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Compartment syndrome
Department of Orthopaedics
Phramongkutkhlao College of Medicine

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  • Four compartments of the leg contain these names muscles and corresponding arteries and nerves. Complete release of all four compartments is mandatory. Physical exam based on sensory loss may be useful in exercise induced CS. The nerves are the most sensitive to ischemic changes.
  • Compartmentsyndrome

    1. 1. (Lower Extremities) Anuchit Nawatthakul Fifth year medical student Department of Orthopaedics Phramongkutkhlao College of Medicine
    2. 2.  What is a compartment? Closed area of muscles group, nerves & bl.vs surrounded by fascia Pressure: 5-15 mmhg
    3. 3. Leg Anatomy
    4. 4. Compartment Syndrome Lower 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
    5. 5.  What is a compartment syndrome? intra comp. pressure (35-40 mmhg) capillaries collapse Blood flow to muscles and nerves Bl.Vs collapse
    6. 6. Why is it dangerous? Nerves: neuropraxia: will regenerate Ischemia: cell death Muscles: contracture (Volkmanns ischemic contracture) Gangrene
    7. 7. Causes Fracture of a long bone (Supracondylar humerus, forearm, hand,tibia and foot)
    8. 8. Dissection Drilling & reamingTourniquet
    9. 9. swellingTight cast Bluish numbness discoloration
    10. 10.  Severe bruised muscle (even if there is no fracture) Don’t take contusion lightly
    11. 11. SYMPTOMS Severe pain inappropriate to the injury(not relieved even with morphia) Pain that out of proportion
    12. 12.  Burning of the affected limb Tight muscle(rigid) Numbness: bad sign
    13. 13. 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
    14. 14. 5 P’s1.Pain2. Paraesthesia3. Pallor4. Paralysis5. PulselessnessSigns :1. tight swelling2. Loss of strength3. Loss of sensation4. Blister(presence of a pulse does not exclude the diagnosis)
    15. 15. The earliest sign : PAIN Pain that out of proportion to the injury Describe as ‘bursting’ sensation Pain that is not responsive to the normal dosage of pain medication Severe pain with passive stretch Passive stretching is a form of static stretching in which an external force exerts upon theDuring passive stretch of a muscle, there is increased limb to move it into theintramuscular pressure. new positionPressure in a volume-loaded compartment increases moreduring passive stretching than in a normally hydratedcompartment.
    16. 16. HigH riskTibia fracturesTibia plateau fracturesPatients casted after injuryPolytrauma patientsDrug overdose/unconscious patients
    17. 17. For obtunded, intubated, or unreliable patients who have aswollen extremity but who otherwise cannot be evaluated Confirmed by measuring intracompartmental pressures
    18. 18. Whiteside maneuver Wick hand held instrument Direct syringe readingmmhgmano. 3 way stopcock electrode
    19. 19. A split catheter is introduced into the compartment & the pressure is measured closed to the level of the fracture.Differential pressure (∆P)=diastolic pressure – compartmentpressure= < 30mmHg Immediate compartment decompression
    20. 20. Complications Leads to muscle death Leads to nerve death Contracture Paralysis Chronic pain NumbnesssequeleAcute renal failure secondary to rhabdomyolysisDisseminated intravascular coagulationVolkmann’s contracture (where infarcted muscle is replaced by inelastic fibrous tissue)Amputation
    21. 21. Don’t wait so long
    22. 22. Non surgical managementCOMPLETELY remove the casts, bandages and dressings.Cast should be removed completelyThe limb should be nursed FLAT.( elevating the limb  further in end capillary pressure  aggravates the muscle ischaemia)
    23. 23.  Surgical management: (FASCIOTOMY) Open skin and fascia down to a compartment
    24. 24. Surgical incision to the fascia to relieve tension or pressure.Complete opening of all fascial envelopes.The wound should be left open and inspected 2 days later.If there is muscle necrosis  debridement.If the tissues are healthy, the wound can be - sutured (without tension) OR - skin-grafted OR - allowed to heal by secondary intention
    25. 25. If no facilities for compartmental pressure measurement, theIf ∆P < 30mmHg decision to operate will make on clinical grounds Examine the limb at 15 minutes intervals. If no improvement within 2 hours of removing the dressings Muscle will be dead after FASCIOTOM 4-6 hours of total ischemia Y
    26. 26. Leg Single Incision Technique
    27. 27. Leg Two Incision Technique
    28. 28. Close skin by 2ry sutures after oedema subsides
    29. 29. It may need skin graft
    30. 30.  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
    31. 31. Thank you
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