Compartment syndrome

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Compartment syndrome

  1. 1. Compartment Syndrome Mosheer Ziadi R1
  2. 2. Objectives • • • • • • • What is it Definition Pathophysiology Eitology Diagnosis Sign and symptoms Treatment
  3. 3. What is it ? • Increase in hydrostatic pressure in closed osteofascial space resulting in decreased perfusion of muscle and nerves within compartment.
  4. 4. What is it? • RAISED PRESSURE WITHIN A CLOSED SPACE with a potential to cause irreversible damage to the contents of the closed space.
  5. 5. Definition • Symptoms resulting from increased pressure within a limited space – compromising • circulation • function
  6. 6. Pathophysiology • A continuous increase in pressure within a compartment occurs until the low intramuscular arteriolar pressure is exceeded and blood cannot enter the capillaries
  7. 7. Pathophysiology • Increased compartment pressure Increased venous pressure Decreased blood flow Decreases perfusion
  8. 8. Pathophysiology • Autoregulatory mechanisms may compensate: – Decrease in peripheral vascular resistance – Increased extraction of oxygen • As system becomes overwhelmed: – Critical closing pressure is reached – Oxygen perfusion of muscles and nerves decreases
  9. 9. Muscle Ischemia • 4 hours - reversible damage • 8 hours - irreversible changes • 4-8 hours - variable Hargens JBJS 1981
  10. 10. Muscle Ischemia • Myoglobinuria after 4 hours – Renal failure – Maintain a high urinary output – Alkalinize the urine • Cell death initiates a “vicious cycle” – increase capillary permeability – increased muscle swelling
  11. 11. Increased muscle swelling Increased permeability Increased compartment pressure
  12. 12. • Increased pressure Increased venous pressure Decreased blood flow Decreases perfusion
  13. 13. Nerve Ischemia • 1 hour - normal conduction • 1- 4 hours - neuropraxic damage reversible • 8 hours - axonotmesis and irreversible change Hargens et al. JBJS 1979
  14. 14. Pathophysiology: • CAUSES: • Increased Volume - internal : hemmorhage, fractures, swelling from traumatized tissue, increased fluid secondary to burns, post-ischemic swelling • Decreased volume - external: tight casts, dressings • Most common cause of hemmorhage into a compartment: fractures of the tibia, elbow, forearm or femur
  15. 15. Etiology • Fractures • Soft Tissue Injury (Crush) • Arterial Injury – Post-ischemic swelling – Reperfusion injury • Drug Overdose (limb compression) • Burns
  16. 16. Fractures • Most common cause • Incidence accompanying compartment syndrome 9.1 % • The Incidence is directly proportional to the degree of injury to soft tissue and bone . • Tibial diphesyal # • Forearm # • Distal radius # Bick et al JBJS 1986
  17. 17. Arterial Injuries • Secondary to revascularization: • Ischemia causes damage to cellular basement membrane that results in edema • With reestablishment of flow, fluid leaks into the compartment increasing the pressure.
  18. 18. Diagnosis • Clinical diagnosis – High index of suspicion • Syndrome – History – Physical Exam
  19. 19. Difficult Diagnosis • Classic signs of the 5 P’s - ARE NOT RELIABLE: – – – – – pain pallor paralysis pulselessness paresthesias • These are signs of an ESTABLISHED compartment syndrome where ischemic injury has already taken place • These signs may be present in the absence of compartment syndrome.
  20. 20. Signs & Symptoms • Pain –Passive muscle stretching –Out of proportion –Progressive –Not relieved by immobilization
  21. 21. Diagnosis • Pain • Compartment pressure – Confirmatory test – Don’t just measure
  22. 22. Diagnosis • Palpable pulses are usually present in acute compartment syndromes unless an arterial injury occurs. • Sensory changes and paralysis do not occur until ischemia has been present for about 1 hour or more
  23. 23. Diagnosis • The most important symptom of an impending compartment syndrome is PAIN DISPROPORTIONATE TO THAT EXPECTED FOR THE INJURY
  24. 24. Signs & Symptoms • Pain –May be worse with elevation –Patient will not initiate motion on own • Be careful with coexisting nerve injury
  25. 25. Signs & Symptoms • Parasthesia –Secondary to nerve ischemia • Must be differentiated from nerve injury
  26. 26. Signs & Symptoms • Paralysis (Weakness) – Ischemic muscles lose function
  27. 27. Signs & Symptoms • Tense compartment on palpation • Elevated compartment pressure
  28. 28. Tissue Pressure • 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 – < 30 mm Hg of diastolic pressure McQueen, et al
  29. 29. Who is at high risk?
  30. 30. High energy fractures • Severe comminution • Joint extension • Segmental injuries • Widely displaced • Bilateral • Floating knee • Open fractures
  31. 31. Impaired Sensorium • Alcohol • Drug • Decreased GCS • Unconscious • Chemically unconscious • Neurologic deficit • Cognitively challenged
  32. 32. Diagnosis • The presence of an open fracture does NOT rule out the presence of a compartment syndrome • 6-9% of open tibial fractures are associated with compartment syndromes • McQueen et al found no significant differences in compartment pressures between open and closed tibial fractures • No significant difference in pressures between tibial fractures treated with IM Nails and those treated with Ex-Fix
  33. 33. Most Common Locations • Leg: deep posterior and the anterior compartments • Forearm: volar compartment, especially in the deep flexor area
  34. 34. Lower leg • 4 compartmens: Lateral: • Proneus longus and previs • • Anterior : • EHL,EDC,tibialis anterior ,peroneus tertius • Superficial post. : • Gastrocnemius and soleus . • Deep posterior : • Tibial posterior , FHL,FDL
  35. 35. Treatment • • • • Remove restricting cast: *comaprtment pressure falls by 30% is split on one side. *Falls by 65% when the cast spread after splitting *Splitting the padding reduces it by further 10 % and complete removalof cast by another 15% • Serial exams • When diagnosis made – Immediate surgery • 4 compartment fasciotomy *Garfin, Mubarak JBJS 1981
  36. 36. Treatment • Don’t wait so long..!
  37. 37. Treatment
  38. 38. Indication of fasciotomy
  39. 39. Fasciotomy Princeples
  40. 40. Treatment • Fasciotomy – One incision • With or without Fibulectomy – Two (double) incisions • All 4 compartments must be released – Not selective
  41. 41. Lower Leg
  42. 42. • Lateral compartment
  43. 43. • Anterior compartment
  44. 44. Lower Leg
  45. 45. Lower Leg
  46. 46. Two incisions • Lateral • Medial
  47. 47. Double Incision • Anterolateral Incision
  48. 48. Double Incision • Posteromedial Incision • Soleus must be detached from tibia in order to adequately decompress proximal portion of deep posterior compartment
  49. 49. Thigh • Rare • Crush injury with femur fracture • Over distraction – relative under distraction
  50. 50. Thigh • Quadriceps –Lateral • Hamstrings –Posterior • Abductor –Medial
  51. 51. Treatment • Based upon involvement • Usually Quadriceps and Hamstrings • Usually, a single lateral incision will suffice
  52. 52. Forearm
  53. 53. Treatment • Volar- Henry approach: • Include a carple tunnel releas • Begins lateral to biceps tendon =>crosses elbow crease and extends radially => extended distally along medial aspect of brachioradialis =>extends across the palm along the thenar crease.
  54. 54. Henry Approach • Fascia over superficial muscles is incised • Care of NV structures
  55. 55. Volar-Henry Approach • Brachioradialis and superficial radial n. are retracted radially and FCR and radial artery are retracted ulnar to expose the deep volar muscles • Fascia of each of the deep muscles is then incised • Consider dorsal approach
  56. 56. Foot
  57. 57. Foot
  58. 58. Hand
  59. 59. Post Fasciotomy… • Must get bone stability – IMN – exfix • ~48hrs after procedure patient should be brought back to OR for further debridement • Delayed skin closure or skin-grafting 37 days after the fasciotomies
  60. 60. Aftercare • VAC dressings • Elevation of limb • Delayed wound closure – Split thickness skin graft
  61. 61. Remember… • Fasciotomies are not benign • Complications are real >25% – Chronic swelling – Chronic pain – Muscle weakness – Iatrogenic NV injury – Cosmetic concerns *** BUT if they are needed do not come up with excuses to not do them !!!
  62. 62. Take home message • • • • Very important to make diagnosis Missed compartment is devastating Physical exam Re-examine patient!

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