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Compartment Syndrome

Compartment Syndrome. Prof. Mamoun Kremli AlMaarefa College. Pathophysiology. Increasing volume in a closed compartment P ressure increased in compartment Decreasing arteriovenous difference Hypoxia : Muscle necrosis. Pathophysiology. > 30 mmHg. N=0-4 mmHg. Compartment pressure.

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Compartment Syndrome

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  1. Compartment Syndrome Prof. Mamoun Kremli AlMaarefa College

  2. Pathophysiology • Increasingvolume in a closedcompartment • Pressureincreasedin compartment • Decreasingarteriovenousdifference • Hypoxia : Musclenecrosis

  3. Pathophysiology > 30 mmHg N=0-4 mmHg Compartment pressure Venous outflow Venous pressure Gradient A.V pressure Arterial perfusion Capillary permeability Ischemia, tissue necrosis, edema

  4. Pathophysiology • Increased compartment pressure: • ICP >30mm Hg (>40mm Hg) • Delta Pressure: Pdiast- Pcomp< 30 mm Hg

  5. Causes • Fractures • Bleeding in closedcompartment • Soft tissuetrauma • Bleedingandedema in closedcompartment • Surgery • Post osteotomy (Tibia / Forearm) • Circumfrentialdressings • Does not allowswellingofskin

  6. Clinical Picture – 5Ps • Pain: • Pain out of proportion of expectation • Increased pressure / burst sensation • Pain with passive motion / stretch • Paresthesia • Paralysis • Pallor • Pulselessness TREAT  too late, >8h

  7. Clinical Picture - Look • Shiny skin • Pallor / or Dusky skin • Swelling of compartment

  8. Clinical Picture - Look • Shiny skin • Pallor / or Dusky skin • Increased volume • Blisters • Clear fluid • Dusky • Bloody -worst

  9. Clinical Picture - Feel • Feels tense • Parasthesia • Pulse ?

  10. Clinical Picture - Move • Pain on passive stretch • Passive dorsiflexion of ankle (leg) • Passive dorsiflexion of wrist (forearm)

  11. Diagnosis • Diagnosis is clinical: • Unrelenting, burstingpain • Unrelifedbyanalgesia • Swollencompartment • Pain on passive stretching • Sensorydeficit? • Pulses always palpable • Open fractures DO NOT necessarily decompress an elevated compartment pressure

  12. Diagnosis • Compartmentpressuremeasurement: • NOT a substitute for clinical diagnosis • Invaluable in unconscious or anesthetized patients

  13. Measuring compart. pressure • When is pressure measurement needed? • Measure pressure only if: • Clinical picture equivocal • Altered consciousness • Multiple injuries • Epidural anesthesia • Concomitant nerve injury • Children

  14. Treatment • Medical • Surgical

  15. Medical Management • ABC’s. • Correct hypotension • Remove circumferential bandages & cast • Limb at level of the heart • more elevation reduces the arterial inflow • Supplemental oxygen administration

  16. Medical Management • With tight cast, compartmental pressure falls: • 30%  when cast is split on one side • 65%  when cast is split Bilaterally • 75%  with Splitting the inside padding • 85 – 90%  complete removal of cast

  17. Surgical Management • Should not be delayed • Fasciotomy • Skin and All compartments

  18. Fasciotomy • Indications: • High suspicion • Unequivocal clinical findings • Significant tissue injury • Delta pressure (DBP - compartment P.) < 25 mm Hg. • Compartment pressure > 30mm Hg. • S&S not resolved after 30-60min of appropriate precautions • Prophylactic with major corrective osteotomy of the leg & forearm • High risk patients

  19. High Risk Patients • Clinical picture equivocal • Altered consciousness • Multiple injuries • Epidural anesthesia • Concomitant nerve injury • Children

  20. Fasciotomy Principles • Long extensile incisions • Release all compartments • Debride necrotic muscles (4C’s) • Preserve neurovascular structures • Never close fascia • Keep wound open • Repeated looks x48h, as needed • Coverage within 7-10 days (usually within 3-5 d)

  21. Fasciotomy Principles

  22. Fasciotomy Principles

  23. Fasciotomy Principles

  24. Fasciotomy Principles • Wound closure: • Bulky dressing with a splint • “Boot lace” vessel loop closure • “V.A.C” dressing (Vacuum Assisted Closure) • Later skin graft / flap: • Usually skin graft • Flap coverage needed if nerves, vessels, or bone exposed

  25. Compartment Syndrome • Evaluation ofmuscleviability (4Cs): • Color • Consistency • Contractility • Capacity to bleed

  26. Treatment - early • Color red • Consistency normal • Capable of bleeding • Contracts when pinched ✓

  27. Treatment – late • Color dark • Consistency abnormal • Not bleeding • No contractions when pinched ✗

  28. Contraindication to fasciotomy • Confirmed acute compartment syndrome diagnosis for > 48 hours • damage cannot be reversed and • significant infection rate when dead tissue exposed • Already dead muscles, as in crush injuries

  29. Complications of untreated C.S. • Volckmann’s contracture • Muscle weakness • Sensory loss • Chronic pain • Amputation

  30. Summary • Compartment syndrome is a clinical diagnosis • Should not be missed - Disaster • Requires urgent treatment • “Time” is the most important factor to avoid irreversible complications • Do NOT apply circumferential dressings

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