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Acute compartment syndrome
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- 2. HISTORY Raised pressurein a closed space Richard von Volkmann Hilderbrand Rowlands Murphy
- 3. PATHOPHYSIOLOGY Raised pressurewithin a confined space Increased volume of compartment
- 4. Ischemia reperfusioninjury 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. ETIOLOGY Decreased compartmentsize 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. DIAGNOSIS : CLINICALASSESSMENT 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. 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. TISSUE PRESSURE MEASUREMENT Incipient vs. fulminant Ideally after every fracture Polytrauma patient Chemical overdose / head injury + long bone fracture Arterial repair
- 9. MEASUREMENT TECHNIQUES 1. Needlemanometer • Landerer • 18 gauge needle, 20ml syringe, column of saline and air, mercury manometer
- 10. 2. Wick catheter •Scholander • Polyglycolic acid suture, polyethylene tubing • Disadvantage
- 11. 3. Slit catheter •Rorabeck • Polyethylene tubing with 5 3mm slits in end
- 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. PRESSURE THRESHOLD FORFASCIOTOMY 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. TREATMENT OF INCIPIENTCOMPARTMENT 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. HAND Clinical feature Crush injury / carpal fracture Longitudinal dorsal incisions
- 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
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- 18. Volar ulnarapproach
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- 20. LEG Fibulectomy –Patman / radical surgery Perifibular fasciotomy – Matsen Single incision technique
- 21. Double incisiontechnique - Mubarak
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- 23. FOOT Claw toedeformity Calcaneal fractures / Lisfranc injury / blunt trauma Difficult to diagnose
- 24. AFTERCARE Collagen /Cuticell Splintage Antibiotics Wound inspection after 48 hrs Opsite roller Vessel loop bootlace Plastic surgery
- 25. COMPLICATIONS 1. COMPARTMENT SYNDROME 2.FASCIOTOMY
- 26. MEDICAL MANAGEMENT Mannitol Hyperbaric oxygen
- 27. SKELETAL INJURIES Fracturemust be stabilized Location, character of fracture / skill of surgeon Plating / nailing / ex fix Soft tissue coverage
- 28. MUST AVOID CONTRACTURE SENSORY DEFICIT PARALYSIS INFECTION NON UNION AMPUTATION