Compartment syndrome

COMPARTMENT SYNDROME
CRUSH INJURIES

1. COMPARTMENT SYNDROME & CRUSH INJURY 7 TH MAY 2018 PRESENTED BY: NASRI

2. Presentation outline Compartment syndrome Definition Compartments of upper and lower limb Clinical symptoms & signs Management Crush injury Introduction Pathophysiology Clinical features management

3. COMPARTMENT SYNDROME

4. INCREASE IN OSTEOFASCIAL compartment PRESSURE . Compartments  are groupings of bone, muscles, nerves , and blood vessels in upper and lower limbs Each compartment is covered by fascia respectively. ∆ P <30 mmHG between diastolic blood pressure (DBP) and fascial pressure definition

5. ETIOLOGY

6. FRACTURES OF ELBOW, FOREARM, PROXIMAL 1/3 OF TIBIA & MULTIPLE FRACTURES OF HAND & FOOT Cascade of event : local trauma and soft tissue destruction>   bleeding and edema   >   increased compartment pressure  >   vascular occlusion   >   myoneural ischemia (after 12 hours or less)

7. Volkman’s ischemic contracture

8. CLINICAL PRESENTATION PAIN (EARLY SYMPTOM) OUT OF PROPORTION TO EXPECTATION STRETCH PAIN TENSE SWELLING NOT RELIEVED BY ADEQUATE ANALGESIA Sigamoney , K., Khincha , P., Badge, R., & Shah, N. (2015). Compartment syndrome: challenges and solutions.  Orthopedic Research and Reviews ,  7 , 137-148.

9. CLASSIC FEATURES 6 P’s PAIN PARAESTHESIA PALLOR PARALYSIS PERISHINGLY COLD PULSELESSNESS

10. ANATOMY UPPER LIMB ARM FOREARM HAND LOWER LIMB THIGH LEG FOOT

11. ARM

12. Arm Compartment Muscle Nerve Anterior Biceps brachii Coracobrachialis Brachialis Musculocutaneous nerve Posterior Triceps Radial nerve

13. FOREARM

14. Forearm Compartment Muscles Nerve Anterior Superficial Middle Deep Pronator teres, Flexor carpi radialis, Palmaris longus, Flexor carpi ulnaris Flexor digitorum superficialis Flexor digitorum profundus, flexor pollicis longus, pronator quadratus Median nerve Ulnar nerve Posterior Superficial Deep Aconeus , Ext digital communis , Ext digital minimi , Ext carpi ulnaris Supinator, Abductor pollucis longus, Ext pollicis brevis, Ext pollicis longus, Ext indicis proprius Posterior interosseous nerve Lateral (Mobile web compartment) Brachioradialis Extensor carpi radialis longus Extensor carpi radialis brevis

15. Hand Compartment Content Thenar Abductor pollicis brevis, Flexor pollicis brevis, Opponens pollicis Hypothenar Abductor digit minimi , Flexor digitiminimi brevis, Opponens digiti minimi Adductor Adductor pollicis Palmar interosseous (3) Palmar interosseous muscles Dorsal interosseous (4) Dorsal interosseous muscles

16. LOWER LIMB

17. THIGH

18. Thigh Compartment Muscle Nerve Anterior Quadriceps Sartorious Femoral nerve Posterior Hamstrings Sciatic nerve Adductor Adductor Gracilis Obturator nerve

19. LEG

20. Leg Compartment Muscle Nerve Action Anterior Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peronues tertius Deep peroneal nerve Dorsiflexion Extension of great toe Extension of 4 other toes Deep Posterior Tibialis posterior Flexor hallucis longus Flexor digitorum longus Popliteus Tibial nerve Plantarflexion Flexion of great toe Flexion of other 4 toes Superficial Posterior Gastrocnemius Plantaris Soleus Tibial nerve Lateral Peoneus longus Peronus brevis Superficial peroneal nerve Evert foot

21. FOOT

22. FOOT Compartment Medial Abductor hallucis Flexor hallucis brevis Flexor hallucis longus tendon Lateral Abductor digiti minimi Flexor digiti minimi Superficial central Flexor digitorum brevis Lumbricals (4) Flexor digitorum longus tendon Deep central (Calcaneal) Quadratus plantae Posterior tibial neurovascular bundle Adductor Adductor hallucis Interosseus (1-2) Dorsal interosseous muscles Interosseus (2-3) Dorsal and plantar interosseous muscles Interosseus (3-4) Dorsal and plantar interosseous muscles Interosseus (4-5) Dorsal and plantar interosseous muscles

23. PASSIVE STRETCH TEST

24. MEASURE THE INTRACOMPARTMENTAL PRESSURRE - A slit catheter is introduced into the compartment and the pressure is measured - Δ P = general diastolic pressure – compartment pressure  if <30 mmHg, need immediate compartment decompression

25. If no facilities to measure pressure: ≥ 3 classical signs (6Ps ) – diagnosis is almost certain If signs are equivocal, limbs examined at 15 minutes intervals & if no improvement within 2 hours of splitting the dressings, fasciotomy should be done. Muscle will be dead after 4-6 hours of total ischemia! APPLEY’S CONCISE ORTHOPAEDICS AND FRACTURES 3 RD EDITION 2005

26. Treatment DECOMPRESSION Casts/bandages/dressing completely removed. Limb is n ursed flat (elevating limb cause further decrease in end-capillary pressure and aggravates muscle ischemia) Δ P <30 mmHg : immediate open fasciotomy Fasciotomy Example: In leg – opening all 4 compartments through medial & lateral incisions, wounds left open and inspected 2 days later - if muscle necrosis  debridement - if tissues are healthy  wound suture OR skin graft

27. Fasciotomy Technique A nterolateral incision  identify and protect the superficial peroneal nerve fasciotomy of anterior compartment performed 1cm in front of intermuscular septum fasciotomy of lateral compartment performed 1cm behind intermuscular septum Posteromedial incision  protect saphenous vein and nerve incise superficial posterior compartment detach soleal bridge from back of tibia to adequately decompress deep posterior compartment

28. CRUSH INJURY

29. INJURY CAUSED AS A RESULT OF DIRECT PHYSICAL CRUSHING OF MUSCLES DUE TO SOMETHING HEAVY EARTHQUAKE MOTOR-VEHICLE ACCIDENT TRAUMA -ENTRAPMENT

30. 80% of crush injury patients die due to severe head injuries or asphyxiation. Of 20% that reach hospital, 10% make an uneventful recovery. Another 10% go into crush syndrome (Bywater & beall,1941) Crush syndrome  series of metabolic changes produced due to an injury of skeletal muscles of such a severity as to cause a disruption of cellular integrity and release of its content into circulation (rajagopalan,2010) Life & limb threatening condition

31. PATHOPHYSIOLOGY ONCE TISSUE TENSION RELEASED  REPERFUSION TO ISCHEMIC DAMAGED MUSCLE DISRUPTS NA⁺/K⁺ -ATPASE MECHANISM THUS, MYOGLOBIN DEGRADATION PRODUCTS IE, LACTIC ACID, URIC ACID, MUSCLES ENZYMES LIKE CREATININE PHOSPHOKINASE AND ALDOLASE, LACTATE DEHYDROGENASE, IONS LIKE POTASSIUM AND PHOSPHATE RELEASED INTO CIRCULATION RELEASED OF SUCH SUBSTANCE  RAISED MUSCLE VOLUME AND TENSION  NITRIC OXIDE SYSTEM IS ACTIVATED  AGGRAVATING MUSCLE VASODILATATION AND HYPOTENSION

32. METABOLIC DERANGEMENT Hypovolemia (fluid sequestration in damaged muscle) Hyperkalemia Hypocalcemia (due to calcium deposition in muscle ), corrected only presence of symptoms Hyperphosphatemia Metabolic acidosis Myoglobinemia / myoglobinuria  OBSTRUCTION & DESTRUCTION OF RENAL TUBULES

33. CLINICAL FEATURES PETECHIAE BLISTERS BRUISES MYALGIA MUSCLE PARALYSIS SENSORY DEFICIT ARRTHYMIA OLIGURIA Sever, M. S., Vanholder , R., & Lameire , N. (2006). Management of crush-related injuries after disasters.  New England Journal of Medicine ,  354 (10), 1052-1063.

34. MANAGEMENT FLUID RESUSCITATION EARLIER IV FLUID COMMENCE IS BETTER (EVEN BEFORE THE EXTRICATION) NORMAL SALINE IS PREFERRED TARGETTED U/O exceeds 300cc/hour once hospitalized Diuresis (by mannitol , diuretics or IV fluids ) should be prompted to increase the tubular flushing and eliminate the proteinaceous material

35. Hyperkalemia in crush syndrome Can occur soon after extrication  fatal arrhythmia May occur before manifestations of renal failure

36. Urgent hemodialysis May be needed following persistent hyperkalemia Persistent metabolic acidosis Oliguric AKI

37. Antibiotics: broad spectrum non nephrotoxic abx may be needed Surgery: fixation over fractures. Conservative amputations may have to be performed as emergencies or elective measures. fasciotomy (any increase in compartmental pressure) Sever, M. S., Vanholder, R., & Lameire, N. (2006). Management of crush-related injuries after disasters.  New England Journal of Medicine ,  354 (10), 1052-1063.

38. REFERENCES APPLEY’S CONCISE ORTHOPAEDICS AND FRACTURES 3 RD EDITION 2005 Rajagopalan , S. (2010). Crush injuries and the crush syndrome.  Medical Journal Armed Forces India ,  66 (4), 317-320 . Sever, M. S., Vanholder , R., & Lameire , N. (2006). Management of crush-related injuries after disasters.  New England Journal of Medicine ,  354 (10), 1052-1063 . Sigamoney , K., Khincha , P., Badge, R., & Shah, N. (2015). Compartment syndrome: challenges and solutions.  Orthopedic Research and Reviews ,  7 , 137-148. http://www.orthobullets.com//