Compartment Sindrome Eiji Present Longcase Ortho

8/3/2019 Compartment Sindrome Eiji Present Longcase Ortho

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NUR HAZIERAH BINTI MOHD RASHID

(C11107279)

LONGCASE BEDAH

ORTOPEDI

Prof. Chairuddin Rasjad, MD, Ph.D



WHAT IS COMPARTMENT SYNDROME?

Increased pressure

within a fascial

compartment Muscle is enclosed in

compartments bound

by relatively rigid

walls of bone andfascia.



WHAT IS COMPARTMENT SYDROME?

Two Types:

1) Acute ² usually due to trauma

» Long bone fractures» Vascular injury

» Crush injury

2) Chronic ² due to repetitive

microtrauma from physicalactivity. (chronic exertional

compartment syndrome)



ETIOLOGY OF

COMPARTMENTSYNDROME

Internal Increase in Compartment

Volume

External Restriction of Compartments

Splints, Casts, Dressings

Burns (Eschar)

Military Antishock Trousers

Tight Ski Boots

Hemorrhage

Hemophilia

Fractures

Gunshot Wounds

Massive IV fluid infusion

Compartment fluid injection

Crush InjuriesGastrocnemius Muscle Tear

Ruptured Baker·s cyst

Knee Arthroscopy



FREQUENCY OF COMPARTMENT

SYNDROME

The incidence varies depending on the inciting event

6% in patients with open tibial fractures.

1.2% in patients with closed tibial fractures.

Prevelance higher in vascular injuries

Reported 19-30% in vascular trauma.

Incidence in chronic compartment syndrome has not

been determined



PATHOPHYSIOLOGY

Postulated that increasedcompartment pressure obstructsvenous outflow and leads toreduced A-V gradient and a

decrease in local blood flowresulting in ischemia of bothmuscles and nerves.

Fluid accumulation leads to

increased pressure in confinedspace.

Viscous cycle of ischemia andswelling then ensues.



INCREASE PRESSURE LEADS TO

ISCHEMIA

pressure in confinedspace decreases bloodflow and leads to

ischemia

Intra-compartmentalpressures greater than30 mm Hg lead tosymptoms ofcompartment syndrome



CLINICAL PRESENTATION

Physical Signs

P

ain or burning, followed bydecrease in strength.

Severe pain at rest or withany movement should raise

suspicion. Pain with passive stretching

of the muscles is the earliestclinical indicator.



CLINICAL PRESENTATION

Determine if neural

compromise exists

Sensory Loss Motor Loss

Limb may feel tense or hardas the compartment

swells with fluid



KNOW YOUR ANATOMY

* It is the key to understanding symptoms



CLASSIFICATIONS

Mild: 2-3 digits are involved

Moderate: increased flexor involvement

Severe: Contracture of both flexor and extensor



DIAGNOSIS

* A high index of suspicion and familiarity with this condition should lead the clinician to get

pressure measurements. Failure to do so, can lead to permanent paralysis and/or amputation

Measure Intracompartmental

Pressures (ICP)-gold standard

Stryker Pressure Tonometer

Direct measurements of pressureby inserting a needle into theCompartment

It measures the pressure that isnecessary to inject a smallquantity of fluid.

Currently recommendedthresholds for fasciotomy:persistent pressure >30 mmHg



DIAGNOSTIC MODALITIES

Methoxy Isonitrile MRI (MIBI MRI)

Phophate Nuclear MRI

*MRI-not sensitive or specific enough so far Technitium Sestamibi

Xenon Scanning

Laser Doppler Flowmetry and Scintigraphy

None of these methods have been shown to be asuseful as direct compartment measurement orclinical exam.



OTHER WORKUP

Creatine Phosphokinase (CPK)

Released into blood with muscledamage/ischemia

Helpful for dx of rhabdomyolysis (In

absence of clinical signs, elev. Couldindicate unsuspected CS. Not helpful forearly dx.)

Complete blood count, PT/INR

Hemoglobin (anemia worsens ischemia)

Pt. predisposed to bleeding?

Renal Panel

BUN/Cr, K+



TREATMENT

Surgical Fasciotomy(compartment release)

Often combined withorthopedic reduction orstabilization and vascular

repair if needed.

Goal is to restore muscleperfusion within 6 hours.



FASCIOTOMY



A) LATERAL INSICION B) MEDIAL INSICION



FASCIOTOMY

After fasciotomy, wet todry dressing changes areperformed.

May require furtherdebridement in OR

Return to OR in 1-3 daysto close the fasciotomyincisions.



FASCIOTOMY

Sometimes partial

closure can only

be done.

Skin Grafting may

be required.



FASCIOTOMY



COMPLICATIONS

Post-Operative Motor Deficits

Foot Drop: treated with appropriate orthotic device

Function usually improves within 1 year

Numbness or Painful Neuropathy

May resolve slowly with time

Medication (Neurontin) may help symptoms

Systemic Complications

Renal Failure from rhabdomyolysis

ARDS



CONCLUSIONS

Compartment syndrome is cause by increased pressure

within muscular compartments that can compromise

blood flow leading to tissue ischemia.

The clinician most have a high suspicion to that prompt

treatment can be implemented to halt tissue ischemia.

Fasciotomy is the treatment of acute compartment

syndrome and sometimes for chronic compartment

syndrome.

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Compartment Sindrome Eiji Present Longcase Ortho