acute compartment syndrome

COMPARTMENT COMPARTMENT SYNDROMESYNDROME

BASSEY, A E M.B, B.S

OUTLINEOUTLINE INTRODUCTION

DEFINITION STATEMENT OF IMPORTANCE

EPIDEMIOLOGY CLASSIFICATION AETIOLOGY RELEVANT ANATOMY PATHOPHYSIOLOGY CLINICAL MANIFESTATION

HISTORY EXAMINATION

MANAGEMENT RESUSCITATION INVESTIGATION DEFINITIVE TREATMENT

REHABILITATION COMPLICATIONS PROGNOSIS CURRENT TRENDS CONCLUSION

INTRODUCTION

INTRODUCTIONINTRODUCTIONCOMPARTMENT SYNDROME IS A POTENTIALLY

LIFE-THREATENING CONDITION RESULTING FROM INCREASED PRESSURE WITHIN A CONFINED BODY SPACE, USUALLY A LEG OR FOREARM

THIS CONDITION WITHOUT INTERVENTION LEADS TO LOSS OF LIMB OR EVEN LIFE UNLESS EARLY DIAGNOSIS IS MADE AND TREATMENT INSTITUTED. IT IS IMPERATIVE FOR TODAY’S PHYSICIAN TO HAVE ADEQUATE UNDERSTANDING OF THIS REMEDIABLE MALADY, MORESO WITH INCREASING INCIDENCE OF TRAUMA DUE TO ROAD TRAFFIC INJURY, TERRORIST ATTACKS & COLLAPSING BUILDINGS

EPIDEMIOLOGY

EPIDEMIOLOGYEPIDEMIOLOGYFRACTURES ARE RESPONSIBLE FOR 69% OF

CASES OF COMPARTMENT SYNDROME

M>F

THE LEG IS THE COMMONEST SITE. TIBIAL FRACTURE IS COMMONEST CAUSE AND ANTERIOR COMPARTMENT IS MOST FREQUENTLY INVOLVED

FOREARM IS 2ND COMMONEST SITE, SUPRACONDYLAR FRACTURE IS THE COMMONEST CAUSE WITH FLEXOR COMPARTMENT MOST FREQUENTLY INVOLVED

CLASSIFICATION

CLASSIFICATIONCLASSIFICATIONACUTE

CHRONIC

AETIOLOGY

AETIOLOGYAETIOLOGYFRACTURESGUNSHOT INJURYCRUSH INJURYBURNSIATROGENICDEEP VEIN THROMBOSISENVENOMATIONINTENSE MUSCLE ACTIVITY↓ SERUM OSMOLARITY

RELEVANT ANATOMY

RELEVANT ANATOMYRELEVANT ANATOMY

RELEVANT ANATOMYRELEVANT ANATOMY

PATHOPHYSIOLOGY

PATHOPHYSIOLOGYPATHOPHYSIOLOGYNORMAL LEG COMPARTMENT

PRESSURES NIGERIANS : 3 – 14 mmHg CAUCASIANS : 0 – 15 mmHg

PERIPHERAL INTRAVASCULAR PRESSURES

ARTERIES : 80 – 120 mmHg ARTERIOLES : 35 mmHg CAPILLARIES : 20 mmHg VENULES : 12 mmHg VEINS : 5 mmHg

PATHOPHYSIOLOGYPATHOPHYSIOLOGYTRAUMA

↓RISE IN INTRACOMP. PRESSURE

↓VENOUS OBSTRUCTION + MUSCLE/NERVE

ISCHAEMIA↓

FURTHER RISE IN COMP. PRESSURE↓

CAPILLARY OBSTRUCTION + MYOCYTE NECROSIS↓

ARTERIAL OBSTRUCTION

CLINICAL MANIFESTATION

CLINICAL MANIFESTATIONCLINICAL MANIFESTATION THE 6 Ps HISTORY

DISPROPORTIONATE PAIN FEELING OF TENSION PARAESTHESIA, NUMBNESS – LATE SYMPTOMS HX OF PRECIPITATING EVENT

EXAMINATION INSPECTION : RESTLESSNESS, BULLAE,

FRACTURE BLISTERS PALPATION : PAIN ON PASSIVE MUSCLE

STRETCH – EARLIEST CLINICAL INDICATOR, WOODY FEELING ON DEEP PALPATION

DECREASED 2-POINT DISCRIMINATION – CONSISTENT EARLY FINDING

SENSORY/MOTOR DEFICITS, PULSELESSNESS ARE LATE FEATURES

MANAGEMENT

MANAGEMENTMANAGEMENTRESUSCITATION

INVESTIGATION: INTRACOMPARTMENTAL PRESSURE

MEASUREMENT – STANDARD OF DIAGNOSIS GLOBALLY

PCV URINALYSIS E,U & Cr ULTRASONOGRAPHY ANCILLARY INVESTIGATIONS

STRYKER PRESSURE STRYKER PRESSURE TONOMETERTONOMETER

MANAGEMENTMANAGEMENTDEFINITIVE TREATMENT –

PRINCIPLES REMOVE ALL CAST, DRESSINGS &

BANDAGES BIVALVE ALONE WILL NOT SUFFICE

RENAL PROTECTION IV CRYSTALLOID 500ml/hr IV MANNITOL 1g/Kg ALKALINIZE URINE

EARLY DECOMPRESSION VIA EMERGENCY FASCIOTOMY

MANAGEMENT - FASCIOTOMYMANAGEMENT - FASCIOTOMYINDICATIONS

NORMOTENSIVE PATIENT WITH CLINICAL FEATURES OF COMPARTMENT SYND. AND COMPARTMENT PRESSURE >30mmHg

HYPOTENSIVE PATIENT WITH COMPARTMENT PRESSURE >20mmHg

UNCONSCIOUS PATIENT WITH COMPARTMENT PRESSURE >30mmHg

OBTAIN INFORMED CONSENTDONE UNDER GADECOMPRESSION OF

COMPARTMENTS + EXCISION OF NECROTIC MUSCLE

DOUBLE-INCISION LEG DOUBLE-INCISION LEG FASCIOTOMYFASCIOTOMY

FOREARM FASCIOTOMYFOREARM FASCIOTOMY

FASCIOTOMY – POST OPFASCIOTOMY – POST OPELEVATE LIMB FOR 24 – 48HRSANALGESIAANTIBIOTICSDELAYED PRIMARY CLOSURESPLIT-THICKNESS SKIN GRAFT IF

CLOSURE NOT POSSIBLE AFTER 5 DAYS

REHABILITATION

REHABILITATIONREHABILITATIONPHYSICAL THERAPY

OCCUPATIONAL THERAPY

COMPLICATIONS

COMPLICATIONSCOMPLICATIONSEARLY

ACUTE RENAL FAILURE MUSCLE INFARCTION SEPSIS

LATE VOLKMANN ISCHAEMIC CONTRACTURE CHRONIC LIMB PAIN PARESIS/PARALYSIS

PROGNOSIS

PROGNOSISPROGNOSISTIME LAPSE BETWEEN INJURY &

INTERVENTION – MOST IMPORTANT

FASCIOTOMY WITHIN 6HRS : ≈100% FULL RECOVERY

WITHIN 12HRS : 68% BEYOND 12HRS : 8%

SITE OF AFFECTATION

CURRENT TRENDS

CURRENT TRENDSCURRENT TRENDSHYPERBARIC OXYGEN

CONCLUSION

CONCLUSIONCONCLUSIONCOMPARTMENT SYNDROME HAS DISASTROUS CONSEQUENCES IF PERMITTED TO RUN ITS COURSE.

TIMELY INTERVENTION IS INDISPENSABLE IF A SATISFACTORY OUTCOME IS TO BE ACHIEVED.

THANKYOU

REFERENCESREFERENCES The clinical diagnosis of compartment syndrome of the lower

leg: are clinical findings predictive of the disorder? J Orthop Trauma 2002 Sep;16(8):572-7

Acute compartment syndromes: diagnosis and treatment with the aid of the wick catheter. J Bone Joint Surg Am. 1978 Dec;60(8):1091-5.

Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br. 1996 Jan;78(1):99-104.

Fasciotomy in the treatment of the acute compartment syndrome. 

J Bone Joint Surg Am. 1976 Jan;58(1):112-5 emedicine.medscape.com/article/307668-overview emedicine.medscape.com/article/2058838-overview Bailey & Love’s Short Practice of Surgery, 24th Ed, pp. Principles & Practice of Surgery including Pathology in the

tropics, 4th Ed, pg. 90 Schwartz’s Principles of Surgery, 8th Ed, pg. 349