Sindrome compartimental

1. Dra. Erika Rojas G.
Residente de 1er año
Febrero 2009
Universidad Central de Venezuela
Instituto Nacional de los Seguros sociales
Hosp. Dr. Miguel Pérez Carreño
Servicio de Traumatología y Ortopedia II

2. SINDROME COMPARTIMENTAL
• DEFINICION
• ETIOLOGIA
• FISIOPATOLOGIA
• SINTOMAS
• SIGNOS
• EXAMENES PARACLINICOS
• DIAGNOSTICO DIFERENCIAL
• TRATAMIENTO
• COMPLICACIONES
• TRABAJOS PUBLICADOS
• CONCLUSION
• REFERENCIAS
CONTENIDO

3. 1881: Richard Von Volkmann, Contractura postraumatica
de la Extremidad lo atribuye a isquemia del musculo
esqueletico.
1926: Jepson, Incremento de presion compartimental
desarrolla isquemia muscular y descompresion temprana
previene contractura.
1940: Segunda Guerra Mundial y Vietnam (Norman
Rich), Fasciotomia en Campo de Batalla.
SINDROME COMPARTIMENTAL
HISTORIA

4. Síndrome Compartimental (SC) (Compartment Syndrome): Elevación de la
presión intersticial, por arriba de la presión de perfusión capilar dentro de un
compartimento osteofacial cerrado, con compromiso del flujo sanguíneo en
músculo y nervio, lo que condiciona daño tisular.
SINDROME COMPARTIMENTAL
DEFINICION

5. SINDROME COMPARTIMENTAL
ETIOLOGIA
Disminución en el tamaño del compartimento
Compresión o constricción externa
Pantalón
militar
antichoque
(MAST).
Vendaje
circunferencial
Escara por
quemadura o
congelacion
Cierre
quirúrgico de
defectos
fasciales
Uso
prolongado de
torniquete

6. Incremento del contenido del
compartimento
Sangre
• Trauma (fractura, lesión
vascular)
• Desórdenes de la
coagulación
• Terapia anticoagulante
Edema
• Isquemia/reperfusión
• Lesiones eléctricas
• Trombosis venosa
• Ejercicio
• Posterior a cirugía cardiaca
• Choque
• Rabdomiólisis
• Eclampsia
• Síndrome nefrótico
Fluidos (exógenos)
• Infusión intracompartimental
• Infusión interósea
SINDROME COMPARTIMENTAL
ETIOLOGIA

7. Síndrome Compartimental Agudo (SCA)
Sindrome Compartimental Cronico (SCC)
Sindrome por Aplastamiento (Crush Syndrome)
SINDROME COMPARTIMENTAL
CLASIFICACION

8. Síndrome Compartimental Agudo (SCA)
Presion
Intracompartimental
Retorno
Venoso
Perfusion
Capilar
Presion
Arterial
ISQUEMIA
SINDROME COMPARTIMENTAL
CLASIFICACION

9. Sindrome Compartimental Cronico (SCC)
Oxigenación
tisular deficiente
Secundaria a
disminución del
retorno venoso
Insuficiente
perfusión del
tejido muscular
Incremento de la
presión
compartimental
SINDROME COMPARTIMENTAL
CLASIFICACION

10. Sindrome por Aplastamiento (Crush Syndrome)
• Efectos sistémicos secundarios
• Isquemia grave de múltiples compartimentos por Ruptura de las células musculares
• Libera a la circulación mioglobina y potasio (Hipercalemia)
• Respuesta inflamatoria grave
• Pérdida de líquidos al tercer espacio
• Acidosis metabólica
• Falla renal aguda y choque
• Requiere de apoyo inmediato por UCI
• Manejo agresivo de líquidos y uso de hemodiálisis
• Fasciotomía temprana de las extremidades afectadas
SINDROME COMPARTIMENTAL
CLASIFICACION

11. SINDROME COMPARTIMENTAL
DIAGNOSTICO
HISTORIA CLINICA
SINTOMAS
SIGNOS
EXAMENES PARACLINICOS

12. SINDROME COMPARTIMENTAL
SIGNOS Y SINTOMAS
SC
DOLOR
PRESION
PARESTESIA
PALIDEZ
PARALISIS
PULSO

13. SINDROME COMPARTIMENTAL
EXAMENES PARACLINICOS
LABORATORIO
•Hematologia Completa
•PT, PTT
•INR
•Perfil Hepatico
•Urea, Creatinina
•Mioglobina
•CK, CKMB
•Electrolitos Sericos
•Examen de Orina
IMAGENOLOGIA
•Rayos X
•Ecosonograma Doppler
•RMN
OTROS
•Medicion de Presion
Compartimental
•Espectroscopia
Infrarroja (Oximetro)

14. SINDROME COMPARTIMENTAL
DIAGNOSTICO DIFERENCIAL
Distension Muscular
Periostitis
Fractura Tibial por Estres
Fractura Peronea por Estres
Neuropraxia del Nervio Peroneo
Compresion de la Arteria Poplitea
Tendinitis del Tibial Posterior
Sindrome de Estres Tibial Interno
Trombosis Venosa Profunda
Estenosis Raquidea
Hernia de un Nucleo Pulposo Lumbar
Neuropatia Periferica Diabetica
Enfermedad vascular Periferica

15. SINDROME COMPARTIMENTAL
TRATAMIENTO
ATENCION DEL PACIENTE
POLITRAUMATIZADO (ABCD)
Fasciotomia del
Muslo
Anterior Interno Posterior

16. ATENCION DEL PACIENTE
POLITRAUMATIZADO (ABCD)
Fasciotomia de la
Pierna
Anterior Lateral
Posterior
Profundo
Posterior
Superficial
SINDROME COMPARTIMENTAL
TRATAMIENTO

17. Fasciotomia del
Antebrazo
Anterior Posterior Lateral
ATENCION DEL PACIENTE
POLITRAUMATIZADO (ABCD)
SINDROME COMPARTIMENTAL
TRATAMIENTO

18. Contractura Isquemica de Volkmann:
Necrosis de musculos isquemicos.
SINDROME COMPARTIMENTAL
COMPLICACIONES

19. Treatment for crush syndrome of extremities with antioxidants
Zhongguo Gu Shang. 2008 Feb;21(2):109-10. PMID: 19105470 [PubMed - in process]
Department of Orthopaedics, Coal General Hospital of Henan Province, Zhengzhou
450002, Henan, China.
OBJECTIVE: To study the clinical therapeutic effect of antioxidants assistant
treatment of extremities crush syndrome (CS)in order to find new therapy.
METHODS: Twenty-one male patients (aged from 24 to 48 years, mean 36 years)
were treated with the next antioxidants in early stage: (1) 20% Mannitol 250 ml
intravenous drip in 30 minutes (one time per 6 to 8 h). (2) Sodium aescinate 20
mg, Salvia Miltiorrhiza 20 ml were dissolved respectively in isotonic saline or 5%
glucose 200 ml and dripped by intravenous drip (50 to 60 drips per minute). The
drugs were used for 5 to 7 days (one time per day). Basifying urine, keeping the
negative liquid balance and electrolyte balance, preventing infection and hold out
treatment were done. When the pressure of muscular osteofascial compartment was
more than 30 mmHg, deep fasia was cut to decompress timely and the above-
mentioned drugs were continuously applied for patients. RESULTS: Myoglobin urine
of 21 cases died out after 2 to 3 days, of them, 13 cases were performed to
decompress. After open decompression, 2 cases suffered from amputation because
of long time of ischemia, 2 cases took place slight dysfunction of lower limbs, one
hand had ischemia muscular contracture in 1 case and one foot down-vertical in 1
case. After followed-up of 8 months to 1 year, according to the function standard,
the result were excellent in 8 cases, good in 7 cases, fair in 2 cases, poor in 4
cases. The excellent and good rate was about 71.4% (15/21). CONCLUSION: After
extremities crushed for long time, application of antioxidents as early as possible
can decrease significantly the incidence and invalidity rate of CS.
Tratamiento de sindrome aplastamiento con antioxidantes.
21 masc, 1. manitol 20%, 2. eoscinato sodico, 5 a 7 dias OD.
30mmhg fasciotomia. Resultados: mioglobina disminuye en 2 a 3
dias. Conclusion: El uso de antioxidantes en etapas
tempranas disminuye la contractura postisquemica.

20. Compartment syndrome of the leg in the coagulopathic, end-stage liver disease patient:
Fasciotomy is not the best answer.
Int J Surg. 2008 Dec;6(6):e31-3. Epub 2006 Nov 1. PMID: 19059130 [PubMed - in
process]. Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles,
CA, USA.
BACKGROUND: Compartment syndrome of the leg secondary to spontaneous
bleeding has been described in coagulopathic patients. Correction of the
coagulopathy and emergency fasciotomy is the recommended treatment. We
present a cirrhotic patient with a short life expectancy who developed compartment
syndrome of the leg secondary to spontaneous bleeding. This patient underwent
fasciotomy of the leg and subsequently developed persistent postoperative bleeding
and required repeated transfusions of blood and blood products. The patient
eventually expired in the hospital 1 month after surgery. RESULTS: Compartment
syndrome of the leg occurring in patients with coagulopathy secondary to cirrhosis
is very difficult to manage. Coagulopathy in these patients is hard to correct and
constant bleeding from fasciotomy site is a major complication mandating frequent
transfusions of blood and blood products. The complications of fasciotomy in these
patients may outweigh the complications of untreated fasciotomy, particularly in
patients with a short life expectancy. CONCLUSIONS: Fasciotomy is not always the
best treatment for compartment syndrome of the leg. In certain patients,
particularly in the coagulopathic, end-stage cirrhotic patient with a short life
expectancy who is not a candidate for liver transplantation, fasciotomy is not
indicated. Fasciotomy should be used selectively, if at all, in patient population with
end-stage and terminal diseases.
SC en pac con coagulopatía por enfemedad teminal hepática, la
Fasc no es la mejor respuesta. Corregir cuagulopatia y fasc de
emergencia es el trat recomendado. Pac cirrosis hepatica terminal
desarrolla SC por sangramiento espontaneo. Se realiza fasc y requiere
post múltiples transfusiones. Pac fallece al mes de cirugia.
Resultados: fasc en estos pac sobrepesan las complic de no
realizar fasc.

21. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia
on diagnosis.
Br J Anaesth. 2009 Jan;102(1):3-11. Epub 2008 Nov 19. PMID: 19022795 [PubMed -
indexed for MEDLINE]. Department of Anaesthesia, St Vincent's Hospital, Melbourne,
PO Box 2900, Fitzroy, 3065 VIC, Australia. gjpmar@yahoo.com.au
Acute compartment syndrome can cause significant disability if not treated early,
but the diagnosis is challenging. This systematic review examines whether modern
acute pain management techniques contribute to delayed diagnosis. A total of 28
case reports and case series were identified which referred to the influence of
analgesic technique on the diagnosis of compartment syndrome, of which 23
discussed epidural analgesia. In 32 of 35 patients, classic signs and symptoms of
compartment syndrome were present in the presence of epidural analgesia,
including 18 patients with documented breakthrough pain. There were no
randomized controlled trials or outcome-based comparative trials available to
include in the review. Pain is often described as the cardinal symptom of
compartment syndrome, but many authors consider it unreliable. Physical
examination is also unreliable for diagnosis. There is no convincing evidence that
patient-controlled analgesia opioids or regional analgesia delay the diagnosis of
compartment syndrome provided patients are adequately monitored. Regardless of
the type of analgesia used, a high index of clinical suspicion, ongoing assessment of
patients, and compartment pressure measurement are essential for early diagnosis.
SCA en pierna y el efecto de analgesia postoperatoria en el
diagnostico. Pac bajo analgesia epidural se diagnostica un SC con
examen clinico no siendo el dolor el sintoma principal. Realizando
un buen ex. Clinico y teniendo presente la sospecha de un SC y
midiendo la presion compartimental se diagnostica SCA

22. Pathology and diagnostic options of lower limb compartment syndrome
Clin Hemorheol Microcirc. 2009;41(1):1-8. PMID: 19136736 [PubMed - in process].
Department of General and Vascular Surgery, Faculty of Medicine, University of Pécs,
Pécs, Hungary.
Background: The indication of surgical treatment in lower limb compartment syndrome
mostly depends on the clinical signs which can be often uncertain, resulting in delayed
insufficient intervention. Aim: The aim of the study was to evaluate the progression of
compartment syndrome by measuring of intracompartmental pressure and monitoring of
decreased tissular oxygenation, indicating an insufficient secondary microcirculation.
Materials and methods: 16 patients were examined in our study (12 males, 4 females,
mean age: 62.7+/-9.5 years), who underwent acute lower limb revascularization surgery
for a critical (lasting more than 4 hours) limb ischemia. The indications were: 5 iliac
artery embolizations and 11 femoral artery occlusions. After revascularization, on the
second postoperative day, we detected significant lower limb edema and swelling of
several grade. To monitor the elevated intracompartmental pressure (ICP) and to evaluate
the extremital circulation, we used KODIAG pressure meter and the tissular oxygen
saturation (StO2) was measured by near-infrared-spectroscopy. Results: In 12 cases the
ICP exceeded the critical 40 mmHg. In these patients the average StO2 was 50-53%, in
spite of complete recanalization. In these cases we made urgent, semi-open fasciotomy.
In 4 cases, where the clinical aspect showed compartment syndrome, the measured
parameters did not indicate a surgical intervention (ICP: 25-35 mmHg, StO2: around
normal).Summary: A novel approach in our examination is that, besides empirical
therapeutic guidelines generally applied in clinical practice, we established an objective,
parameter-based ("evidence based medicine") surgical indication strategy for the lower
limb compartment syndrome. Our parameter results produced by the above pressure and
saturation measurements help the clinicians to decide between conservative and
operative treatment of the disease.
Patologia y Opcion diagnostica de SC en piernas. Objetivo: evaluar
progresion de SC midiendo presion intracompartimental y monitoreo de
disminucion de oxigenacion tisular, indicando microcirculacion deficiente
secundaria. 16 pac revascularizacion (2 dia PO). Resultados: 12 casos
ICP >40mmhg – StO2 50 – 53% se realiza fasciotomia. 4 casos ICP 25
– 35 mmhg – StO2 normal. Conclusion: el uso de ICP y medida de
saturacion ayuda a la decision quirurgica.

23. Arato, E. y cols. Pathology and diagnostic options of lower limb compartment syndrome. Clin Hemorheol Microcirc.
2009;41(1):1-8. PMID: 19136736 [PubMed - in process]. Department of General and Vascular Surgery, Faculty of
Medicine, University of Pécs, Pécs, Hungary. 2009.
Bucholz, R. y cols. Rockwood y Green, Fracturas en el Adulto. Editorial MARBAN. Philadelphia, USA. 2003.
Caceres, E. y cols. Manual SECOT de cirugia ortopedica y traumatologia. Editorial Panamericana, Espana, 2004.
Fitzgerald, R. y cols. Ortopedia. Editorial Panamericana. St. Louis Missouri, USA. 2004.
Fu, CG. Treatment for crush syndrome of extremities with antioxidants. Zhongguo Gu Shang. 2008 Feb;21(2):109-
10. PMID: 19105470 [PubMed - in process] Department of Orthopaedics, Coal General Hospital of Henan Province,
Zhengzhou 450002, Henan, China.
Mar, GJ. y cols. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on
diagnosis. Br J Anaesth. 2009 Jan;102(1):3-11. Epub 2008 Nov 19. PMID: 19022795 [PubMed - indexed for MEDLINE].
Department of Anaesthesia, St Vincent's Hospital, Melbourne, PO Box 2900, Fitzroy, 3065 VIC, Australia.
gjpmar@yahoo.com.au. 2009.
Mendoza, A. y Manzo, H. Síndrome compartimental en extremidades. Conceptos actuales. Compartment
syndrome in the extremities. Current concepts. Servicio de Cirugía General. Hospital General Balbuena. DDF.
México. Cirujano General Vol. 25 Núm. 4 – 2003.
Milanchi, S. y cols. Compartment syndrome of the leg in the coagulopathic, end-stage liver disease patient:
Fasciotomy is not the best answer. Int J Surg. 2008 Dec;6(6):e31-3. Epub 2006 Nov 1. PMID: 19059130 [PubMed - in
process]. Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA. 2008.
SINDROME COMPARTIMENTAL
REFERENCIAS