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Compartment Syndromes of the Forearm and Hand
 

Compartment Syndromes of the Forearm and Hand

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Compartment Syndromes of the Forearm and Hand

Compartment Syndromes of the Forearm and Hand

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    Compartment Syndromes of the Forearm and Hand Compartment Syndromes of the Forearm and Hand Presentation Transcript

    • Compartment Syndromes of the Forearm and Hand Chris Oliver DM FRCS (Tr & Orth) Consultant Trauma Surgeon Edinburgh Orthopaedic Trauma Unit Part-Time Orthopaedic Senior Lecturer
    • History
      • Volkmann 1881 (described)
      • Petersen 1888 (treatment)
      • Hildenbrand 1906 (ischaemic contracture)
      • Rowlands 1910 (reperfusion)
      • Murphy 1914 (fasciotomy)
      • WW2 (arterial spasm)
      • Kelly & Whitesides (1967) 4 Compartment Leg
      • McQueen & Court-Brown (1990’s)
    • Definition Compartment Syndrome
      • is a condition characterised by raised pressure within a closed space with a potential to cause irreversible damage to the contents of the closed compartment
    • Most Common Aetiology
      • iatrogenic
      • tight cast +/- dressing
        • medico-legal problem
    • Aetiology
      • burns
      • high pressure injection
      • trauma
        • fractures
        • crush (behaves differently)
      • reperfusion injuries
      • medical: coagulation, dialysis, traction
      • Drug addicts
    • Pathophysiology
      • volume ~ pressure in a closed space
      • arterial > venous
      • not comparable to acute ischaemia
      • “ zone of Injury”
      • age
      • rigidity of fascia
    • Diagnosis
      • may not be obvious
      • open wounds do not exclude
      • lack abnormalities in sensory nerves
      • if consider diagnosis must monitor
      • polytrauma, head injury, chemical overdose
    • Differential Diagnosis
      • arterial occlusion
      • crush syndrome
      • injury to peripheral nerve
    • Clinical Features
      • disproportionate pain
      • swelling, hard shiny skin
      • passive stretch
      • pulses (BP)
      • sensory deficit (late)
      • muscle weakness (late)
      • deep flexor compartments
    • Tissue Pressure Monitoring
      • tissue versus compartment
      • techniques
        • needle, wick, slit catheter
        • modern transducers
      • Trend is the most important factor
    • Pressure difference - Delta P
      • difference between diastolic pressure and measured compartment pressure
      • 30mm Hg
      • McQueen, Court-Brown 1996
      • “ Zone of Peak Pressure”
    • Incipient Compartment Syndrome
      • high fasciotomy rates
      • monitor
      • bivalve cast and remove dressing
      • limb position
    • Treatment Goals
      • must decompress all compartments at risk
      • skin, fat, fascia widely decompressed
      • debridement of necrotic tissue
      • do not use elastic bands
    • Upper Limb Compartment Syndromes
      • hand
      • forearm
      • elbow
    • Compartment Syndrome of Hand
      • occur most often from iatrogenic injuries
      • arterial-line or IV medications
    • Hand Compartment Syndrome Physical signs
      • non specific aching of the hand
      • disproportionate pain
      • loss of digital motion & continued swelling
        • MP extension and PIP flexion “intrinsic position”
      • difficult to measure tissue pressure
    • Anatomy of Hand Compartments
      • 10 separate osteofascial compartments
        • dorsal interossei (4)
        • palmar interossei (3)
        • adductor pollicis - thenar and hypothenar (2)
        • transverse carpal ligament (1)
    • Hand Decompression of Compartments
      • dorsal metacarpal incisions
        • 2 longitudinal dorsal incisions 2nd & 4th metacarpals
        • extensor tendons are retracted, allowing access to dorsal and volar interosseous compartments which are separate
        • longitudinal slits
      • thenar, hypothenar, CTD
    • Forearm Compartment Syndrome
      • common after high energy injury
        • wrist, forearm #
      • may follow supracondylar # of humerus
      • may result in functionless extremity
    • Anatomy of Forearm Compartment Syndrome
      • three osseofascial compartments
        • superficial Flexor
        • deep Flexor
        • extensor
      • antecubital aponeurosis - lacertus fibrosus
    • Forearm Decompression of Compartments
      • volar Henry approach
        • superficial and deep flexor
      • volar ulna approach
        • extensor
      • no tourniquet
    • Volar Henry Approach
      • medial to biceps to carpal tunnel
      • superficial radial nerve
      • FCR , brachioradialis
      • must decompress deep muscles
        • watch proximal edge of pronator teres
    • Volar Ulna Approach
      • similar to Henry
      • FCU, FDS
        • watch proximal edge of FDS
      • decompress ulnar nerve at wrist
    • Dorsal Approach
      • determine by pressure measurements
      • pronate arm
      • lateral epicondyle to midline of wrist
      • ECRB and EDC
    • Volkmann’s Ischaemic Contracture
      • children
      • disaster
      • advancement of flexor muscles
    • Aftercare Fasciotomy Wounds
      • disfiguring
      • re-inspect at 48 hours
      • further debridement
      • DPC or SSG