DR HARDEV SINGHP.G IN ORTHOPAEDICS

BHMRCNEW DELHI

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.

Pathophysiology:Normal tissue pressure 0-4 mm Hg 8-10 with exertionAbsolute pressure theory30 mm Hg - Mubarak45 mm Hg - Matsen

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/ ParalysisPulselessnessPallor

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 SyndromeTissue Survival

• Muscle– 3-4 hours - reversible changes– 6 hours - variable damage– 8 hours - irreversible changes

• Nerve – 2 hours - looses nerve conduction– 4 hours - neuropraxia– 8 hours - irreversible changes

COMPARTMENT SYNDROME

ManagementNon surgical management:

Remove any tight bandage, 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

syndrome

Single Incision• Perifibular Fasciotomy

– Matsen et al (1980)– Single incision just

posterior to fibula– Common peroneal nerve

Double Incision

Mubarak et al JBJS 1977

Forearm FasciotomyVolar-Henry

approachInclude a carpal

tunnel releaseRelease lacertus

fibrosus and fascia

Protect median nerve, brachial artery and tendons after release

Compartment syndrome foot9 compartments -medial superficial

lateral calcaneal interossei(4) adductor.

Suspicion with-lisfranc fracture -calcaneal fracture

Compartment syndrome foot Dorsal incision to

release the interossei and adductor

Median incision to release the medial superficial lateral and calcaneal compartment

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