The document provides an overview of pathology and management of compartment syndrome in orthopedics. It discusses the definition, classification, risk factors, pathophysiology, clinical presentation, diagnosis, and treatment of compartment syndrome. The main treatment is surgical fasciotomy to decompress the pressure in the affected compartment. Early diagnosis and treatment are important to prevent permanent muscle and nerve damage. Complications can include paralysis, contractures, limb loss or death if not properly managed.
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1) Subtrochanteric Fracture
Subtrochanteric typically defined as area from lesser trochanter to 5cm distal fractures with an associated intertrochanteric component may be called peritrochanteric fracture.
*Unique Aspect
Blood loss is greater than with femoral neck or trochanteric fractures – covered with anastomosing branches of the medial and lateral circumflex femoral arteries branch of profunda femoris trunk.
2) Femoral Shaft Fracture
Femoral shaft fracture is defined as a fracture of the diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle
The femoral shaft is padded with large muscles.
- reduction can be difficult as muscle contraction displaces the fracture
- healing potential is improved by having this well-vascularized
*Age
-usually a fracture of young adults and results from a high energy injury
-elderly patients should be considered ‘pathological’ until proved otherwise
-children under 4 years the suspected possibility of physical abuse
*FRACTURES ASSOCIATED WITH VASCULAR INJURY
Warning signs of an associated vascular injury are
(1) excessive bleeding or haematoma formation; and
(2) paraesthesia, pallor or pulselessness in the leg and foot.
~Warm ischemia in 2-3H
~If > 6H – salvage not possible
*‘FLOATING KNEE’
Ipsilateral fractures of the femur and tibia may leave the knee joint ‘floating’
3) Distal Femoral Fracture
Defined as fractures from articular surface to 5cm above metaphyseal flare
*clinical feature
The knee is swollen because of a haemarthrosis – this can be severe enough to cause blistering later
Movement is too painful to be attempted
The tibial pulses should always be checked to ensure the popliteal artery was not injured in the fracture.
Reference: Apley's System of Orthopaedic and Fracture (9th edition)
Vertebral osteomyelitis( spondylodiskitis )
usually seen in adults (median age is 50 to 60 years)
Location
50-60% of cases occur in lumbar spine
30-40% in thoracic spine
~10% in cervical spine
Spinal stenosis is a degenrative spine disorder in which the AP and transverse diameter are decreased causing neural compression and symptoms of chronic & acute nerve compression
1) Subtrochanteric Fracture
Subtrochanteric typically defined as area from lesser trochanter to 5cm distal fractures with an associated intertrochanteric component may be called peritrochanteric fracture.
*Unique Aspect
Blood loss is greater than with femoral neck or trochanteric fractures – covered with anastomosing branches of the medial and lateral circumflex femoral arteries branch of profunda femoris trunk.
2) Femoral Shaft Fracture
Femoral shaft fracture is defined as a fracture of the diaphysis occurring between 5 cm distal to the lesser trochanter and 5 cm proximal to the adductor tubercle
The femoral shaft is padded with large muscles.
- reduction can be difficult as muscle contraction displaces the fracture
- healing potential is improved by having this well-vascularized
*Age
-usually a fracture of young adults and results from a high energy injury
-elderly patients should be considered ‘pathological’ until proved otherwise
-children under 4 years the suspected possibility of physical abuse
*FRACTURES ASSOCIATED WITH VASCULAR INJURY
Warning signs of an associated vascular injury are
(1) excessive bleeding or haematoma formation; and
(2) paraesthesia, pallor or pulselessness in the leg and foot.
~Warm ischemia in 2-3H
~If > 6H – salvage not possible
*‘FLOATING KNEE’
Ipsilateral fractures of the femur and tibia may leave the knee joint ‘floating’
3) Distal Femoral Fracture
Defined as fractures from articular surface to 5cm above metaphyseal flare
*clinical feature
The knee is swollen because of a haemarthrosis – this can be severe enough to cause blistering later
Movement is too painful to be attempted
The tibial pulses should always be checked to ensure the popliteal artery was not injured in the fracture.
Reference: Apley's System of Orthopaedic and Fracture (9th edition)
Vertebral osteomyelitis( spondylodiskitis )
usually seen in adults (median age is 50 to 60 years)
Location
50-60% of cases occur in lumbar spine
30-40% in thoracic spine
~10% in cervical spine
Spinal stenosis is a degenrative spine disorder in which the AP and transverse diameter are decreased causing neural compression and symptoms of chronic & acute nerve compression
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
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3. INTRODUCTION
• Compartment syndrome: clinical condition in which increased pressure
within one or more confined spaces in the body results in insufficient
blood supply to tissues and organs within that space and hence
threatening their viability.
• Head, Chest, abdomen, extremities
• Orthopedics concerns with compartment syndrome affecting the
extremities.
4. INTRODUCTION
• Extremity compartment syndrome is limb threatening condition and an
orthopedic emergency
• It is an elevation of the interstitial pressure in a closed osteo-fascia
compartment that results in microvascular compromise.
• It can occur anywhere skeletal muscles is surrounded by substantial
fascia such as buttock, thigh, leg, foot, hand, forearm, arm and lumbar
para-spinal muscles
• Most commonly occurs following blunt trauma ± fracture
5. HISTORY
• 1881: Richard Von Volksmann suggested that interruption of
blood supply to the extremity muscle resulted in paralysis and
contracture later known as Volkmann’s contracture.
• 1922: Brooks implicated both arterial and venous obstruction as
possible causes of Volkmann's ischemic contracture
• 1924: Paul Jepson reproduced ischaemic contracture in animals
• 1949: Cater described the pathophysiology of limb compartment
syndrome
• 1970: First clinical measurement of intra-compartmental
pressure was introduced.
7. EPIDEMIOLOGY
• Compartment syndrome is an uncommon surgical emergency
• The average annual incidence in the US 3.1/100,000 people
• Fracture caused by accounts for 75% of cases
• It is one of the highly litigated conditions in Orthopedic surgery
with awards as high as $14million for failure to diagnose and
adequately manage.
• Male: Female 10:1
8. EPIDEMIOLOGY
• In south-eastern Nigeria
• Incidence is 1.02% despite the high number of limb injuries.
• Male are more commonly affected
• Age bracket between 31-40years
• Tibia fracture is most commonly implicated in 57% of cases,
tight TBS splints (14%), burns (7%).
15. AETIOLOGY
Conditions that increase compartment volume
• Fracture
• Soft tissue injury
• Exercise
• Ruptured ganglia/cysts
• Snake bite
• Reperfusion injury
• Bleeding disorder
• Iatrogenic: Osteotomy, fluid infusion (including arthroscopy),
Prolonged/abnormal positioning during anaesthesia
• 48 mm Hg with the head resting on the forearm
16. AETIOLOGY
• 178 mm Hg when the forearm was under the ribcage
• 72 mm Hg when one leg was folded under the other
Conditions That Reduce Compartment Volume
Tightly fitted cast
Very tight occlusive dressings
Burns
Fascia closure
Medical Comorbidity
Bleeding diathesis/anticoagulants
• Compartment syndrome has been shown to occur in neonates from
intrauterine malposition or strangulation of the extremity by the umbilical
cord.
17. PATHOPHYSIOLOGY
• The pathophysiology ACS remains unclear
• Primarily from increased intra-compartmental pressure
• Normal resting limb intra compartmental pressure is 0-4mmHg. With
exertion it may rise up to 10mmHg
• Compartmental pressure vary among individuals and in a person from
time to time depending on the diastolic pressure
• Tissue perfusion is proportional to the difference between capillary
perfusion pressure(CPP) and the interstitial fluid pressure.
• LBF = (PA - PV)/R
18. PATHOPHYSIOLOGY
• Normal myocyte metabolism requires a 5-7 mm Hg oxygen tension
• Readily be obtained with a CPP of 25 mm Hg and an interstitial tissue
pressure of 4-6 mm Hg
• A primary hypothesis behind the development of compartment
syndrome is the arterio-venous Pressure gradient theory.
• When fluid is introduced into a fixed-volume compartment, tissue
pressure increases and venous pressure rises.
• When the interstitial pressure exceeds the CPP (a narrowed arterio-
venous [AV] perfusion gradient), capillary collapse leading to muscle
and tissue ischemia and irreversible damage.
30. MANAGEMENT
Slit Catheter
• Developed by Rorabeck
• Need the catheter
• Can use the measuring unit for Stic
system
• Can leave indwelling for continuous
monitoring
31. MANAGEMENT
Other methods of measuring ICP
• Laser Doppler ultrasound
• Methoxyl isobutyl isonitrile enhanced MRI
• Phosphate-nuclear magnetic resonance spectroscopy
• Thallous chloride-201 and Technetium 99 sestamibi and Xenon
scanning
33. MANAGEMENT
TREATMENT
• Non-operative
• Operative
Non-operative
• Loosening of compression dressing
• Splints: uni or bivalving of constricting cast
• Analgesics
• Elevation of limbs not higher than the level of the heart
• Avoidance of knee flexion and ankle dorsiflexion
37. MANAGEMENT
INTRA-OPERATIVELY
• Positioning
• Anaesthesia
• General
• Regional
• Analgesia
• Antibiotic
• Skin preparation and draping
• Skin incision
• Accurate length, depth and land mark for incision.
• Avoid injuries to underlying vital structures
• Full release of constricted compartments
43. MANAGEMENT
• Henry’s approach for flexor compartment and mobile wad:
from 1cm proximal and 2cm lateral to the medial epicondyle
extending to the mobile wad. Then carried distally to the midline
down to the proximal wrist crease.
• Thompson’s approach for dorsal compartment: A single
straight incision from distal aspect of the lateral epicondyle
aiming to the center of the wrist
45. MANAGEMENT
INTRA-OPERATIVELY
• Debridement of ischaemic and necrotic tissue
• Copious irrigation with normal saline
• Incision wound left open
• Adsorbent dressing applied
• Blood transfusion where indicated
• Monitoring
• Reduction and retention of associated fracture
46. MANAGEMENT
POST-OPERATIVE
• Antibiotics
• Adequate analgesia
• Supplemental oxygen
• Adequate hydration
• Monitoring
• Return to the theater every 24-72hrsfor dressing changing, debridement
as necessary and assessment of tissue viability
• Early ambulation via axillary clutches
• Closure of skin via skin grafting, flap or delay closure between 7-10days
• Physiotherapy
48. COMPLICATIONS
Fasciotomy related
• Pain related to wound
• Hemorrhage
• Surgical site infection
• Neurovascular injury
• Abnormal Scars
• Dyschromic scars
• Pruritus
• Recurrent ulceration
49. FOLLOW UP
Essential to :
• Monitor treatment
• Early detection of complications
• Treatment
50. PROGNOSIS
The prognosis of compartment syndrome is dependent on
• Time of presentation
• Type
• Age
• Commodity
• Availability and accessibility of effective health care
51. PREVENTION
• Primordial: Legislation, regulation of activities of TBS, funding of
health sector, good roads, adherence to road safety regulations
• Primary : Training and retraining of health workers, provision and
use of personal protective equipment (PPEs), health campaigns
• Secondary : Early presentation, identification and treatment
• Tertiary: Rehabilitation
52. CONCLUSION
• Acute compartment syndrome of the extremity is an orthopedic
emergency
• Most are due to closed proximal tibia fracture
• Diagnosis is largely clinical with measurement of intra-
compartmental pressure as adjunct where diagnosis is in doubt.
• High index of suspicion and early intervention is key to optimum
outcome
• No one will blame the surgeon for carrying out fasciotomy but
everybody will blame the surgeon for missing the diagnosis of
compartment syndrome.
53. REFERENCES
• Agu TC, Orjiaku ME (2016). The Prevalence and Patterns of Acute
Compartment Syndrome of the limbs in a Private Orthopedic and
Trauma Center, South-East Nigeria, 8years Retrospective Study.
Afri J Trauma;5:10-15.
• Sriram BM.(2013). SRB’S Manual of surgery. General surgery:
Compartment Syndrome. Jaypee Brothers Publishers Limited,
New Delhi, India. 4th Ed. Chapter 1; Page 8-9.
• Joanne P, Melanie ML (2016). Acute Compartment Syndrome of
the Leg: A Review. J Nurse Pract.12(4):265-270
• James D, Behrooz H, Wasim SK (2014). The Pathophysiology,
diagnosis and current management of acute compartment
syndrome. The open orthopaedic journal. Vol.8;1:185-193.
54. REFERENCES
• Apley’s System of Orthopedics and Fractures, 9th Ed (2010), pp
556-557
• Campbells operative orthopaedics volume 2; 12th edition
• Archampong EQ, Naaeder SB, Ugwu B.(2015 ). Baja’s principles
and practice of surgery including pathologies in the tropics:
Orthopedic surgery. 5thEd. Vol2. Repro India Ltd. Chapt.54, page
1202-1207
• Godwin Iwegbu (2004). Principles and Management of Acute
Orthopaedic Trauma: Complications of Fracture and Fracture
Treatments. 1st Ed. AuthorHouse Publishers Indiana, USA.
Chapt.6,Pg 134-140.
• Emeka Kesieme (2017). VIVA in Surgical Principles and Operative
Surgery. 1st Ed. Afrobrilliance Academic Publishers Edo, Nigeria.
55. REFERENCES
• Abraham TR (2020). Acute Compartment Syndrome. @
Medscap.
• Abraham TR (2019). Fasciotomy for Acute Compartment
Syndrome. @ Medscap.
