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Compartment syndrome
- 1. Compartment Syndrome Dr AbhishekPathak Associate Professor Orthopaedics GMC Bhopal
- 2. Definition • Compartment syndrome isa condition in which the circulation within a compartment is compromised by an increase in pressure within the osteofascial compartment, causing necrosis of muscles, nerves, and eventually the skin because of excessive swelling.
- 3. • The firstreport of the condition was attributed to Hamilton in 1850. • 1881-Volkman described contracted state believed due to ischemic muscle • 1884-Lesser developed clinical model • 1906-Hildebrand coined “Volkman’s ischemic contracture” • 1914-Murphy recommended fasciotomy to prevent contracture • 1940-Griffiths ‘4 Ps’ • 1967-Whiteside stressed 4 compartment fasciotomy
- 4. Types • Can bedivided into two types 1. Acute compartment Syndrome 2. Chronic Exertional Compartment Syndrome 3. Volkman’s Ischaemic Contracture
- 5. Acute Compartment Syndrome •Acute compartment syndrome is defined as the elevation of intracompartmental pressure (ICP) to a level and for a duration that without decompression will cause tissue ischemia and necrosis.
- 6. Chronic Exertional compartment syndrome •Exertional compartment syndrome is the elevation of intracompartmental pressure during exercise, causing ischemia, pain, and rarely neurologic symptoms and signs. It is characterized by resolution of symptoms with rest
- 7. Volkman’s Iscaemic Contracture •Volkmann ischemic contracture is the end stage of neglected acute compartment syndrome with irreversible muscle necrosis leading to ischemic contractures.
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- 9. Causes • Most commoncause is a fracture with tibia fracture being the commonest, followed by both bone forearm and supracondylar humerus (esp in children) • Soft Tissue Injury ( impact increases if associated with fracture) • Crush Syndrome • Burns
- 10. Causes • Snake Bite •Arterial Injury • Nephrotic Syndrome • Exercise
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- 12. Arteriovenous (AV) gradienttheory • According to this theory the increases in local tissue pressure reduce the local AV pressure gradient and thus reduce the blood flow. • When flow diminishes to less than the metabolic demands of the tissues (not necessarily to zero), then functional abnormalities result.
- 13. SITES Common: 1. Leg Compartmentsyndrome 2.Hand compartment syndrome 3. Forearm compartment syndromes 4.Foot compartment syndrome Rare: 5.Thigh compartment syndrome 6.Arm compartment syndrome
- 14. Tissue Threshold to Ischaemia •Muscle 4 hrs • Nerve 8 hrs • Fat 12 hrs • Skin 24 hrs • Bone 72-96 hrs Therefore for a viable functional limb the upper threshold is about 6 hrs
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- 16. Symptoms • Deep achingPain out of proportion to the injury Signs: • Incredible pain on passive movement of leg – due to stretched ischaemic muscles • As arterial supply cut off – Pulselessness ? • Parasthesia - distally • Pallor • Perishing Cold • Paralysis • Tight tense swollen limb • Redness, mottling, blisters • 6P’s may or may not be present; cannot exclude condition based on their absence Clinical Diagnoses
- 17. Classically out ofproportion to injury Exaggerated with passive stretch of the involved muscles in compartment Earliest symptom but inconsistent Not available in obtunded patient Pain
- 18. Pallor • The extremitymay appear cyanotic or mottled early in the course of events. • Cyanosis is present early, whereas marked pallor in the distal extremity occurs late, after major arterial occlusion has occurred. • Neither pallor nor cyanosis should be considered a sign that is necessary for the diagnosis of Compartment Syndrome
- 19. Also early sign Peripheralnerve tissue is more sensitive than muscle to ischemia Permanent damage may occur in 75 minutes Difficult to interpret Will progress to anesthesia if pressure not relieved Paresthesia
- 20. Paralysis : • Developmentof motor dysfunction suggests that ischaemia has been established and permanent damage has Occurred. • Irreversible muscle fibre changes occurs early as six hours after the onset on tissue ischaemia
- 21. Pulselessness • The lossof palpable pulse has been shown to occur late, or sometimes not at all, in the course of Compartment Syndrome. • • Clinical experience and experimental evidence verify that irreversible tissue damages can occur in a patient with palpable pulse.
- 22. Measuring Intracompartment Pressure •When compartment syndrome is suspected and the necessary equipment is available, compartment pressures should be obtained to confirm the diagnosis. • Compartment pressures over 30 mm Hg or within 20 mm Hg of the diastolic pressure are indicative of compartment syndrome.
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- 24. Stryker stic handheld monitor
- 25. • In mostof practicle scenario the diagnosis of compartmental syndrome is essentially clinical with all the investigations aiding in substantiating the diagnosis
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- 27. Fasciotomy • Impending tissueischemia may be considered when the tissue pressure reaches between 30 and 20 mm Hg below the diastolic blood pressure. • As a general rule, when in doubt, the compartment should be released. If it proves later to have been unnecessary, only a scar will result. However, if a fasciotomy should have been done but was not, loss of muscle tissue and worse may result.
- 28. Fasciotomy • Fasciotomy shouldbe performed in (1) normotensive patients with positive clinical findings and compartment pressures of greater than 30 mm Hg, and when the duration of the increased pressure is unknown or thought to be longer than 8 hours; (2) uncooperative or unconscious patients with compartment pressures of greater than 30 mm Hg; and (3) patients with low blood pressure and compartment pressures of greater than 20 mm Hg.
- 30. A DELAY INDIAGNOSIS WAS THE MOST IMPORTANT DETERMINING FACTOR FOR POOR OUTCOME.
- 31. Fasciotomy of leg Threeapproaches have been described for release of the compartment of the lower leg • Double-incision fasciotomy • Single-incision fasciotomy • Fibulectomy
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- 35. Fasciotomy Closure Shoe lacetechnique
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- 42. Disadvantage of Fasciotomy 1.Close Fracture converted into compound fracture. 2.Loss of stability.
- 43. Management of associated fractures: Fracturestabilization should be performed after fasciotomy. Stabilization of fracture allows easy excess to the soft tissue and protect the soft tissues, permitting it to heal.
- 44. Wound Care • Softtissue coverage by 5-7 days • Delayed closure –Vascular loop ‘lace technique’ • Split thickness skin graft • Flaps or free tissue transfer
- 45. Prognosis • Fair ifdiagnosed in time and timely fasciotomy is done • Delay in diagnosis is most common cause of poor results with significant sequelae, including muscle contractures, muscle weakness, sensory loss, infection, and nonunion of fractures and in severe cases even amputation due to lack of function
- 46. Chronic exertional compartment syndrome(CECS) • Chronic exertional compartment syndrome (CECS) is defined as reversible ischemia secondary to a noncompliant osteofascial compartment that is unresponsive to the expansion of muscle volume that occurs with exercise
- 47. Epidemeology • Common in –young recreational athelete – New military recruits – Elite atheletes • The anterior and lateral compartments are most often affected • Symptoms are bilateral in about 75% of patients. • A 2-year delay in diagnosis is typical for CECS.
- 48. Diagnosis (1) preexercise, restingpressure of 15 mm Hg or more; (2) pressure of 30 mm Hg or more 1 minute after exercise; and (3) pressure of 20 mm Hg or more 5 minutes after exercise.
- 49. Conservative • Anti inflamatory •Rest • Muscle Stretching • Structured strengthening exercises
- 50. Fasciotomy double mini-incision fasciotomyfor chronic anterior compartment syndrome. A, Two vertical 2-cm skin incisions. B, Development of subcutaneous flap with blunt dissection. C, Skin retraction to allow fasciotomy under direct vision. D, After wound closure
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- 52. Complication Volkmann's Ischemic Contracture •Volkmann ischemic contracture is a sequel of untreated or inadequately treated compartment syndrome in which necrotic muscle and nerve tissue has been replaced with fibrous tissue. • The typical posture includes elbow flexion forearm pronation, wrist flexion, and thumb adduction with the metacarpophalangeal joints extended and the interphalangeal joints flexed
- 54. Tsuge's Classification ofVIC Mild Moderate Severe Flexor Digitorum Profundus Flexor Pollicis longus Involvement of FDP + FPL Supperficial finger flexor Wrist Flexors Thumb flexors all flexors Few extensors Neurologic deficit Contracutre of Joint Skin scarred Bones deformed.
- 55. TREATMENT :- Mild type 1.Dynamic splinting 2. Physioherapy 3. Total excision if single muscle is involved. .
- 56. TREATMENT :- Moderate type l.Max page's muscle sliding operation 2. Excision of cicatrix. 3. Neurolysis consists of freeing the peripheral nerves from the surrounding fibrous tissue. 4. Tendon transfer
- 57. TREATMENT :- Severe type 1.Excision of the scar. 2. Seddon's carpectomy 3. Arthrodesis of the wrist in functional position. 4. Amputation for very server cases of VIC with gangrene.
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