DR ASHWANI PANCHAL P.G IN ORTHOPAEDICS JSS HOSPITAL MYSORE
Nov 02, 2014
DR ASHWANI PANCHALP.G IN ORTHOPAEDICS
JSS HOSPITALMYSORE
What is a compartment?
Closed area of muscles group, nerves & blood vessels surrounded by fascia
Pressure: 5-15 mmhg
Definition:An increased pressure within enclosed
osteofascial space that reduces capillary perfusion below level necessary for tissue viability; the underlying mechanism is:
- increased volume within space- decreased space for contents- combination of both
What is a compartment syndrome?
intra comp. pressure (35-40 mmhg) capillaries collapse
Blood flow to muscles and nerves
Bl.Vs collapse
Pathophysiology:Increased compartment pressure
leads to increased venous pressure which decreases A-V gradient resulting in muscle and nerve ischemia.
Consequences –vicious cycle
Why is it dangerous? Nerves:
neuropraxia: will regenerate
Ischemia: cell death
Muscles: contracture (Volkmann's ischemic contracture)
Gangrene
Compartment Syndrome- CAUSESCauses
Fractures Contusions Surgery Post Ischemic swelling after arterial occlusion Major vascular trauma Crush injuries Burns Prolonged limb compression
CausesFracture of a long
bone (Supracondylar
humerus, forearm, hand,tibia
and foot)
CAUSES
Drilling & reaming
Dissection
Tourniquet
CAUSES
Tight cast
swelling
Bluish discolorationnumbness
CAUSES
Severe bruised muscle
(even if there is no fracture)
Don’t take contusion lightly
COMPARTMENT SYNDROME
Signs and SymptomsIncreased Pressure and TightnessProgressive pain out of proportion to initial
injuryMarkedly swollen areaProgressive neurologic deficitSeven P’s
PainPressurePain with passive stretchParethesiaParesis/ ParalysisPulsesPallor
SYMPTOMS
Severe pain inappropriate to the injury(not relieved even with morphia)
SYMPTOMSBurning of the affected limb
Tight muscle(rigid)tightness feeling
Numbness: bad sign
SIGNS & DIAGNOSIS
Passive stretching of fingers or toes (muscle stretch)will lead to severe pain (diagnostic sign)
Never wait for signs of ischemia (5 Ps):irreversible damage
STRECH TESTIt is possible to strech
the affected muscles by passively moving the joints in direction opposite to that of the damaged muscles,s action (( e.g. ::: passive extension of fingers produces pain in flexor compartment of forearm
TechniqueSTRYKER
TECHNIQUEMERCURY
MANOMETERWick hand held
instrument
Whiteside maneuver Wick hand held instrument
syringe
3 way stopcock
mmhg mano.
electrode
Direct reading
Stryker Stic SystemEasy to useCan check multiple compartmentsDifferent areas in one compartment
Complications related to CSLate Sequelae
Volckmann’s contracture Weak dorsiflexors Claw toes Sensory loss Chronic pain Amputation
COMPARTMENT SYNDROME
ManagementNon surgical management:
Remove any tight bandage, tubigrip or soaked dressing
Cast should be removed completely
Elevation
•managementSurgical management: (FASCIOTOMY) Open skin and fascia
down to a compartment
It is a surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to the tissue
Fasciotomy PrinciplesMake early diagnosisLong extensile incisionsRelease all fascial compartmentsPreserve neurovascular structuresDebride necrotic tissuesCoverage within 7-10 days
Compartment SyndromeIndications for Fasciotomy
Unequivocal clinical findingsPressure within 15-20 mm hg of DBPRising tissue pressureSignificant tissue injury or high risk pt> 6 hours of total limb ischemiaInjury at high risk of compartment
syndromeCONTRAINDICATION -
Missed compartment syndrome (>24-48 hrs)
Forearm FasciotomyVolar-Henry
approachInclude a carpal
tunnel releaseRelease lacertus
fibrosus and fasciaProtect median
nerve, brachial artery and tendons after release
Flexor digitorum longus
Gastroc-soleus
Superficial peroneal nerve
Intermuscular septum
Fasciotomy of Hand
10 separate osteofascial compartmentsdorsal interossei (4) palmar interossei (3)thenar and
hypothenar (2)adductor pollicis (1)
Close skin by 2ry sutures after oedema subsides
It may need skin graft
Wound ManagementWound is not closed at initial surgerySecond look debridement with
consideration for coverage after 48-72 hrsLimb should not be at risk for further swellingPt should be adequately stabilized Usually requires skin graft DPC possible if residual swelling is minimalFlap coverage needed if nerves, vessels, or
bone exposedGoal is to obtain definitive coverage
within 7-10 days
Wound ManagementAfter the fasciotomy, a bulky compression
dressing and a splint are applied.“VAC” (Vacuum Assisted Closure) can be used Foot should be placed in neutral to prevent
equinus contracture. Incision for the fasciotomy usually can be
closed after three to five days
Complications Related to Fasciotomies
Altered sensation within the margins of the wound (77%)
Dry, scaly skin (40%) Pruritus (33%) Discolored wounds (30%) Swollen limbs (25%) Tethered scars (26%) Recurrent ulceration (13%) Muscle herniation (13%) Pain related to the wound (10%) Tethered tendons (7%)
Fitzgerald, McQueen Br J Plast Surg 2000Fitzgerald, McQueen Br J Plast Surg 2000
Compartment syndrome is a serious syndrome, Which needs to be diagnosed early.Palpable pulse doesn’t exclude compartment syndromeIf diagnosis and fasciotomy were done within 24 hrs, the prognosis is good.If delayed, complications will develop.
The earlier you diagnose, the safer you are