Compartment Syndromes of the Forearm and Hand

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Compartment Syndromes of the Forearm and Hand

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Compartment Syndromes of the Forearm and Hand

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

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