Compartment syndrone
-
Upload
bashir-bnyunus -
Category
Health & Medicine
-
view
161 -
download
1
Transcript of Compartment syndrone
COMPARTMENT SYNDROME
ORTHOPEDICS UNIT PRESENTATION
DR. BASHIR YUNUS
4/3/14
10/14/2014 1
OUTLINE
• INTRODUCTION• AETIOLOGY• RELEVANT ANATOMY• CLASSIFICATION• PATHOPHYSIOLOGY• CLINICAL FEATURES• DIAGNOSIS• TREATMENT• PREVENTION• PROGNOSIS
10/14/2014 2
INTRODUCTION
An elevation of interstitial pressure in a closed osteofascial compartment that would lead to microvascular compromise with resultant ischemia and necrosis
10/14/2014 3
INTRODUCTION
Normal intra compartmental pressure is 0-10mmHg. Acute compartment syndrome occurs if pressure increase to 25-30mmHg or about 30mmHg below diastolic
10/14/2014 4
INTRODUCTION
• Usually occurs in younger patients(usu males under 35years)
• Site: any where skeletal muscle is surrounded by an unyielding fascial compartment; legs, forearm, thigh, arm, abdomen, buttocks, hand, feet of DM patient, lumber paraspinalmuscles
10/14/2014 5
10/14/2014 6
10/14/2014 7
10/14/2014 8
AETIOLOGY
The causes results from either increase in content of the compartment or a reduction in its volume from external compression.
Common causesTRAUMA :- About 40% accompany tibia fracture(ant> lat>post)
– 23% accompany soft tissue trauma
– 18% complicate fore-arm fracture
– In the US 2-12% anterior distal LL injuries result in CS
– 30% of Limbs devp CS fol vascular injury
10/14/2014 9
AETIOLOGY
• Constrictive dressings/ Tight casts• TBS Splinting• Ischaemic reperfusion injuries following
vascular injuries• Burns esp circumferential• Prolonged limb compression• Poor prolonged positioning during surgery &
in drug users• Envenomations e.g Snake bites
10/14/2014 10
10/14/2014 11
RELEVANT ANATOMY
• LEG : muscle compartments
– Lat compart.
– Ant. Compart.
– Post. Compart. -superficial -deep
10/14/2014 12
10/14/2014 13
• FOREARM: - superficial flexor
deep flexor
extensor
10/14/2014 14
10/14/2014 15
10/14/2014 16
RELEVANT ANATOMY
• These compartment are separated and enclosed by tight fascial separation.
• Running through these areas are blood vessels and nerves.
• The functions of all the above mentioned structures are affected if ICP rises above Capillary pressure.
10/14/2014 17
CLASSIFICATION
• ACUTE:
is a surgical emergency which if not
recognised and treated early can lead to
devastating disabilities, amputation and even
death in some situations
• CHRONIC:
Seen in long standing runners
10/14/2014 18
CLASSIFICATION
CHRONIC
• Transient rise in compartmental pressure following activity
• Symptoms
• Pain
• Weakness
• Neurologic deficits.
10/14/2014 19
PATHOPHYSIOLOGY
• Local blood flow= arteriovenous pressure gradient(Pₐ -Pᵥ)
local vascular resistance• Injury to tissue leads to oedema with increase
tissue pressure and increase Pᵥ. There is deminished arteriovenous pressure gradient with resultant deminished or absent local blood flow.(Pᵥ >30mmHg for a prolong period)
• Arterial blood flow however continued until late stages.
10/14/2014 20
Pathophysiology
• Increased compartment pressure
Increased venous
pressureDecreased blood
flow
Decreases
perfusion
Increased muscle
swelling
Increased
permeability
Increased compartment
pressure
10/14/2014 23
10/14/2014 24
CLINICAL FEATURES
• Pain• Paraesthesia• Pallor• Pulselesness• Paralysis – loss of vibration sense is early.• ‘Perishing cold’–• Patients prone to compartment syndrome;• Hypotension• External compression• Coagulopathy• Vascular injury or repair
Less prone if well resuscitated
10/14/2014 25
CLINICAL FEATURES
• PAIN
– Earliest symptom & most important
– Severe & out of proportion, rest pain and pain on passive stretch
– Occasionally not reliable eg. Unconscious anaesthesized, children and in nerve injury
– It is 19% sensitive and 97% specific
– There is false negative or missed cases
10/14/2014 26
CLINICAL FEATURES
• PARASTHESIA/HYPOESTHESIA
– Occur in the territory of the Nerve within the compartment.
– It is the first sign of Nerve ischaemia
– It can be due to N. injury
– 13% sensitive and 98% specific
10/14/2014 27
CLINICAL FEATURES
• PARALYSIS
– It affects the muscle within the compartment
– It is a late sign
– Can be due to inhibition by pain, muscle injury or N injury
– It has a low sensitivity
– ACS with muscle deficit, complete recovery is rare
10/14/2014 28
CLINICAL FEATURES
• PERISHING COLD– The part of the body affected feels cold due to
decreased blood flow
• PULSELESSNESS– It is a very late features,it follows onset of gangrene– It can be as a result of major vascular injury
• SWELLING– The affected compartment is usually swollen – It may be difficult to assess b/cos of cast ,dressing or
the location of the compartment– Skin changes are late features ACS
10/14/2014 29
DIAGNOSIS
• Mainly clinical
• There should be high index of suspicion.
Passive stretching of fingers or toes (muscle stretch)will lead to severe pain (diagnostic sign)
Never wait for signs of ischemia (5Ps): irreversible damage
10/14/2014 30
Objective method of diagnosing ACS
Involves dynamic measurement of ICP which was introduced in 1970 following Matson unified concept of identifying increase ICP irrespective of aetiology.
10/14/2014 31
Indications include:(i) Unconscious patient(ii) Uncooperative patient(iii) Children(iv) Equivocal features(v) Multiply injured patients(vi) Assessment of adequacy of decompressive
fasciotomy.Current Concept is that ICP should be measured in
all cases of suspected
10/14/2014 32
Devices adopted for measurement include:
(i) Hand-held needle manometer
(ii) The wick – catheter
(iii) The Slit – catheter
(iv) Solid – state transducer intra-compartment catheter (STIC)- stryker
(v) Transducer – tipped – probe
(vi) Whiteside manuever
10/14/2014 33
Stryker STIC Monitor
10/14/2014 34
Wick hand held instrument
10/14/2014 35
Whiteside maneuver
10/14/2014 36
Interpretations of measurement of intra-compartmental pressure
I. Absolute intracompartment pressure
level of >30mmHg
(ii) Differential pressure: the concept is that the level of ICP at which ischaemic of tissue occurs is related to the perfusion pressure.
10/14/2014 37
(iii) Delta pressureDiastolic – ICPrange 10-35mmHg< 30mmHg
Time factor - The intracompartmentalpressure should however not be treated in isolation rather the trend of ICP over time or Delta Pressure should be observed.
10/14/2014 38
Other supportive inx
Lab studies:
• FBC,Creatine, phosphokinase & Urine myoglobin,Serum
• myoglobin,Urinalysis,PT & APTT, Urine
• toxicology screen,
X-RAY of affected extremity
10/14/2014 39
DIFFERENTIAL DIAGNOSIS
• Cellulitis
• Coelenterate and Jellyfish Envenomations
• DVT and Thrombophlebitis
• Gas Gangrene
• Necrotizing Fasciitis
• Peripheral Vascular injuries
• Rhabdomyolytis
10/14/2014 40
Treatment
• Don’t wait so long
10/14/2014 41
Treatment
GENERAL: ABCD OF RESUSCITATION Since ACS is often due to trauma,follow the ATLS
protocol to stabilize the patient
SPECIFIC:(i) Remove all the circumferential dressing down
to the skin eg bandage, casts(ii) Do not elevate the limb above heart level(iii) fasciotomy.
This must be prompt and adequate.
10/14/2014 42
Treatment
catastrophic clinical results were inevitable iffasciotomy were delayed for over 12hrs butfull recovery was achieved if decompressionwas performed within six hours of makingdiagnosis.
10/14/2014 43
INDICATIONS FOR FASCIOTOMY
1. Clinical features highly suggestive of ACS
2. Absolute compartment pressure >30-40 mmHg
3. Mean arterial pressure – ICP >40mmHg
4. Diastolic BP – ICP (delta p) <30mmHg
10/14/2014 44
10/14/2014 45
10/14/2014 46
10/14/2014 47
COMPLICTIONS OF FASCIOTOMY
• Complications are real >25%
– Chronic swelling
– Chronic pain
– Muscle weakness
– Iatrogenic NV injury
– Cosmetic concerns
10/14/2014 48
Early complicatios of CS
• Myoglobinemia
• Hypercalemia
• Acidosis
• Infection
• Acute renal injury
10/14/2014 49
10/14/2014 50
Prevention
• High index of suspicion on complaint of extremity pain esp post high velocity injury & px on cast
• Health education of px in cast on recognition of symptoms & early re-presentation in the hospital
• Waiting for swellings to resolve b4 application of cast
• Splitting of cast
• Routine measurement of ICP
• Prompt tx on diagnosis
10/14/2014 51
prognosis
1. Nerve dysfxn maybe reversible with time but infarcted muscle is damaged permanently.
2. Early surgery gives good fxnal outcome but delay results in muscle ischaemia & necrosis
10/14/2014 52
Role of TBS
10/14/2014 53
Conclusion
• Compartment syndrome is a serious syndrome, Which needs
• to be diagnosed early.• Palpable pulse doesn’t exclude compartment
syndrome• If 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
10/14/2014 54
1.Apley’s system of orthopedics and fractures; Louis et al, 9th edition
2.Principles Of Surgery; Schwartz.7th edition.1999.
3. A.H.CrenshawCampbell,s Operative Orthopedics;
8th Edition,20024.E-medicine;5.Ronald Mcrae, Max Esser;Practical Fracture Treatment, 4th ed. Churchill
Livingstone,200
10/14/2014 55