Acute compartment syndrome
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Transcript of Acute compartment syndrome
ACUTE COMPARTMENT SYNDROME
HISTORY Raised pressure in a closed space Richard von Volkmann
Hilderbrand Rowlands Murphy
PATHOPHYSIOLOGY
Raised pressure within a confined space Increased volume of compartment
Ischemia reperfusion injury MAJOR VESSEL RARELY OBSTRUCTED Difference between compartment and
diastolic pressure Crush syndrome Anesthetized / sedated / intubated patient Prolonged surgery Tight cast / constrictive dressing /
pneumatic anti shock garment
ETIOLOGY Decreased compartment size
Constrictive dressings and casts Closure of fascial defects Thermal injuries and frostbite Localized external pressure Pneumatic tourniquetIncreased compartment contents Primary edema accumulation Postischemic swelling Arterial injuries Arterial thrombosis or embolism Reconstructive vascular and bypass surgery Replantation Prolonged tourniquet time Arterial spasm Cardiac catheterization and angiography Ergotamine ingestion Prolonged immobilization with limb compression Drug overdose with limb compression General anesthesia with limb compression
Increased capillary pressure or permeability Exercise Venous obstruction Thermal injuries and frostbite Exertion, seizures, and eclampsia Venous disease Intraarterial injection Venomous snake bite Infection
Primarily hemorrhage accumulation Hereditary bleeding disorders (e.g., hemophilia) Anticoagulant therapy Vessel laceration Combination of edema and hemorrhage accumulation Fractures Supracondylar elbow Both-bone forearm Distal radius Soft tissue injury Crush Severe muscle tear, contusion Gunshot wounds Iatrogenic (i.e., postoperative bleeding, inflammation) Miscellaneous Intravenous infiltration (e.g., blood, saline) High-pressure injection
DIAGNOSIS : CLINICAL ASSESSMENT Symptoms may be masked by other injuries ?? Open fracture Disproportionate pain In regional/epidural anesthesia Numbness / tingling Signs Compartment Stretch pain Sensory deficit Paresis
Pulse / capillary refill Differential – artery occlusion, nerve injury,
crush syndrome ?? Delay in diagnosis of major arterial
injury Arterial pressure index Nerve injury – diagnosis of exclusion Crush syndrome
TISSUE PRESSURE MEASUREMENT Incipient vs. fulminant Ideally after every fracture Polytrauma patient Chemical overdose / head injury + long
bone fracture Arterial repair
MEASUREMENT TECHNIQUES
1. Needle manometer• Landerer• 18 gauge needle, 20ml syringe, column
of saline and air, mercury manometer
2. Wick catheter• Scholander• Polyglycolic acid suture, polyethylene
tubing• Disadvantage
3. Slit catheter• Rorabeck• Polyethylene tubing
with 5 3mm slits in end
4. STIC catheter• Hand held device
5. Micro capillary infusion
6. Arterial transducer measurement
7. Tc 99m-methoxyisobutylisonitrile
8. Doppler flow measurement
9. Near infrared spectroscopy
PRESSURE THRESHOLD FOR FASCIOTOMY
Within 10-30 mm Hg of diastolic pressure (Whitesides)
Above 45mm Hg (Matsen) 30mm Hg difference between
compartment and diastolic pressure (Mc Queen)
40mm Hg difference between mean arterial pressure and compartment pressure (Heppenstall)
TREATMENT OF INCIPIENT COMPARTMENT SYNDROME
Incipient compartment syndrome Remove tight dressings and casts Limb position at the level of heart Oxygen support Hydration
ESTABLISHED COMPARTMENT SYNDROME
Surgical decompression
HAND Clinical feature Crush injury /
carpal fracture Longitudinal
dorsal incisions
FOREARM Fracture / soft tissue fluid infiltration / gun
shot injury / deep infection / iv drug abuse 3 compartments Volar Henry / volar ulnar / Thompson Both superficial and deep compartment
should be released
Henry approach
Volar ulnar approach
Dorsal approach
LEG Fibulectomy – Patman / radical surgery Perifibular fasciotomy – Matsen
Single incision technique
Double incision technique - Mubarak
THIGH 3 compartments
FOOT Claw toe deformity Calcaneal fractures /
Lisfranc injury / blunt trauma
Difficult to diagnose
AFTERCARE Collagen / Cuticell Splintage Antibiotics Wound inspection after
48 hrs Opsite roller Vessel loop bootlace Plastic surgery
COMPLICATIONS1. COMPARTMENT SYNDROME2. FASCIOTOMY
MEDICAL MANAGEMENT Mannitol Hyperbaric oxygen
SKELETAL INJURIES Fracture must be stabilized Location, character of fracture / skill of
surgeon Plating / nailing / ex fix Soft tissue coverage
MUST AVOID CONTRACTURE SENSORY DEFICIT PARALYSIS INFECTION NON UNION AMPUTATION