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Compartment syndrome
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- 2. 2 “An elevation of interstitial pressurein a closed osteo-fascialcompartment that results in microvascular compromise.” Itis a serious condition Requires emergency medical attention The first medical referencewasin 1881, whenGerman doctor Richard von Volkm`ann described a permanent contractureof theforearm related to ischemia within muscle compartmentsof the arm Compartments– grouping of muscles, nerves and blood vessels in the extremities. Inelastic fascia encases the compartments, protects the tissues, and maintains tissue shape ANATOMY COMPARTMENT SYNDROME FIRST DOCUMENT
- 3. 3 Lower Extremity Compartments – Calf Anterior Lateral Deep Posterior Superficial Posterior MOST likely to be affected a) Tibialis anterior Extensor muscles of toes b) Anterior Tibial artery c) Deep peroneal nerve a. Peroneus longusand peroneus brevis b. superficial peroneal artery a. Tibialis posterior b. flexor digitorum longus c. flexor hallus longus a. Gastrocnemius b. soleus muscle c. Suralnerve d. Lithotomy positions
- 4. 4 Lower Extremity Compartments – Thigh
- 5. 5 Cross sectional anatomy of thigh
- 6. 6 Lower Extremity - Calf Lower Extremity – Thigh Upper Extremity 1. Deep PeronealNerve (most commonlyaffected) - Anterior compartment. Sensoryterritoryis confined to webspace between 1st and 2nd toes and activates dorsiflexion 2. SuperficialPeronealNerve runsalong lateralcompartment and supplies dorsum of the foot (except 1st webspace) 3. PosteriorTibialNerve is within deep posterior compartmentand provides sensation to plantar surfaceof the foot – motor function is flexion of the toes FemoralNerve Anterior Compartment Most commonly affected Obturator Nerve Medial Compartmentof thigh Sciatic Nerve Posterior Compartmentof thigh 1. Radial Nerve Back of the arm and wraps around to skin of forearms and hands 2. Median Nerve Main nerves of arm that runsfull length Axilla injury 3. UlnarNerve • Extends from cervical collar • 4th and 5th digits PHYSICAL ASSESSMENT
- 7. 7 Complications if not treated Volkmann’scontracture Permanentsensory and motor deficit Infection Chronic Pain Amputation TISSUE SURVIVAL RATE
- 8. 8 Myoglobinuria after4 hours Renal failure Maintain a high urinaryoutput Alkalinize the urine Celldeath initiates a “viciouscycle” o increase capillary permeability o increased muscle swelling PATHOPHYSIOLOGY
- 10. 10 RISK FACTORS
- 11. 11 Pain that is out of proportion to the injury • Pain with passive stretch of muscle • Persistent deep ache or burning • FIRSTpresenting symptom DIAGNOSIS PAIN PRESSURE
- 12. 12 Often not utilized – proper equipmentrequired and user errorsare common • >30-40 mmHg considered diagnostic A condition in which you feel sensation of numbnessor prickling Pins & Needles Early →contained to one compartment Late→ globally within limb Rarely present Often times, redness progressesto pallor Sign of vascular injury and quickly leads to ischemia LATE stage – emergent intervention require The existence of distal pulses DO NOT exclude compartmentsyndrome Check above and below area of concern Late stage – indicates progression PARESTHESIA PALLOR PULSELESSNESS
- 13. 13 Complete loss of muscle function for one or moremuscle groups Verylate finding→indicating nerve damage DIFFERENTIALDIAGNOSIS INVESTIGATION Full blood count Coagulation Profile X-ray/ultrasound Creatinine Phosphokinase Urine myoglobin PARALYSIS Cellulitis DVTand thrombophlebitis Gas Gangrene Necrotizing fasciitis Peripheral vascular injuries
- 14. 14 EVALUATION 1. Stryker Manometer 2. Mercurymanometer 3. Wick hand instrument Surgical(Should notbedelayed) Medical Management Physical therapyManagement TREATMENT
- 15. 15 Medical Management ABC’s. Correcthypotension Remove circumferentialbandages& cast Limb at level of the heart o moreelevation reduces the arterialinflow Supplementaloxygen administration With tight cast, compartmentalpressurefalls: o 30% when cast is split on one side o 65% when cast is split Bilaterally o 75% with Splitting the inside padding o 85 – 90% complete removal of cast Surgical Management Fasciotomy Skin and All compartments. 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
- 16. 16 Clinical pictureequivocal Altered consciousness Multiple injuries Epiduralanesthesia Concomitantnerveinjury Children Types 1. Singleincision HIGH RISK
- 17. 17 2. Double incision Late treatment Early treatment
- 18. 18 Contra-indications to fasciotomy Confirmed acute compartmentsyndromediagnosisfor > 48 hours o damagecannotbe reversed and o significantinfection rate when dead tissue exposed o Alreadydead muscles, as in crush injuries EDUCATION: Wearing moreappropriatefootwear Choosing more appropriatesurfacesand terrain for exercise Pacing your activities Avoiding certain activities altogether PT MANAGEMENT Stretching. ROM Muscle Stengthenin g Manual therapy Education Modalitie s
- 19. 19 Modifying your workplace to lower risk of injury PRICE(protection, rest, ice, compression, elevation) Summary Compartmentsyndromeis a clinical diagnosis should not be missed - disaster Requires urgenttreatment “Time” is the most important factor to avoid irreversible complications Do NOT applycircumferential dressings