosis
Long extensile incisions
Release all fascial compartments
Preserve neurovascular structures
Debride necrotic tissues
Coverage within 7-10 days
35. Compartment Syndrome
Indications for Fasciotomy
Unequivocal clinical findings
Pressure within 15-20 mm hg of DBP
Rising tissue pressure
Significant tissue injury or high risk pt
> 6 hours of total limb ischemia
Injury at high risk of compartment syndrome
CONTRAINDICATION - Missed compartment
syndrome (>24-48 hrs)
38. 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
41. Forearm Fasciotomy
Volar-Henry approach
Include a carpal tunnel
release
Release lacertus
fibrosus and fascia
Protect median nerve,
brachial artery and
tendons after release
42. Fasciotomy of Hand
10 separate osteofascial
compartments
dorsal interossei (4)
palmar interossei (3)
thenar and hypothenar (2)
adductor pollicis (1)
43.
44. 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
Primary closure 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
45. 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
48. 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%)
Fitzgerald, McQueen Br J Plast Surg 2000Fitzgerald, McQueen Br J Plast Surg 2000
49. Compartment syndrome is a serious syndrome, Which needs
to be diagnosed early.
Palpable pulse doesn’t exclude compartment syndrome
If diagnosis and fasciotomy were done within 24 hrs, the
prognosis is good.
If delayed, complications will develop.
The earlier you diagnose, the safer you are
Editor's Notes
Seven P’s:
Pain- pain in excess of the presenting injury
Pressure- affected compartment may be tense to palpation
Pain with passive stretch- pain increases with passive ROM
Paresthesia- Numbness over the cutaneus distribution of the nerve that runs through the affected compartment
Paresis/Paralysis- Ischemia or necrosis of the nerves or muscles develops within the affected compartment
Pulses- could be absent but frequently palpable
Pallor- skin discoloration may be visible due to impaired venous drainage
Co-Morbidities include:
Mild:
~ mm weakness
~fatigue
~ Myositis ossificans
Severe
~ Severe life threatening vascular compromise
~ decreased arteriovenous gradient
**To Remember**
~ Do not elevate limb above hear because it decreases the arteriovenous gradient therefore decreasing blood flow
~ Instead limb should be elevated at heart level to maintain arteriovenous gradient and assist with venous drainage
~ Remove any compression casts or dressings
These are indications for surgical decompression. A missed CS &gt; 24-48 hours should not be opened. (see Rockwood and Green 5th edition and Campbell’s 10 th edition) The damage cannot be reversed and there is a significant infection rate when the dead tissue is exposed to the hospital environment. The surgeon must deal with the residual contractures of the ischemic muscle and not risk the chance of infection. Some have suggested that the scarred ant tib muscle can serve as a check rein and limit foot drop sequelae.
Volar approach use Henry Approach to release superficial and deep flexors flexors followed by the pronators and supinator. The dorsal approach is centered over the proximal forearm and can be used to release the Mobile Wad (BR, ECRL,ECRB). It is important to remember when treating and electrical injury with a compartment syndrome, the most damage is deep along the bone (i.e. the Pro and Sup muscles) and may require debridement at the initial surgery…Do not miss this!
