compartment syndrome

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detailed review of compartmental syndrome ...!! mainly i covered acute condition only ...!!!

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  • 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 > 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!
  • compartment syndrome

    1. 1. DR ASHWANI PANCHAL P.G IN ORTHOPAEDICS JSS HOSPITAL MYSORE
    2. 2.  What is a compartment?  Closed area of muscles group, nerves & blood vessels surrounded by fascia  Pressure: 5-15 mmhg
    3. 3. Definition: An increased pressure within enclosed osteofascial space that reduces capillary perfusion below level necessary for tissue viability; the underlying mechanism is: - increased volume within space - decreased space for contents - combination of both
    4. 4.  What is a compartment syndrome?  intra comp. pressure (35-40 mmhg)  capillaries collapse  Blood flow to muscles and nerves  Bl.Vs collapse
    5. 5. Pathophysiology: Increased compartment pressure leads to increased venous pressure which decreases A-V gradient resulting in muscle and nerve ischemia.
    6. 6. Consequences –vicious cycle
    7. 7. Why is it dangerous?  Nerves: neuropraxia: will regenerate Ischemia: cell death  Muscles: contracture (Volkmann's ischemic contracture)  Gangrene
    8. 8. Compartment Syndrome- CAUSES Causes Fractures  Contusions  Surgery  Post Ischemic swelling after arterial occlusion  Major vascular trauma  Crush injuries  Burns  Prolonged limb compression 
    9. 9. Causes  Fracture of a long bone (Supracondylar humerus, forearm, hand,tibia and foot)
    10. 10. CAUSES
    11. 11. Drilling & reaming Tourniquet Dissection
    12. 12. CAUSES swelling Tight cast numbness Bluish discoloration
    13. 13. CAUSES  Severe bruised muscle (even if there is no fracture)  Don’t take contusion lightly
    14. 14. COMPARTMENT SYNDROME
    15. 15. Signs and Symptoms Increased Pressure and Tightness Progressive pain out of proportion to initial injury Markedly swollen area Progressive neurologic deficit Seven P’s  Pain  Pressure  Pain with passive stretch  Parethesia  Paresis/ Paralysis  Pulses  Pallor
    16. 16. SYMPTOMS  Severe pain inappropriate to the injury(not relieved even with morphia)
    17. 17. SYMPTOMS  Burning of the affected limb  Tight muscle(rigid)tightness feeling  Numbness: bad sign
    18. 18. 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
    19. 19. 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
    20. 20. Technique STRYKER TECHNIQUE MERCURY MANOMETER Wick hand held instrument
    21. 21. Whiteside maneuver Wick hand held instrument Direct reading syringe mmhg mano. 3 way stopcock electrode
    22. 22. Stryker Stic System Easy to use Can check multiple compartments Different areas in one compartment
    23. 23. Complications related to CS Late Sequelae Volckmann’s contracture  Weak dorsiflexors  Claw toes  Sensory loss  Chronic pain  Amputation 
    24. 24. COMPARTMENT SYNDROME
    25. 25. Management  Non surgical management:  Remove any tight bandage, tubigrip or soaked dressing  Cast should be removed completely  Elevation
    26. 26. •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
    27. 27. Fasciotomy Principles Make early diagnosis Long extensile incisions Release all fascial compartments Preserve neurovascular structures Debride necrotic tissues Coverage within 7-10 days
    28. 28. 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)
    29. 29. Forearm Fasciotomy Volar-Henry approach Include a carpal tunnel release Release lacertus fibrosus and fascia Protect median nerve, brachial artery and tendons after release
    30. 30. Gastroc-soleus Flexor digitorum longus
    31. 31. Intermuscular septum Superficial peroneal ner
    32. 32. Fasciotomy of Hand 10 separate osteofascial compartments dorsal interossei (4) palmar interossei (3) thenar and hypothenar (2) adductor pollicis (1)
    33. 33. Close skin by 2ry sutures after oedema subsides
    34. 34. It may need skin graft
    35. 35. 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
    36. 36. 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
    37. 37. 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 2000
    38. 38. 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

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