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Compartment Syndrome by dr bedru mo.pptx
- 1. Compartment Syndrome Moderator: DrDagmawi ( Consultant PRS) Presentor: Dr Natnael Fikru (OSR II) 3/11/2024 1
- 2. Content • Definition • Historicalbackground • Pathogenesis • Clinical presentation • Diagnosis • Treatment • Complication • Referrence 3/11/2024 2
- 3. Objective • To understandkey definitions in compartment • To have clear diagnostic plan • To determine treatment options • To understand complications and preventive options 3/11/2024 3
- 4. Introduction • ACS- isa surgical emergency where the ICP is elevated to a level and for a duration that with out emergent fasciotomy and decompression leads to muscle ischemia and necrosis. 3/11/2024 4
- 5. Terms • Exersional CS: Elevation of ICP during exercise • Volkmann ischemic C: is the end stage of neglected ACS with irreversible muscle necrosis leading to ischemic contractures . • The crush syndrome is the systemic result of muscle necrosis commonly caused by prolonged external compression of an extremity 3/11/2024 5
- 6. History • Richard VonVolkmann, 1881 • “for many years I have noted on occasion, following the use of bandages too tightly applied, the occurrence of paralysis and contraction of the limb, NOT … due to the paralysis of the nerve by pressure, but as a quick and massive disintegration of the contractile substance and the effect of the ensuing reaction and degeneration” 6 3/11/2024
- 7. • In 1911Bernhard Bardenheuer first considered fasciotomy as a potential therapy, shortly before JB murphy in 1914 suggested, that fasciotomy should be used to relieve the pressure in edematous extremities. • PN Jepson established fasciotomy in 1926 • Finochietto started research on compartment syndrome of upper limb in 1920, but the current term "compartment syndrome" was not established before 1963 by Reszel et al. from mayo clinic 7 3/11/2024
- 8. • 1970 numerousinvestigators established the pathophysiology of CS • In 2005 data of computerized search of US national pediatric trauma registry reported 85% of cases as a sequel to fractures, while 13% where STI 8 3/11/2024
- 9. Epidemiology • 3.1 per100,000 per annual among western • 7.3 per 100000 in male and 0.7 per 100,000 in female ( 10x increase) 3/11/2024 9
- 10. Etiology and Riskfactor • Most commonly fracture ( 69% in adult & 76% in children) Tibia>>>> Distal radius>>> forearm • Soft tissue injury • Male • Adolescence/young more at risk { in tibia # 3x less in age > 35 and 35X lower for distal radius in older patient} • Low energy >>>>> High energy 3/11/2024 10
- 11. • 61% ofACS of non-fracture in children is iatrogenic • Non fracture ACS is more in older pt with associated co-morbidity with M=F, use of anti-coagulant is also risk factor • Polytrauma patient risk for delay in dx so high suspicious for risk factor 3/11/2024 11
- 12. Pathogenesis I. Critical closingPressure theory • States there is CCP in the small vessels when transmural pressure drops • TM= IVP-Tissue P • TM is moderated by constricting force governed by smooth muscle on the walls • States as the tissue pressure increase arteriolar closure resulting blood flow to cease • Critics claim ischemia is major trigger for compensatory arteriole vasodilation 3/11/2024 12
- 13. II. Arteriovenous gradientTheory • According to this theory the increases in local tissue pressure reduce the local AV pressure gradient and thus reduce the blood flow • LBF = (Pa − Pv) ÷ R • Most accepted • Elevation of limb in presence of raised tissue further decrease AV gradient 3/11/2024 13
- 14. III. Micro-vascular OcclusionTheory • Postulate capillary occlusion is main stay for ACS • Animal based study • Claims capillary closure further capillary leaking and further worsen tissue pressure 3/11/2024 14
- 15. Diagnosis of AcuteCompartment Syndrome Prompt diagnosis of ACS is the key to a successful outcome. Delay in diagnosis - single cause of failed ACS treatment. Clinical symptoms and signs and/or ICP monitoring for the diagnosis. 3/11/2024 15
- 16. I. Clinical Diagnosis pain on passive stretching(Sn-13%,Sp-97%) Pain( progressive, not relieve with imm, refractory) Pain out of proportion to the injury(Sn-13%,Sp-97%) Paresthesia(Sn-13%,Sp-98%) Paralysis Pulselessness Pallor Absent capillary refill poikilothermia Tense swelling(Sn-54%, Sp-76%) XR must be obtained to rule out Fx 3/11/2024 16
- 17. • Tissue survival –Muscle • 3-4hr reversible changes • 6hrs- variable damage • 8hrs- irreversible ischemia • Central is most affected • Some are more vulnerable – Nerve • 2hrs- looses nerve conduction • 4hrs- neurapraxia • 8hrs- irreversible changes Effect on Bone Non union Psudo-arthrosis Reperfusion Injury After reestablishment of blood flow to ischemic muscle after fasciotomy Due to inflammatory response for muscle breakdown like pro- coagulant If large muscle can result systemic presentation 3/11/2024 17
- 18. Risk factors fordelayed ACS Dx Reliance on clinical signs alone Children Sedated pts Patient controlled analgesia/regional anesthesia Unconscious/obtunded pts pts with Learning disabilities Psychiatric pts Pts with neurologic deficit 3/11/2024 18
- 19. Diagnostic performance ofclinical Sxs & Sns Employing a combination of clinical signs and symptoms raises the Dxtic sensitivity. Pain, pain on passive stretching, paresthesia and paralysis utilized. One positive sign has sensitivity of < 26 %. To achieve a probability of > 90 %, 3 clinical findings must be noted and the 3rd finding must be paresis. 3/11/2024 19
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- 21. II. ICP measurement Is the most sensitive and specific ACS Dxtic method and considered confirmatory. Invasive and non invasive methods are available. 3/11/2024 21
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- 25. Technique of ICPmeasurement Mark the proper entry site Strict asepsis of entry site. Needle entered perpendicular to skin. Transducer placed level with the compartment being measured. Avoid placement of catheter at Fx site but within 5cm of Fx site. Checking correct placement of catheter within the desired compartment. 3/11/2024 25
- 26. Normal tissue compartmentpressure • Normal resting ICP is up to 10 mm Hg, but may reach 18 mmHg and less than 20 mmHg is well tolerated. 3/11/2024 26
- 27. ICP threshold forACS Dx Absolute ICP > 40mmHg Delta(∆) P= DBP- ICP, value < 30mmHg In children MAP is used instead of DBP ∆P is more has a better diagnostic performance. Thresholds apply equally for anatomic areas other than leg. 3/11/2024 27
- 28. AICP vs Delta(∆)P 3/11/2024 28
- 29. Clinical Dx vsDx with CICP 3/11/2024 29
- 30.
- 31. • Both thetime and severity is factor for fasciotomy • Continuous ICP measurement is gold standard • Persistent delta pressure <30 for more than 2 hrs is indication to go for fasciotomy • Fasciotomy should not be done with single measurement unless in extreme cases 3/11/2024 31
- 32. Management principles • PrepareOR • Drape the patient – sterile technique • Administer prophylactic antibiotics • Make your skin incisions extensile • Decompress all compartments • May require individual epimysiotomy • Debride obvious muscle necrosis at initial operation • Second look at 24 to 72 hours for muscles vascularity uncertain 32 3/11/2024
- 33. Treatment consists of decompression: •Remove the tight bandage or plaster cast/spltting and spreading • Escharotomy (decompression of the skin)—in cases of burns • Fasciotomy • Epimysiotomy (decompression of the connective tissue between muscles and fascia) • Limb should not be elevated above the level of heart 3/11/2024 33
- 34. Timing • After 6-8hrsof decreased MPP muscle extensive necrosis is inevitable • Peripheral nerve will also have permanent functional impairment • After 8-10hrs infection risk is very high and amputation is likely therefore decision for fasciotomy should be done by most senior surgeon 3/11/2024 34
- 35. Leg Approach forDecompression of CS 3/11/2024 35
- 36.
- 37. • Single incisionfasciotomy with Vs without fibulectomy • Double Vs single incision fasciotomy 3/11/2024 37
- 38. Approach to ThighCS • Compartment syndrome of the thigh is a rare but serious condition that may result in high rate of morbidity and mortality. • Limited resource 3/11/2024 38
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- 43. Treatment • Non operative •expedient fasciotomy – Single Vs. double incision – Relook(48-72hrs) 3/11/2024 43
- 44. • Close medialwound 1st • Attempt delayed 1ry closure (3-4trials) then, • STSG 3/11/2024 44
- 45. Approach to forearmCS • the forearm contains 3 compartments • Volar • Dorsal • Mobile wad 45 3/11/2024
- 46. Standard Anterior dermato-faciotomy 1.Make anterior curvilinear incision medial to biceps tendon 2. Cross elbow flexion crease at an angle 3. Divide bicipital aponeurosis 4. Go distally into palm to allow carpal tunnel release, but avoid wrist flexion crease at right angle 5. Divide flexor retinaculum at wrist 6. With scissors free the fascia over superficial compartment muscles 46 3/11/2024
- 47. Volar incision 5. IdentifyFCU and retract it with its underlying ulnar NV bundle medially 6. Retract FDS and median nerve laterally to expose the FDP in its deep compartment 7. Check if its overlying fascia or epimysium is tight, and incise it longitudinally 8. Continue disection distally by incising transverse carpal ligament along the ulnar border of PL and median nerve 47 3/11/2024
- 48. Modified Anterior dermato-faciotomy approach •Extend over carpal tunnel and guyons canal ( for Median and ulnar nerve decompression) • As henrys approach • If needed can cross AL of elbow • Avoid incision over cubital fossa 3/11/2024 48
- 49. Modified Approach toforearm CS 3/11/2024 49
- 50. Dorsal incision • Straightline 5cm distal to lateral epicondyle between EDC and ECRB and extend it about 10 cm distally • Gently undermine subcutaneous tissue and release fascia overlying mobile wad of henry Apply a sterile moist dressing and a long-arm splint. The elbow should not be left flexed beyond 90 degree 50 3/11/2024
- 51. Hand decompression • Twolongitudinal incisions over 2nd and 4th metacarpals. With this incisions we can decompress dorsal and palmar interrossei , adductor compartment 51 3/11/2024
- 52.
- 53. • longitudinal incisionradial side of 1st metacarpal • decompresses thenar compartment • longitudinal incision over ulnar side of 5th metacarpal • decompresses hypothenar compartment 3/11/2024 53
- 54. Hand decompression 54 • Incisethe fascia, and release the compression of the distended muscles by allowing them to extrude into the wound if necessary. 3/11/2024
- 55. Hand decompression 55 • Ifthe digit require decompression incision made at mid axial plane on independent side. – Ulnar side : middle , index and ring finger – Radial side : little finger and thumb 3/11/2024
- 56. Post fasciotomy wound •Pack wound loosely open with saline-dampened gauze and apply a bulky dressing • Never close incisions immediately after fasciotomy • Second look at 24 to 72 hours for possible repeat debridement • Active and active-assisted ROM of adjacent joint on 2nd day post op • If split thickness skin graft, immoblize limb for 3-5 days to decrease sheer forces across graft • When graft incorporated, re-institute ROM 56 3/11/2024
- 57. Delayed surgical closure •Fasciotomy wound is clean, fracture stabilized and swelling subsided ( Closure in 3-7 days) Elastic vessel loop Skin graft vacuum wound management Immobilize with long splint/ don’t Flex > 90 3/11/2024 57
- 58. Late diagnosis after8-10 hrs? • Finkelsein et al, conclued that sequel of infection after delayed fasciotomy is worse than the late muscle contracture due to the fibrosis • Sheridan and matsen reported an infection rate of 46% and amputation rate of 21% after late fasciotomy • Sometimes, doing nothing is the treatment of choice 58 3/11/2024
- 59. Complications • Classic complicationis VIC • Weak muscle function • Claw hands • Decreased sensation • Neurologic deficit (21%) • Infection • Muscle herniation • Wound discoloration 59 3/11/2024
- 60. Summary • ACS isorthopedic emergency • Delayed or missed diagnosis can result in devastating loss of function and limb loss • Difficult in diagnosis in children, obtunded and comatous patient, so high degree of suspision • Decompression of all the compartments is the mainstay of treatment • Appropriate care should be given to post operative wounds 3/11/2024 60
- 61. Reference • Campbell’s operativeorthopedics 11th Ed • Rockwood and green’s fractures in adults 8th Ed • Chapman’s orthopedic surgery 3rd edition • Orthobullet 2021 • PubMed – publications • Internet 3/11/2024 61
- 62.
Editor's Notes
- #6 the elevation of intracompartmentalpressure during exercise, causing ischemia,pain, and rarely neurologic symptoms and signs. It is characterized by resolution of symptoms with rest but may proceed to acute compartment syndrome if exercise continues The crush syndrome is the systemic result of muscle necrosiscommonly caused by prolonged external compression of an extremity. In crush syndrome muscle necrosis is established by the time of presentation, but ICP may rise as a result of intracompartmental edema, causing a superimposed acute compartment syndrome.
- #7 Although larrey in 1812 and hamilton in 1850 gave some descriptions of CS, the first man to do publication was RVV who in 1881 said …
- #11 Used to believe high energy usually open is more associated with ACS but large eidnberg study show more associated with closed in 59% …… suggested that high energy disrupt each compartment fascia so gives autodecompression……. But low energy doesnot ………. Also for tibia 60 is gA type III but only 20% has ACS Reason why young is with the same fascia layer has larger muscle bulk so low free space. Older atrophied muscle is protective also hypertension is also protective from ACS In karge eidinburg study youth and being male has shown association of o.oo1 with ACS The only exception for being young is soft tissue injury wher average age is 36 years and older than those with fracture
- #12 Base deficit… requirment for transfusion……high serum lactate is risk group in polytrauma
- #13 is a critical closing pressure in the small vessels when the transmural pressure (TM) (the difference between intravascular pressure and tissue pressure) drops.19 TM is balanced by a constricting force (TC) consisting of active and elastic tension derived from smooth muscle action in the vessel walls.
- #14 According to this theory the increases in local tissue pressure reduce the local AV pressure gradient and thus reduce the blood flow. When flow diminishes to less than the metabolic demands of the tissues (not necessarily to zero), then functional abnormalities result. The relationship between AV gradient and the local blood flow (LBF) is summarized in the equation:LBF = (Pa − Pv) ÷ R where Pa is the local arterial pressure, Pv is the local venous pressure, and R is the local vascular resistance. Veins are collapsible tubes and the pressure within them can never be less than the local tissue pressure. If tissue pressure rises as in the acute compartment syndrome, then the Pv must also rise, thus reducing the AV gradient (Pa − Pv) and therefore the local blood flow. At low AV gradients compensation from R is relatively ineffective62 and local blood flow is primarily determined by the AV gradient. Matsen et al.92 presented results on humansubjects demonstrating reduction of the AV gradient with elevation of the limb in the presence of raised tissue pressure
- #15 Measurement of capillary pressure in dogs with normal tissue pressures revealed a mean level of 25 mm Hg. Hargens et al.52 suggested that a tissue pressure of similar value is sufficient to reduce capillary blood flow
- #17 Peripheral pulses and capillary return are always intact in ACS. Absent peripheral pulses, pallor, and reduced capillary return are late clinical signs of ACS and will be associated with a vascular injury requiring an angiogram, or an established ACS where amputation is often inevitable. Conversely, it is dangerous to exclude the diagnosis of ACS because distal pulses are present. The pain is Out of proportion Progressive Not relieved by immobilization Present on passive muscle stretch Refractory to analgesia Pain – a subjective symptom can be reduced/unreliable If there is concomitant nerve injury Obtunded Anesthesized Children 4 cases of ACS without pain, diagnosis confirmed after fasciotomy Badhe et al. the ‘silent compartment syndrome
- #18 Evidence indicates that muscle necrosis is present in its greatest extent centrally in the muscle, and that external evaluation of the degree of muscle necrosis is unreliable. The duration of muscle ischemia dictates the amount of necrosis, although some muscle fibers are more vulnerable than others to ischemia. For example, the muscles the anterior compartment of the leg contain type I fibers or red slow twitch fibers, whereas the gastrocnemius contains mainly type II or white fast twitch fibers. Type I fibers depend on oxidative metabolism of triglycerides for their energy source and are more vulnerable to oxygen depletion than type II fibers whose metabolism is primarily anaerobic. The mechanism of damage to nerve is as yet uncertain and could result from ischemia, ischemia plus compression, toxic effects, or the effects of acidosis caused obliteration of the “musculodiaphyseal” vessels and caused frequent pseudarthrosis.
- #23 Asyringe filled with air is attached to this column, as is a pressure manometer or transducer. The ICP is the pressure that is required to inject air into the tubing and flatten the meniscus between the saline and the air. This method was modified by Matsen et al. to allow infusion of saline into the compartment.90,91 The ICP is the pressure resistance to infusion of saline. These methods, although simple and inexpensive, have some drawbacks. A danger exists of too large a volume being infused, possibly inducing acute compartment syndrome. Itis probably the least accurate of the measurement techniques available, with falsely high values having been recorded in comparison with other technique. The wick catheter was first described for use in acute compartmentsyndrome by Mubarak et al.105 This is a modification of the needle technique, in which fibrils protrude from the bore of the catheter assembly. This allows a large surface area for measurement and prevents obstruction of the needle; it is ideal for continuous measurement. A disadvantage of this technique is the possibility of a blood clot blocking the tip or air in the column of fluid between the catheter and the transducer, which will dampen the response and give falsely low readings. There is a theoretical risk of retention of wick material in th The slit catheter was first described by Rorabeck et al.127 This operates on the same principle as the wick catheter in that it is designed to increase the surface area at the tip of the catheter by means of being cut axially at the end of the catheter (Fig. 29-3). The interstitial pressure is measured through a column of saline attached to a transducer. Patency can be confirmed by gentle pressure over the catheter tip; an immediate rise in the pressure should be seen. Care must be taken to avoid the presence of air bubbles in the system as this can, like the wick catheter, result in falsely low readings. The slit catheter is more accurate than the continuous infusion method104 and is as accurate as the wick catheter Attempts to improve the reliability of ICP measurement ledto the placement of the pressure transducer directly into compartment. thesolid state transducer intracompartmental catheter (STIC) was described in 1984 and measurements were correlated with conventional pressure monitoring systems.93 This device is now commercially available and widely used, although to retain patency of the catheter for continuous monitoring an infusion must be used with its attendant problems. The alternative is intermittent pressure measurements, which is likely to cause significant discomfort to patients and is more labor intensive
- #33 WHY TORNIQUET? do fasciotomy in blood less field to save time and to reduce risk of iatrogenic tissue damage, especially to nerves deflate immediately after procedure – 5-10 minutes WHY EXTENSILE? - limited exposure may not allow for complete decompression - blind procedure is prone to iatrogenic tissue damage - post ischemic hyperemia following fasciotomy increases volume of limb further, resulting even muscles to protrude through the incision site - limited incision will not allow that swelling
- #36 The anterior compartment contains the extensor muscles of the foot and ankle. Its medial boundary is the lateral (extensor) surface of the tibia, and its lateral boundary is the extensor surface of the fibula and anterior intermuscular septum. The anterior compartment is enclosed by the deep fascia of the leg and all its muscles are supplied by the deep peroneal nerve. The compartment’s artery is the anterior tibial artery The peroneal compartment is bounded by the anterior intermuscular septum in front, by the posterior intermuscular septum behind, and by the fibula medially. It contains the peroneal muscles which evert the foot. The superficial peroneal nerve supplies all the muscles in the compartment. No artery runs in it; its muscles receive their supply from several branches of the peroneal artery The superficial flexor compartment contains three muscles: the gastrocnemius, soleus, and plantaris. The compartment is separated from the lateral (peroneal compartment) by the posterior intermuscular septum. It is separated from the deep posterior flexor compartment by a fascial layer
- #37 To decompress the anterior and lateral compartments, make a longitudinal incision overlying the anterolateral aspect of the lower leg. A: Begin at the level of the tibial tubercle and extend the incision to end 6 cm above the level of the ankle. B: Incise the fascia overlying the anterior and lateral compartments in the line of the skin incision To decompress the superficial and deep flexor compartments, make a longitudinal incision overlying the posteromedial aspect of the lower leg. Begin at the level of the tibial tubercle and extend the incision distally, ending 6 cm above the ankle. At right, transverse section showing the fascial compartments. Incising the fascia overlying the anterior, lateral, and superficial flexor compartments is easy. Decompressing the deep flexor compartment may involve lifting the soleus muscle of the intermuscular septum and dividing that septum under direct vision, taking care to avoid the posterior neurovascular bundle
- #38 First with fibula excision was introduced …. More extensive muscle debridedment and risk of common peroneal nerve injury Single incision four-compartment fasciotomy without fibulectomy can be performed through a lateral incision that affords easy access to the anterior and lateral compartments.22 Anterior retraction of the peroneal muscles allows exposure of the posterior intermuscular septum overlying the superficial posterior compartment. The deep posterior compartment is entered by an incision immediately posterior to the posterolateral border of the fibulaDouble incision fasciotomy is faster and probably safer than single incision methods because the fascial incisions are allsuperficial Using the single incision method, it can be difficult to visualize the full extent of the deep posterior compartment.Both methods seem to be equally effective at reducing ICP. In the thigh and gluteal regions decompression is simple and the compartments are easily visualized.
- #39 Less common due to volumious space
- #44 Nonoperative treatment for TCS is controversial. At minimum, it should be reserved for the awake, interactive patient who can be properly followed up clinically. It should be undertaken in a hospital setting, and the patient, family, and all members of the medical team should have a clear dialogue Medial approach_ The pubic tubercle and saphenous hiatus are palpated and an incision starting between the 2 and coursing toward the medial epicondyle is made along the course of the saphenous vein Lateral approach_ A line is drawn from the tip of the greater trochanter proximally to the lateral epicondyle of the femur distally
- #45 For patients in whom the diagnosis has been delayed for more than twelve hours (or even 6 hours in the face of high intracompartmental pressures), strong consideration should be given to avoid exposing these damaged tissues to the environment due to increased infection risk
- #46 The volar compartment contains three layers superficial - PT, FCR, PL, FCU intermediate - FDS and deep - FDP, FPL, PQ extensor compartment - ECRL, ECRB, ECU - ED, EI, EDM - APL, EPB, EPL - all are held in place in the wrist region by the ER, preventing them to bowstring when hand is extended at wrist joint mobile wad is brachioradialis, ECRB, ECRL
- #49 It continues with a curved incision towards the radial side of the mid-forearm and proximally on the anterolateral aspect of the forearm, as in a standard Henry approach. If needed, the dermato-fasciotomy should cross the anterolateral aspect of the elbow, maintaining coverage of the neurovascular bundle running through the cubital fossa in those cases where the wound is left open. A straight incision across the anterior elbow may result in contracture of the joint
- #50 In the mid-forearm, the curved incision with its apex on the anterolateral aspect of the mid-forearm will expose the flexor compartment. Through this part of the incision, the deep volar compartment may be approached between the radial artery and the flexor carpi radialis muscle. The artery is retracted laterally (and not medially as with the standard approach to the midshaft of the radius. The superficial flexor muscle mass is exposed and the overlying fascia released. This includes the finger and wrist flexors, and exposes the median nerve, which should be identified between the deep and superficial flexor muscles and protected, gently retracting it medially with the superficial flexor muscle mass. The radial artery is retracted laterally with the brachioradialis muscle and superficial radial nerve, to expose and permit division of the fascia over the deep flexor muscles. Releasing the extensor carpi ulnaris muscle belly from the posterior aspect of the ulna may be sufficient, although there are no data to support this and a clinical decision has to be made during the procedure
- #55 Identify each muscle individually to ensure that a complete release is done. Passively flex the metacarpophalangeal joints, and extend the proximal interphalangeal joints to stretch the muscles, ensuring that all are adequately released
- #58 Vacuum wound management devices are often used in this setting and they may reduce the swelling more quickly and potentially allow earlier skin closure with less need for grafting. In many cases, a complete delayed primary closure of a dermato-fasciotomy wound can be achieved in the pediatric patient. VACUUM ASSISTED - How wound is exposed to subatmospheric pressure of about 125 mmHg (50-200) sterile polyurethane sponge is cut to fit with the entire wound surface -adherent plastic sheet is placed to cover the wound and tubing, which is connected a reservoir and pumb -edema fluid is removed from extravascular space benefit - the mechanical tension stimulates proliferation of granulation tissue if VAC is done, higher proportions of vacuum treated wounds undergo primary closure without needing skin graft skin grafting - gives poor coverage and sensation to wound - cosmetically non appealing the best way to avoid skin graft is to avoid post fasciotomy edema
- #61 Appropriate care should be given to post operative wounds