Dr. Md.Abdul Mannan ChowdhuryNorthern Medical College, Rangpur

Early complications of Fractures

1.visceral injury2.vascular injury

3.compartment syndrome4.nerve injury

5.infections6.hemarthrosis

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There is no accepted time for a complication to be considered ‘early’, but the term is usually applied to complications that occur during the acute phase of treatment.

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DefinitionAn elevation of the interstitial pressure in a closed osteofascial compartment that results in microvascular compromise.

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It is a True Orthopedic Emergency

Elevated tissue pressure within a closed fascial space Reduces Tissue Perfusion- IschemiaResult in cell Death--Necrosis

True Orthopedic Emergency

Compartments:

Closed area of muscles group, nerves & blood veseles surrounded

by fascia

What is a compartment?

Muscles are arranged in different compartments and surrounded by one fascia , this arrangement called osteofascial compartment.

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Lower Extremity

GlutealThighLower LegFoot

Where it occurs?Upper Extremity

DeltoidArmForearmHand

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Normal compartment pressure: 5 – 15 mmHg

Intra-compartmental pressure rises to 35-40 mm hg

Capilaries are collapsedBlood flow to muscle & nerves are reduced

Types of compartment syndromeAcute compartment syndrome (ACS(

medical emergencycaused by a severe injurycan lead to permanent muscle damage.Chronic compartment syndrome (CCS( known as exertional compartment syndrome not a medical emergencymost often caused by athletic exertion.

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Compartment syndromeElevated tissue pressure Within a closed fascial space

Reduced Tissue perfusion Ischaemia

Results in cell Death (Necrosis(

Types of compartment syndromeAcute compartment syndrome (ACS(

medical emergencycaused by a severe injurycan lead to permanent muscle damage.Chronic compartment syndrome (CCS( known as exertional compartment syndrome not a medical emergencymost often caused by athletic exertion.

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Decrease compartment sizeIncrease compartment contents

Any condition that reduces the volume of a compartment or  increases the content of a compartment can lead to an acute compartment syndrome

Compartment Syndrome:AetiologyReduced compartment size:

Tight Bandage , Dressing,

Cast

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Increased Compartment Pressure:

Fracture Bleeding

Why does it occur?(aetiology(

Tight Cast or SplintCircumferential constricting dressingClosure of fasciaMilitary antishock trousers (MA S T(3rd degree Burns (circumferential(

Lithotomy position

Reduce the Volume

Etiology of ACS

Tight dressings and Bandage /closure of fascial defect

External pressures : casts, splints , burn eschar, lying on limb for long period, lithotomy position

Decrease compartment size

Compartment Syndrome: Aetiology

Increased Compartment Pressure:

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Fracture Bleeding

Vascular Injury

Tissue SurvivalMuscle 3-4 hour: Reversible Change

6 hours : Variable Damage8 hours :Irreversible Changes

Nerves 2 hours-Looses nerve conduction4 hours – Neuropraxis

8 hours – Irreversible Changes

Delayed DiagnosisPermanent sensory & motor

deficitContractures

Infections & Amputations

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Vicious circle :Compartment syndrome :

Fracture of the arm and leg can give rise to severe ischemia even if there is no damage to major vessel. Bleeding or edema will increase the pressure within one of the osteofascial compartments, this lead to decrease in capillary blood flow which in turn leads to muscle ischemia, further edema, still greater pressure, and yet more profound ischemia….vicious circle.

Compartmental syndrome may lead to

the Volkmann's ischaemia:

After 12 hours or less, this vicious circle ends in necrosis of nerves and muscles within the compartment.Nerve are capable of regeneration, but the muscle once infarcted can never recover and are replaced by fibrous tissue. This condition is called volkmann s ischemic contracture.

Compartment syndrome is a clinical diagnosis

High level of suspicion

Compartment syndromeEarly signs

TightEscalating painPain with passive stretch of the involved muscle

Clinical Evaluation of ACSClinical presentations :

Swelling/ Tightness of compartmentInappropiate and uncontrolled pain

Severe pain at rest or passive stretching

Pallor/CyanosisHyperesthesia /Paresthesia

Paralysis : full recovery is rare

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Presentation of Compartment Syndrome –

Signs of ischemia (5 P's:(

Pain,Paraesthesia, Pallor, Paralysis,Pulselessness(

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Acute Compartment Syndrome

Whiteside maneuver Wick hand held instrument

syringe

3 way stopcock

mmhg mano.

electrode

Direct reading

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Clinical Evaluation of ACSClinical presentations :

Swelling/ Tightness of compartmentInappropiated and uncontrolled painSevere pain at rest or passive stretchingPallor/CyanosisHyperesthesia/ParesthesiaParalysis : full recovery is rare

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diagnostic sign:

Never wait for signs of ischemia (5Ps): irreversible damage

Severe pain inappropriate to the injury(not relieved even with morphia(

Passive stretching of fingers or toes (muscle stretch(will lead to severe pain

Complications ofCompertment Syndrome

Acute renal fai lure secondary to rhabdo-

myolysisVolkmann's contracture

(where infarcted muscle is replaced by inelastic f ibrous

t issue(

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Complications:

Late sequelae : valkmann contracture

Week DorsiflexionClaw handSensory lossUseless hand

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Don’t wait for the obvious sings of ischemia to appear. If you suspect An impending compartment syndrome, start treatment straightaway

MANAGEMENT

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Immediate ActionCut & Spread Plaster and cotton woolRemove Plaster and other external Splints & Bandage

Limb Elevation ?decreases Compartment Pressure BUT BP in elevated Limb is Decreased

53% decreased in Perfusion PressureDON’TElevate the Limb

TreatmentNon Surgical Treatment:

(Immediate treatment before Operation(

Removal of all tight bandage , Cast.

Surgical management: (FASCIOTOMY(

Open skin and fascia down to a compartment

Surgical incision to the fascia to relieve tension or pressure.Complete opening of all fascial envelopes.The wound should be left open and inspected 2 days later.If there is muscle necrosis debridement.

If the tissues are healthy, the wound can be- sutured (without tension) OR

- skin-grafted OR- allowed to heal by secondary

intention

Treatment of ACS:

Operative treatment (Procedure(:

Single incision FasciotomyDouble incision Fasciotomy

After Operation: Wound is left openSecondary sutureskin-graft

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Surgical Treatment

FasciotomyFasciotomy

Fasciotomy –all compartment !!!

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After Operation: Wound is left openSecondary sutureskin-graft

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Keep the wound open

Close skin by Secondary

sutures after oedema subsides

It may need skin graft

Conclusion: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.

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The earlier you diagnose, the safer you are

Thank You

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