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Compartment Syndrome.ppt
- 2. Compartment Syndrome Definition • Elevated tissue pressure within a closed fascial space • Reduces tissue perfusion • Results in cell death • Pathogenesis – Too much inflow (edema, hemorrhage) – Decreased outflow (venous obstruction, tight dressing/cast)
- 3. Compartment Syndrome Historical Review • Late complications of ischemic contracture – Volkmann, 1881 • Ischemia of forearm venous stasis leading to irreversible contracture – Ellis, 1958; Seddon, 1966 • Lower extremity • Retrospective reviews – Advised the early recognition of the syndrome and fasciotomies of the affected limbs
- 4. Compartment Syndrome Pathophysiology • Normal tissue pressure – 0-4 mm Hg – 8-10 with exertion • Absolute pressure theory – 30 mm Hg - Mubarak – 45 mm Hg - Matsen • Pressure gradient theory – < 20 mm Hg of diastolic pressure – Whitesides – McQueen, et al
- 5. Compartment Syndrome Tissue Survival • Muscle – 3-4 hours - reversible changes – 6 hours - variable damage – 8 hours - irreversible changes • Nerve – 2 hours - looses nerve conduction – 4 hours - neuropraxia – 8 hours - irreversible changes
- 6. Compartment Syndrome Etiology • Fractures-closed and open • Blunt trauma • Temp vascular occlusion • Cast/dressing • Closure of fascial defects • Burns/electrical • Exertional states • GSW • IV/A-lines • Hemophiliac/coag • Intraosseous IV(infant) • Snake bite • Arterial injury
- 7. Compartment Syndrome Diagnosis • Pain out of proportion • Palpably tense compartment • Pain with passive stretch • Paresthesia/hypoesthesia • Paralysis • Pulselessness/pallor
- 8. Compartment Syndrome Differential diagnosis • Arterial occlusion • Peripheral nerve injury • Muscle rupture
- 9. Compartment Syndrome Pressure Measurements • Suspected compartment syndrome • Equivocal or unreliable exam • Clinical adjunct • Contraindication – Clinically evident compartment syndrome
- 10. Compartment Syndrome Pressure Measurements • Infusion – manometer – saline – 3-way stopcock (Whitesides, CORR 1975) • Catheter – wick – slit wick • Arterial line – 16 - 18 ga. Needle (5-19 mm Hg higher) – transducer – monitor • Stryker device – Side port needle
- 11. Compartment Syndrome Pressure Measurements • Arterial line – Zero at the level of the affected limb
- 12. Compartment Syndrome Pressure Measurements • Needle – 18 gauge – Side ported • Catheter – wick – slit wick • Performed within 5 cm of the injury if possible- Whitesides, Heckman Side port
- 13. Compartment Syndrome Emergent Treatment • Remove cast or dressing • Place at level of heart (DO NOT ELEVATE to optimize perfusion) • Alert OR and Anesthesia • Bedside procedure • Medical treatment
- 14. Compartment Syndrome Surgical Treatment • Fasciotomy - prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma. • Fracture care – rigid stabilization – Ex-fix – IM Nail
- 15. Compartment Syndrome Indications for Fasciotomy • Unequivocal clinical findings • Pressure within 15-20 mm hg of DBP • Rising tissue pressure • Significant tissue injury or high risk pt • > 6 hours of total limb ischemia • Injury at high risk of compartment syndrome • CONTRAINDICATION - Missed CS (>24- 48 hrs)
- 16. Fasciotomy Principles • Make early diagnosis • Long extensile incisions • Release all fascial compartments • Preserve neurovascular structures • Debride necrotic tissues • Coverage within 7-10 days
- 17. Compartment Syndrome Forearm Anatomy • Anatomy-3 compartments – Mobile wad-BR,ECRL,ECRB – Volar-Superficial and deep flexors, Pronator teres, Supinator – Dorsal-Extensors
- 18. Forearm Fasciotomy • Volar-Henry approach – Include a carpal tunnel release • Release lacertus fibrosus and fascia
- 19. Forearm Fasciotomy • Protect median nerve, brachial artery and tendons after release • Consider dorsal release
- 20. Compartment Syndrome Leg Anatomy • 4 compartments – Lateral: Peroneus longus and brevis – Anterior: EHL, EDC, Tibialis anterior, Peroneus tertius – Posterior-Gastrocnemius, Soleus – Deep posterior-Tibialis posterior, FHL, FDL
- 21. Leg Fasciotomies • Generous skin incisions – medial – lateral • Release completely all 4 fascial compartments • Beware of neurovascular structures to prevent iatrogenic injury
- 22. Fasciotomy: Medial Leg Flexor digitorum longus Gastroc-soleus
- 23. Fasciotomy: Lateral Leg Superficial peroneal nerve Intermuscular septum
- 24. Compartment Syndrome Thigh • Lateral to release anterior and posterior compartments • May require medial incision for adductor compartment Lateral septum Vastus lateralis
- 25. Compartment Syndrome Foot • Four major compartments • Multiple layers • Careful exam with any swelling • Clinical suspicion with certain mechanisms of injury – Lisfranc fracture dislocation – Calcaneus fracture
- 26. Compartment Syndrome Foot Fasciotomies • Dorsal incision-to release the interosseous, central and lateral compartments • Medial incision-to release the medial compartment
- 27. Compartment Syndrome Other Areas • Can occur anywhere in the body • Hand-dorsal incisions, thenar, hypothenar • Arm-lateral incision • Buttock-posterior (Kocher) approach • Abdominal- with the Trauma surgeons
- 28. Interim Coverage Techniques • Simple absorbent dressing • Semipermeable skin-like membrane • Vessel loop “bootlace” • Sutures progressively tightened in ensuing days • “VAC” (Vacuum Assisted Closure)
- 29. Aftercare • Wound is not closed at initial surgery • Second look debridement with consideration for coverage after 48-72 hrs – Limb should not be at risk for further swelling – Pt should be adequately stabilized – Usually requires skin graft – DPC possible if residual swelling is minimal • Goal is to obtain definitive coverage within 7-10 days – DPC/STSG/flap if nerves, vessels, bone exposed
- 30. Compartment Syndrome Medical-Legal • Most frequent cause of litigation • 1992-average award $225K-Hennepin County, Minn. • Medical health care providers • Lawyers • Mass media