Compartment Syndrome

04/12/2023 sridevirajeeve_august2014_ortho 1

COMPARTMENT SYNDROME

By;

Sridevi RajeeveIntern

2008 Batch


DEFINITION Compartment syndrome is defined as the

elevated interstitial tissue pressure within a confined space in the body (an osseo-fascial compartment) leading to inadequate tissue perfusion and eventually leading to tissue necrosis within the compartment

True Orthopaedic Emergency!


ANATOMIC CONSIDERATIONS May occur in varied locations where closed

compartments exist in the bodyLeg (most common)Forearm (classic)ArmThighFootHandButtockAbdomen


Classic location - Flexor compartment of the Forearm This location has several unique anatomic features that predispose CS

Strong fascial roof and at its entrance lie two potential obstructions○ First and lying most superficialis the lacertous fibrous fascia, which

fans medially from the biceps tendon as the latter inserts on the proximal radius.

○ The second is the bulky pronator teres muscle, which arises from the medial epicondyle and passes obliquely beneath the inelastic lacertous fibrosus to create a V-shaped sphincter beneath which the brachial artery and the median nerve must pass to enter the flexor compartment.

○ Collateral vessels serving the flexor compartment are minimal Oedema, haematoma or intramuscular haemorrhage in this crucial region

may cause sufficient compression of these neurovascular structures to precipitate the ischaemia–oedema vicious cycle.


AETIOLOGY1. ACUTE COMPARTMENT SYNDROME

(1) Increased Compartment Volume Fracture

○ Supracondylar humerus○ Forearm bones○ Distal radius○ Tibia

Soft-tissue injury○ Crush syndrome○ Severe contusion○ Muscle tear○ Gunshot wounds

Iatrogenic ○ Postoperative inflammation ○ Fracture fixation with oversize implants

Exertion (intensive muscle use)


• Tetany• Eclampsia• Seizures• Bleeding• Bleeding or coagulation disorder (e.g. haemophilia)• Anticoagulant therapy• Postoperative vascular injury• Traumatic rupture of vascular malformation• Fluid extravasations into soft tissues• Ruptured cysts/ganglia• During arthroscopy with fluid extravasation• Infection (acute haematogenous osteomyelitis)• Increased capillary permeability or pressure• Venous obstruction/ligation• After prolonged ischaemia/tourniquet• Arterial bypass grafting• Ergotamine ingestion• Thermal injury• Electrical injury• Frostbite• Snakebite• Intra-arterial drug injection

Most common – FRACTURE!Tibial Diaphyseal >Radial Shaft >Supracondylar


(2) Decreased Compartmental Volume

Tight casts/splints Prolonged limb pressure

Lengthy surgeries Anaesthesia Comatose patient

Excessive traction on fractured limb


PATHOPHYSIOLOGY Classical aetiopathogenesis: increased ICP in the

interstitium over itscapillary perfusion pressure, due to the accumulation of necrotic debris and/or haemorrhage, contents within the closed compartment of the deep fascia swell, raising the ICP to such a high level that blood cannot circulate in this closed compartment

Contents undergo varied degrees of necrosis and eventually fibrosis


THE VICIOUS CYCLE – OF DOOM?!


Normal resting intramuscular pressure is usually less than 6 mmHg

In compartment syndrome, the intramuscular pressure can increase to more than 100 mmHg The initial insult causes haemorrhage, oedema or

both in the closed fascial compartments of the extremities.

Rising compartment pressure ultimately leads to compartmental tamponade, microcirculatory impairment and sustained ischaemia


Compartmental pressures more than 30 mmHg maintained for more than 8 hours can cause irreversible muscle damage

Type 1 aerobic fibres (red/slow-twitch fibres), are more vulnerable to ischaemia than type 2 anaerobic fibres (white/fast-twitch fibres). That explains why some muscle groups are more vulnerable to ischaemic damage than others

Reduces the healing capacity of long bones, by possibly reducing the extra-osseous blood supply and Non-union can be a possible complication


DIAGNOSIS Medical/Orthopaedic emergency Any delay in its diagnosis is the single most

important cause of morbidity with potential to cause disastrous consequences including Amputation and even Death

Diagnosis of acute compartment syndrome is made clinically

Confirmed by actual measurement of compartmental tissue fluid pressure

A high index of suspicion is important to make a diagnosis!


CLINICAL DIAGNOSIS Classically, there are 6 "Ps" associated with

compartment syndromePain (out of proportion to what is expected based on

the physical exam findings)Paraesthesia Pallor Paresis/Paralysis Pulselessness Poikilothermia

The first signs of compartment syndrome are numbness, tingling and paresthesia


Reliability? Pain itself is an unreliable and variable indicator Pain if used as a diagnostic indicator of acute

compartment syndrome has a high proportion of missed or false negative cases

It cannot be elicited in unconscious patients and is an unreliable indicator in small children

Pain on passively stretching the muscles of the affected compartment (e.g. passively extending the fingers in acute compartment syndrome affecting the volar compartment of the forearm) is a recognized symptom


Palpable tenseness of the swollen affected compartment is often the earliest sign and palpating reproduces the patient’s pain

The compartment may feel very hard depending on the ICP and the overlying skin often appears shiny

Peripheral pulses are almost always present in acute compartment syndrome, unless the injury involves damage to vessels

Thus, if pulses are present, it does not exclude the diagnosis of compartment syndrome!


INTRACOMPARTMENTAL PRESSURE MEASUREMENT AND MONITORING CS is confirmed by measuring the ICP Most important investigation in ACS Several methods are available to measure the ICP:

1. Needle Manometer Method2. Wick Or Slit Catheter Technique3. Continuous Monitoring Infusion Technique4. Hand-held Transducers (Stryker Intra-compartmental

Pressure System)5. Near-infrared spectroscopy (NIRS)6. Pressure transducer modules (with a simple intravenous

catheter and needle) that are attached to most modern anaesthetic machines


ADJUNCT DIAGNOSTICS Radiographs

These are required to investigate for possible underlying fractures and fracture dislocation, their reduction and possible radio-opaque foreign bodies

Doppler flowmetry and arteriographyDoppler flowmetry and arteriography are valuable

in verifying a suspected arterial injury, but not for diagnosis of acute compartment syndrome. These investigations should not delay fasciotomy.


DELAYED DIAGNOSIS! Patients prone to delay in diagnosis of

compartment syndromeHead injuryCerebrovascular accidentSpinal cord injuryPeripheral nerve injuryAnaesthetized patients (general/local)Alcoholic/drug-overdosed patientsMentally disabled patientsBurn patientsInfants/young patients


MANAGEMENT

Goals for the management of acute compartment syndrome are to restore tissue perfusion to the affected

muscles and nerves of the compartment affected, to prevent or minimize the injury

to avoid any residual loss of function Treatment may be Non-operative for

Impending Compartment Syndrome Surgical for Established Compartment

Syndrome


NON-OPERATIVE MANAGEMENT Ensure patient is normotensive, as hypotension

reduces prefusion pressure and facilitates further tissue injury

Remove cicumferential bandages and cast. Alternative methods of immobilization or fixation should be chosen if necessary to maintain fracture reduction

Maintain the limb at level of the heart as elevation reduces the arterial inflow and the arterio-venous pressure gradient on which perfusion depends

Supplemental oxygen administration


Borderline symptomatic patients may be monitored with an indwelling catheter

Persistently borderline or doubtful patients should preferably have a fasciotomy rather than delay treatment

Fasciotomy: Prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma


OPERATIVE MANAGEMENT

GOLD STANDARD: FASCIOTOMY! Open and extensive fasciotomies of all the

compartments within the part of the limb affected by CS


FASCIOTOMY INDICATIONS

Unequivocal clinical findingsPressure within 15-20 mmHg of DBPRising tissue pressureSignificant tissue injury or high risk pt > 6 hours of

total limb ischemiaInjury known for high risk of compartment syndromeAbsolute: >30-35mmHg with positive clinical

correlation CONTRA-INDICATION

Missed compartment syndrome (>24-48 hrs)


FASCIOTOMY

PrinciplesMake early diagnosisLong extensile incisionsRelease all fascial compartmentsPreserve neurovascular structuresDebride necrotic tissuesCoverage within 7-10 days


FASCIOTOMY

Fasciotomy not only relieves compartmental pressure, but also helps in re-establishing tissue perfusion if done timely enough and if there is no arterial injury or compromise


Legall four compartments must be decompressed, usually

via two long, longitudinal incisions. It will be necessary to debride necrotic tissue,

sometimes several times. Forearm

The three compartments (the mobile wad of three, the volar and extensor) can be released via two incisions (one curvilinear volar incision across the elbow and straight to the wrist to include releasing the carpal tunnel and one straight incision along the extensor ulna border)

HandHas 10 compartments(requiring five incisions) Similarly, the foot


POST-FASCIOTOMY CARE Wound Management after Fasciotomy

a bulky compression dressing and a splint are applied.

VAC (Vacuum Assisted Closure) can be usedFoot should be placed in neutral to prevent

equinus contractureWound is not closed at initial surgeryIncision for the fasciotomy usually can be closed

after 3 - 5 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%)


COMPLICATIONS OF COMPARTMENT SYNDROME

Volkmann’s contracture Weak dorsiflexors Claw toes Sensory loss Chronic pain Amputation Rhabdomyolysis Renal failure


CHRONIC COMPARTMENT SYNDROME

Chronic Compartment Syndrome usually occurs in young active patients afterintense muscular activity

Usually detected in the anterior compartment (anterior or posterior deep compartment)

Main symptoms involve pain, parasthesia of the musclewithin the affected compartment, after intense and continuing (over than 20-30 min) streching of musclegroups.

The symptoms recess progressively by interrupting any kind of exercise (15-20min)

Differential diagnosis include stress fracture, superficialfibular nerve entrapment syndrome, posterior tibialmuscle tendonitis.


Conservative treatment includes rest, anti-inflammatories, and manual decompression

Ideally, the affected limb should be positioned at the level of the heart

Patient adviced to decrease the level of activity

No relief forthcoming – Surgical Decompression


VOLKMANN’S ISCHEMIC CONTRACTURE Severe manifestation of Compartment

syndrome of Forearm Permanent flexion-contracture deformity of

hand at wrist and fingers Most affected muscles: Flexor digitorum

profundus and Flexor pollicis longus Classical claw-hand deformity


Volkmann’s Sign: in established VIC Extension of wrist produces exaggeration

of flexion deformity while on flexion, the deformities are less marked

Extensive scarring of forearm + Thin and fibrotic forearm Joint and soft tissue contractures Neurological deficits Gangrene (rare)


Treatment plan Moderate VIC

MAX-PAGE’S MUSCLE SLIDING OPERATION: releasing common flexor origin from medial epicondyle and passivele stretching fingers

CICATRIX EXCISION NEUROLYSIS TENDON TRANSFERS

Severe VIC CICATRIX EXCISION SEDDON’S CARPECTOMY: excising proximal row of carpal bones

to shorten forearm to overcome the effects of contacted muscles ARTHRODESIS of wrist in functional position AMPUTATION


THANK YOU!

Compartment Syndrome

Health & Medicine

Transcript of Compartment Syndrome