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DR. SIDHARTH YADAVDEPT. OF ORTHOPAEDICS
NKPSIMS
ACUTE COMPARTMENT SYNDROME
Compartment SyndromeDefinition
Elevated tissue pressure within a closed osteofascial space
Reduces tissue perfusion – ischemia
Results in cell death - necrosis
HistoryVolkmann 1881
Richard von Volkmann published an article in which he attempted to describe the condition of irreversible contractures of the flexor muscles of the hand to ischemic processes occurring in the forearm
Application of restrictive dressing to an injured limb
HistoryHildebrand 1906
First used the term Volkmann ischemic contracture to describe the final result of any untreated compartment syndrome.
First to suggest that elevated tissue pressure may be related to ischemic contracture.
History
Thomas 1909
Reviewed the 112 published cases of Volkmann ischemic contracture and found fractures to be the predominant cause.
Also, noted that tight bandages, an arterial embolus, or arterial insufficiency could also lead to the problem
History
Murphy 1914
First to suggest that fasciotomy might prevent the contracture.
Also, suggested that tissue pressure and fasciotomy were related to the development of contracture
History
Ellis 1958
Reported a 2% incidence of compartment syndrome with tibia fractures, and increased attention was paid to contractures involving the lower extremities
History
Seddon, Kelly, and Whitesides 1967
Demonstrated the existence of 4 compartments in the leg and to the need to decompress more than just the anterior compartment. Since then, compartment syndrome has been shown to affect many areas of the body, including the hand, foot, thigh, and buttocks
Types of compartment syndrome
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Compartment syndromes can be classified as :
Acute compartment syndrome (ACS)
Chronic compartment syndrome (CCS) depending on the cause of increased intra-compartmental pressure and the duration of symptoms
Sites of Acute Compartment Syndrome
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Acute compartment syndrome can develop anywhere a skeletal muscle is surrounded by a substantial fascia.
ACS may occur in foot, leg, thigh, buttocks, lumbar paraspinous muscles, hand, forearm, arm and shoulder.
Compartments
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Foot 9
Leg 4 (anterior,lateral, sup & deep posterior )
Hand 4
Thigh 3 (anterior, posterior, medial )
Forearm 4 (sup &deep volar,dorsal, mobile wad of Henry)
QUADRICEPS
MOBILE WAD
VOLAR COMPARTMENT
DORSAL
Pathophysiology of ACS
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CS develops after prolonged elevated intra-compartmental pressure , which results from either externally applied or internally expanding pressure forces.
Increased tissue pressure will decrease capillary blood flow leading to local tissue necrosis caused by O2 deprivation .
Local blood flow (LBF) =Pa-Pv/R.
Pathophysiology of ACS
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The elevated intra-compartmental pressure increases the local venous pressure leading to narrowed arteriovenous perfusion gradient and compartment tamponade, resulting -if uncontrolled - in nerve injury and muscle ischemia
Etiology of ACS
External Restriction of Compartment Size :
- casts - tight dressings - splints - lying on limb for long period - burn eschar - closure of fascial defect - lithotomy position
Etiology of ACS
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•Factures (the most common are) :
In adults --- closed and open tibial shaft fracture , distal radial fracture
In children --- radial head or neck fracture , supracondylar fracture , forearm fractures
Etiology of ACS
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Hemorrhage (e.g. due to vascular injury )
Coagulopathy (e.g. hemophilia , thrombolytics , sickle cell disease or trait )
Muscle edema (e.g. severe exercise , crush injury, trauma with or without fx )
Etiology of ACS
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Surgically related (e.g. knee arthroscopy , tibial osteotomy without drainage , after epidural anesthesia )
Massive crystalloid infusion
Ruptured Backer’s cyst
Muscle hypertrophy ( androgens )
Etiology of ACS
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Intracompartmental fluid infusion (interosseosus infusion)
Capillary leak syndrome
Intra-arterial injections of sclerosing agents
Post –ischemic reperfusion
Compartment SyndromeTissue Survival
Muscle 3-4 hours - reversible changes6 hours - variable damage8 hours - irreversible changes
Nerve 2 hours - looses nerve conduction4 hours - neuropraxia8 hours - irreversible changes
Compartment SyndromePathophysiology
Normal tissue pressure 0-4 mm Hg 8-10 with exertion
Absolute pressure theory30 mm Hg - Mubarak45 mm Hg - Matsen
Pressure gradient theory< 20 mm Hg of diastolic pressure – Whitesides
McQueen, et al
Compartment Syndrome Diagnosis
Pain out of proportion
Palpably tense compartment
Pain with passive stretch
Paresthesia/hypoesthesia
Paralysis
Pulselessness/pallor
PainClassically out of portion to injury
Exaggerated with passive stretch of the involved muscles in compartment
Earliest symptom
ParesthesiaAlso early sign
Peripheral nerve 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
ParalysisVery late finding
Irreversible nerve and muscle damage present
Paresis may be present earlyDifficult to evaluate because of pain
Pallor & PulselessnessRarely present
Indicates direct damage to vessels rather than compartment syndrome
Vascular injury may be more of contributing factor to syndrome rather than result
Compartment Pressure
Technique
Whiteside infusion
Stic technique: side port needle
Wick catheter
Slit catheter
Whiteside TechniqueSimple techniqueReadily available suppliesWith 18 gauge needle least accurateMore accurate if use side port needle
Stryker Stic SystemEasy to useCan check multiple compartmentsDifferent areas in one compartment
Management of ACS
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Removal of the possible cause (release of tight dressings or circular constrictive bandages, splitting of casts)
Correction of coagulopathy
Positioning of the limb at the level of the heart
Management of ACS
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If symptoms don’t resolve in 30 to 60 min after appropriate treatment ,pressure measurement should be repeated,and,if equivocal, fasciotomy is indicated
Management of ACS
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The definitive treatment of acute compartment syndrome is FASCIOTOMY
Procedure is done without a tourniquet,each potentially limiting envelope is opened over the entire length of the compartment, all muscle groups should be soft to palpation at the end of the procedure
Muscle debridement should be kept to a minimum
FACIOTOMY OF LOWER LIMBFOR THIGH Make a lateral incision distal to
intertrochantric line extending to the lateral epicondyle.
Expose the iliotibial band & make aa straight incision in line with skin incision
Reflect the vastus lateralis off the intermuscular septum
• FOR LEG
Single incision faciotomy
Double incision faciotomy
fibuloectomy
Chronic Compartment Syndrome
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Also known as exertional CS, recurrent CS and subacute CS
Exercise –induced pain
Occur mainly in the lower limb
Typical patient is young (20-30s) athlete (long distance runner)or military recruits pushed past normal limits of functional tolerance
Pathophysiology of CCS
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Not yet fully understood
Probably occurs from increased muscle relaxation pressure during exercise , which causes decreased muscle blood flow, leading to ischemic pain and impaired muscle function
COMPLICATION OF COMPARTMENT SYNDROMEReperfusion injuryVolkmann’s contractureWeak dorsiflxorsClaw toeSensory lossChronic painAmputation
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