Acute compartment syndrome

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Acute compartment syndrome

  1. 1. ACUTE COMPARTMENT SYNDROME
  2. 2. HISTORY  Raised pressure in a closed space  Richard von Volkmann  Hilderbrand  Rowlands  Murphy
  3. 3. PATHOPHYSIOLOGY  Raised pressure within a confined space  Increased volume of compartment
  4. 4.  Ischemia reperfusion injury  MAJOR VESSEL RARELY OBSTRUCTED  Difference between compartment and diastolic pressure  Crush syndrome  Anesthetized / sedated / intubated patient  Prolonged surgery  Tight cast / constrictive dressing / pneumatic anti shock garment
  5. 5. ETIOLOGY  Decreased compartment size    Constrictive dressings and casts    Closure of fascial defects    Thermal injuries and frostbite    Localized external pressure    Pneumatic tourniquet Increased compartment contents    Primary edema accumulation        Postischemic swelling          Arterial injuries          Arterial thrombosis or embolism          Reconstructive vascular and bypass surgery          Replantation          Prolonged tourniquet time          Arterial spasm          Cardiac catheterization and angiography          Ergotamine ingestion       Prolonged immobilization with limb compression          Drug overdose with limb compression          General anesthesia with limb compression         Increased capillary pressure or permeability          Exercise          Venous obstruction          Thermal injuries and frostbite          Exertion, seizures, and eclampsia          Venous disease          Intraarterial injection          Venomous snake bite          Infection  Primarily hemorrhage accumulation       Hereditary bleeding disorders (e.g., hemophilia)       Anticoagulant therapy       Vessel laceration    Combination of edema and hemorrhage accumulation       Fractures          Supracondylar elbow          Both-bone forearm          Distal radius       Soft tissue injury          Crush          Severe muscle tear, contusion          Gunshot wounds          Iatrogenic (i.e., postoperative bleeding, inflammation)    Miscellaneous       Intravenous infiltration (e.g., blood, saline)       High-pressure injection
  6. 6. DIAGNOSIS : CLINICAL ASSESSMENT  Symptoms may be masked by other injuries  ?? Open fracture  Disproportionate pain  In regional/epidural anesthesia  Numbness / tingling  Signs  Compartment  Stretch pain  Sensory deficit  Paresis
  7. 7.  Pulse / capillary refill  Differential – artery occlusion, nerve injury, crush syndrome  ?? Delay in diagnosis of major arterial injury  Arterial pressure index  Nerve injury – diagnosis of exclusion  Crush syndrome
  8. 8. TISSUE PRESSURE MEASUREMENT  Incipient vs. fulminant  Ideally after every fracture  Polytrauma patient  Chemical overdose / head injury + long bone fracture  Arterial repair
  9. 9. MEASUREMENT TECHNIQUES 1. Needle manometer • Landerer • 18 gauge needle, 20ml syringe, column of saline and air, mercury manometer
  10. 10. 2. Wick catheter • Scholander • Polyglycolic acid suture, polyethylene tubing • Disadvantage
  11. 11. 3. Slit catheter • Rorabeck • Polyethylene tubing with 5 3mm slits in end
  12. 12. 4. STIC catheter • Hand held device 5. Micro capillary infusion 6. Arterial transducer measurement 7. Tc 99m-methoxyisobutylisonitrile 8. Doppler flow measurement 9. Near infrared spectroscopy
  13. 13. PRESSURE THRESHOLD FOR FASCIOTOMY  Within 10-30 mm Hg of diastolic pressure (Whitesides)  Above 45mm Hg (Matsen)  30mm Hg difference between compartment and diastolic pressure (Mc Queen)  40mm Hg difference between mean arterial pressure and compartment pressure (Heppenstall)
  14. 14. TREATMENT OF INCIPIENT COMPARTMENT SYNDROME  Incipient compartment syndrome  Remove tight dressings and casts  Limb position at the level of heart  Oxygen support  Hydration  ESTABLISHED COMPARTMENT SYNDROME Surgical decompression
  15. 15. HAND  Clinical feature  Crush injury / carpal fracture  Longitudinal dorsal incisions
  16. 16. FOREARM  Fracture / soft tissue fluid infiltration / gun shot injury / deep infection / iv drug abuse  3 compartments  Volar Henry / volar ulnar / Thompson  Both superficial and deep compartment should be released
  17. 17. Henry approach
  18. 18.  Volar ulnar approach
  19. 19.  Dorsal approach
  20. 20. LEG  Fibulectomy – Patman / radical surgery  Perifibular fasciotomy – Matsen Single incision technique
  21. 21.  Double incision technique - Mubarak
  22. 22. THIGH  3 compartments
  23. 23. FOOT  Claw toe deformity  Calcaneal fractures / Lisfranc injury / blunt trauma  Difficult to diagnose
  24. 24. AFTERCARE  Collagen / Cuticell  Splintage  Antibiotics  Wound inspection after 48 hrs  Opsite roller  Vessel loop bootlace  Plastic surgery
  25. 25. COMPLICATIONS 1. COMPARTMENT SYNDROME 2. FASCIOTOMY
  26. 26. MEDICAL MANAGEMENT  Mannitol  Hyperbaric oxygen
  27. 27. SKELETAL INJURIES  Fracture must be stabilized  Location, character of fracture / skill of surgeon  Plating / nailing / ex fix  Soft tissue coverage
  28. 28. MUST AVOID  CONTRACTURE  SENSORY DEFICIT  PARALYSIS  INFECTION  NON UNION  AMPUTATION

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