Compartment syndrome & VIC.

Compartment Syndrome etiology, clinical symptoms and sign, diadnosis, conservative and operative treatment.

1. Dr. Anshu Sharma COMPARTMENT SYNDROME & VOLKMANN’S ISCHAEMIC CONTRACTURE

2. DEFINATION COMPARTMENT SYNDROME IS DEFINED AS AN ELEVATION OF THE INTERSTITAL PRESSURE IN A CLOSED OSTEOFASICAL COMPARTMENT THAT RESULTS IN A MICROVASCULAR COMPROMISE.

3. COMPARTMENT WITH RELATIVELY NONCOMPLIANT FASICAL OR OSSEOUS STRUCTURES ARE INVOLVED ESPECIALLY THE ANTERIOR AND DEEP POSTERIOR COMPARTMENTS OF LEG AND THE VOLAR COMPARTMENT OF FOREARM.

4. ANATOMY AND PATHOPHYSIOLOGY THE PATHOPHYSIOLOGY OF COMPARTMENT SYNDROME INVOLVES AN INSULT TO NORMAL LOCAL TISSUE HOMEOSTASIS THAT RESULTS IN INCREASED TISSUE PRESSURE DECREASED CAPILLARY BLOOD FLOW LOCAL TISSUE NECROSIS DUE TO OXYGEN DEPRIVATION

5. Increased compartment pressure Increased venous pressure Decreased blood flow Decreases perfusion

6. MUSCLE ISCHEMIA 4 hours - reversible damage 8 hours - irreversible changes 4-8 hours - variable

7. EXPERIMENTAL EVIDENCES SUGGESTS THAT SIGNIFICANT MUSCLE NECROSIS CAN OCCUR IN PATIENT WITH NORMAL BLOOD FLOW IF INTRACOMPARTMENTAL PRESSURE IS INCREASED TO MORE THAN 30mm HG FOR LONGER THAN 8 HOURS.

8. CLASSIFICATION ON THE BASIS OF CAUSE OF INCREASED PRESSURE AND DURATION OF SYMPTOMS ACUTE CHRONIC

9. ACUTE COMPARTMENT SYNDROME CAUSES: FRACTURES SOFT TISSUE TRAUMA ARTERIAL INJURY LIMB COMPRESSION DURING ALTERED CONSCIOUSNESS ANTICOAGULANTS

10. CLINICAL EVALUATION PHYSICAL SIGNS TIGHTNESS OF THE INVOLVED COMPARTMENT PAIN WITH PASSIVE MOTION OF THE MUSCLE WEAKNESS OF THE MUSCLE

11. THE MOST IMPORTANT SIGN IS THE PAIN OUT OF PROPORTION TO THAT EXPECTED OF INJURY. HYPESTHESIA OR PARESTHESIA SHOULD BE EVALUATED BY TESTING WITH PIN PRICK,LIGHT TOUCH AND 2 POINT DISCRIMINATION. THE DIAGNOSIS OF COMPARTMENT SYNDROME MAY BE DELAYED IN PATIENTS WITH MULTIPLE INJURIES,ALTERED CONSCIOUSNESS AND IN CHILDREN.

12. 5P’S PAIN OUT OF PROPORTION TO THAT OF INJURY PALLOR PULSELESSNESS PARAESTHESIA PARALYSIS

13. BECAUSE OF THE VARIABLITY OF CLINICAL SIGNS AND SYMPTOMPS THE POSITIVE PREDICTIVE VALUE ARE LOW HOWEVER THE SPECIFICITY AND NEGATIVE VALUES ARE HIGH IF COMPARTMENT SYNDROME IS SUSPECTED AND AN ADEQUATE EXAMINATION CAN NOT BE PERFORMED PRESSURE LEVEL SHOULD BE MEASURED

14. DEVICES FOR MEASURING PRESSURE IN COMPARTMENT SYNDROME ARTERIAL LINE MANOMETER WHITESIDES THREE WAY STOPCOCK APPARATUS WICK MONITOR ULTRASONOGRAPHY TO MEASURE SUBMICROMETER DISPLACEMENT OF FASCIA WALL HOWEVER PREASURE MEASURMENTS SHOULD NOT BE USED AS FIRST LINE FOR FASCIOTOMY

15. METHOD OF MEASURING LARGE BORE NEEDLE IS INSERTED INTO THE COMPARTMENT AND IS CONNECTED TO A FLUID FILLED ASSEMBLY WITH THE MANO METETR. THE MILIMETERS OF MERCURY PRESSURE NECESSARY TO OVERCOME THE RESISTANCE WHEN ATTEMPTING TO INJECT THE FLUID INTO THE COMPARTMENT IS NOTED.

16. IF TISSUE PRESSURE APPROACHES THE RANGE WITHIN 10mmHG TO 20mmHG OF THE DIASTOLIC PRESSURE,CESSATION OF BLOOD FLOW IS EMINENT. WHEN TISSUE PRESSURE REACHES 40mmHG TO 50mmHG MUSCLE THREATNING COMPRESSION AND ISCHEMIA ARE PRESENT. A PRESSURE OF 30mmHG OR GREATER MAY BE USED AS A CRITERIA FOR FASCIOTOMY.

17. TREATMENT IF COMPARTMENTAL PRESSURE IS GREATER THAN 30MMHG IN THE PRESENCE OF CLINICAL FINDINGS IMMIDIATE FASCIOTOMY IS INDICATED IN PATIENTS WITH MAJOR DISRUPTION OF ARTERIAL CIRCULATION OF MORE THAN FOUR HOURS FASCIOTOMY SHOULD BE PERFORMED AT THE TIME OF INITIAL SURGERY

18. IN INSOLATED LIMB INJURIES SPLITTING OF THE CAST AND UNDERLYING PADDING CAN DECREASE THE PRESSURE AS MUCH AS 50 TO 85 % . PLACING THE LIMB AT THE LEVEL OF HEART PRODUCES THE HIGHEST AV GRADIENT. IF THE SYMPTOMS DON’T RESOLVE WITHIN 30 TO 60 MINUTES AND CONDITION REMAINS THE SAME THEN FASCIOTOMY SHOULD BE DONE.

19. IF FASCIOTOMY IS DONE WITHIN 25 TO 30 HOURS PROGNOSIS IS GOOD LITTLE OR NO RETURN OF FUNCTION IS EXPECTED IF TREATMENT IS DELAYED NO BENEFIT FROM FASCIOTOMY HAS BEEN REPORTED AFTER 3 RD OR 4 TH DAY IF FASCIOTOMY IS DONE LATE THAN SEVERE INFECTIONS HAVE BEEN REPORTED

20. ACUTE COMPARTMENT SYNDROME OF THIGH IT IS ASSOCIATED WITH HIGH LEVELS OF MORBIDITY IN ONE STUDY OF 23 PATIENTS WITH ACUTE THIGH COMPARTMENT SYNDROME 4 PATIENTS REQUIRED AMPUTATION

21. COMMON CAUSES BLUNT TRAUMA WITH OR WITHOUT FRACTURES VASCULAR INJURIES BURNS TOURNIQUET USE SURGERY MUSCLE OVERUSE QUADRICEPS TENDON RUPTURE

22. THE THIGH IS DIVIDED INTO 3 DISTINCTIVE COMPARTMENTS ANTERIOR MEDIAL POSTERIOR

23. Compartments Anterior Medial Posterior Deep Superficial EDL FDL TP Gastroc Soleus TA EHL FHL Peroneus

24. ANTERIOR COMPARTMENT QUADRICEPS MUSCLE GROUPS SARTORIUS FEMORAL NERVE AND ITS SENSORY BRANCH SAPHENOUS NERVE FEMORAL ARTERY AND VEIN

25. MEDIAL COMPARTMENT ADDUCTOR MUSCLES GROUP PROFUNDA FEMORIS OBTURATOR ARTERY OBTURATOR NERVE

26. POSTERIOR COMPARTMENT BICEPS FEMORIS SEMIMEMBRANOSUS SEMITENDINOSUS ARTERIAL BRANCHES OF PROFUNDA FEMORIS SCIATIC NERVE

27. MOST COMMON SIGNS OF THIGH COMPARTMENT SYNDROME ARE PAIN AND INCREASED THIGH CIRCUMFRENCE AS COMPARED TO OPPOSITE SIDE. WEAKNESS OF THE INVOLVED THIGH MUSCLES AND SENSORY OR MOTOR DEFICITS IN THE ANATOMICAL DISTRIBUTION OF NERVE CAN HELP TO DETERMINE WHICH AREA IS INVOLVED.

28. FASCIOTOMY FOR ACUTE COMPARTMENT SYNDROME OF THIGH PREPARE AND DRAPE THE THIGH IN A STERILE FASHION EXPOSING THE LIMB FROM ILIAC CREST TO THE KNEE JOINT. MAKE A LATERAL INCISION BEGINNING JUST DISTAL TO THE INTER TROCANTRIC LINE AND EXTENDING TO LATERAL EPICONDYLE

29. USE SUBCUTANEOUS DISSECTION TO EXPOSE THE ILIOTIBIAL BAND AND THEN MAKE A STRAIGHT INCISION IN LINE WITH THE SKIN INCISION THROUGH THE ILIOTIBIAL BAND

30. REFLECT THE VASTUS LATERALIS OF LATERAL INTERMUSCULAR SEPTUM MAKE 1.5 CM INCISION IN THE LATERAL INTER MUSCULAR SEPTUM AND EXTENDING IT PROXIMALY AND DISTALLY THE LENGTH OF INCISION AFTER THE ANTERIOR AND POSTERIOR COMPARTMENT HAVE BEEN RELEASED MEASURE THE PRESSURE OF THE MEDIAL COMPARTMENT IF THE PRESSURE IS ELEVATED MAKE A SEPARATE MEDIAL INCISION TO RELEASE THE ADDUCTOR COMPARTMENT.

31. ACUTE COMPARTMET SYNDROME OF LOWER LEG MOST COMMON CAUSES ARE TIBIAL FRACTURES SECOND MOST COMMON CAUSE IS BLUNT SOFT TISSUE INJURY

32. TREATMENT SINGLE INCISION PERIFEBULAR FASCIOTOMY- IF THE SOFT TISSUE OF THE LIMB IS NOT EXTENSIVELY DISTORTED DOUBLE INCISION FASCIOTOMY – IT IS SAFER AND MORE EFFECTIVE IF THE DIFFERENCE BETWEEN COMPARTMENT PRESSURE AND PREOPERATIVE DIASTOLIC BP IS GREATER THAN OR EQUAL TO 30mm HG POSTERIOR COMPARTMENT ARE NOT RELEASED.

33. DOUBE INCISION FASCIOTOMY MAKE A 20 TO 25CM INCISION IN THE ANTERIOR COMPARTMENT CENTERED HALF WAY BETWEEN THE FIBULAR SHAFT AND THE CREST OF TIBIA.

34. MAKE A TRANSVERSE INCISION TO EXPOSE THE LATERAL INTERMUSCULAR SEPTUM AND IDENTIFY THE SUPERFICIAL PERONEAL NERVE JUST POSTERIOR TO SEPTUM USING SCISSOR RELEASE THE ANTERIOR COMPARTMENT PROXIMALY AND DISTALY IN LINE WITH ANTERIOR TIBIAL MUSCLE PERFORM FASCIOTOMY OF THE LATERAL COMPARTMENT PROXIMALLY AND DISTALLY IN LINE WITH THE FIBUALR SHAFT

35. MAKE A SECOND LONGITUDINAL INCISION 2CM POSTERIOR TO THE POSTERIOR MARGIN OF TIBIA AND IDENTIFY THE FASCIAL PLANES RETRACT THE SAPHENOUS VEIN AND NERVE ANTERIORLY MAKE A TRANSVERSE INCISON TO IDENTIFY THE SEPTUM AND RELEASE THE FASCIA

36. MAKE ANOTHER FASCIAL INCISON OVER THE FLEXOR DIGITORUM LONGUS MUSCLE AND RELEASE THE ENTIRE DEEP POSTERIOR COMPARTMENT AFTER RELEASE IF INCREASED TENSION IS EVIDENT RELEASE IT OVER THE EXTENT OF MUSCLE BELLY.

37. DELAYED PRIMARY CLOSURE

38. CHRONIC EXERTIONAL COMPARTMET SYNDROME IT IS DEFINED AS REVERSIBLE ISCHEMIA SECONDARY TO A NONCOMPLIANT OSTIOFASCIAL COMPARTMENT THAT IS UNRESPONSIVE TO THE EXPANSION TO MUSCLE VOLUME THAT OCCOUR WITH EXERCISE

39. DIFFERENTIAL DIAGNOSIS MEDIAL TIBIAL STRESS SYNDROME STRESS FRACTURE TENOSYNOVITIS PERIOSTITIS DVT NERVE ENTRAPMENT SYNDROME

40. LUMBOSACRAL RADICULOPATHY NUROGENIC CLAUDICATION POPLITEAL ARTERY ENTRAPMENT SYNDROME VASCULAR CLAUDICATION INFECTION MYOPATHY TUMOR

41. CLINICAL EVALUATION A TYPICAL PATIENT IS COMPETITIVE RUNNER 20 TO 30 YRS OLD WHO DESCRIBES EXERCISE INDUCED PAIN AND A FEELING OF TIGHTNESS THAT BEGINS AFTER 20 TO 30 MINUTES AFTER RUNNING AND PAIN USUALLY RESOLVES AFTER 15 TO 30 MINUTES OF CESSATION OF EXERCISE

42. TREATMENT NON OPERATIVE REST ANTI INFLAMATORY MEDICATION STRETCHING AND STRENTHNING OF INVOLVED MUSCLES

43. OPERATIVE DOUBLE MINI INCISION FASCIOTOMY FOR CHRONIC ANERIOR COMPARTMENT SYNDROME SINGLE INCISION FASCIOTOMY FOR CHRONIC ANTERIOR AND LATERAL COMPARTMENT SYNDROME DOUBLE INCISION FASCIOTOMY FOR CHRONIC POSTERIOR COMPARTMENT SYNDROME

44. VOLKMANN’S ISCHEMIC CONTRACTURE IT IS DEFINED AS ISCHEMIC NECROSIS OF THE STRUCTURE CONTAINED WITHIN THE VOLAR COMPARTMENT OF THE FOREARM USUALLY FOLLOWING A SEVERE INJURY ABOVE THE ELBOW OR DIRECTLY IN THE FOREARM.

45. ETIOLOGY IN THE CHILD UNDER 10 YEARS SUPRACONDYLAR FRACTURE OF HUMERUS IS THE MOST COMMON PRECIPITATING FACTOR. CONTUSION OR CRUSH INJURY OF FOREARM

46. CLINICAL PICTURE AT FIRST SEVERE,DEEP PAIN DEVELOPS IN THE FOREARM. THE VOLAR ASPECT OF THE FOREARM IS SWOLLEN,RED,WARM AND TENSE TO PALPATION. THE FINGERS ARE HELD IN FLEXION AND ATTEMPT TO EXTEND THE FINGER INTENSIFIES THE PAIN.

47. INITIAL NERVE INVOLVMENT IS EVIDENCED BY DIMINISHED SENSATION IN THE AUTONOMOUS SENSORY ZONE OF THE AFFECTED NERVE. THE MOST COMMON NERVE INVOLVED IS MEDIAN NEVE.

48. COMPLETE GLOVE ANESTHESIA DURING THE EARLY STAGE IMPLIES EXTREME ISCHEMIA. ADVANCED NERVE DEFICIET RESULTS IN PARALYSIS OF NOT ONLY FLEXOR BUT ALSO THE INTRINSIC MUSCLES OF HAND. WITH IN THE FUE DAYS PAIN AND SWELLING SUBSIDES AND FOREARM DEVLOPS A WOODEN INDURATION.

49. TREATMENT IF POSSIBLE SURGICAL DECOMPRESSION SHOULD BE DONE BEFORE THE PERIPHERAL PULSATIONS ARE LOST. WHEN TISSUE PRESSURE APPROACHES THE LEVEL OF DIASTOLIC BLOOD PRESSURE SEVERE IRRETRIEVABLE MUSCLE NECROSIS IS IMINENT AND THE COMPARTMENT SHOULD BE OPENED BY FASCIOTOMY.

50. SURGICAL EXPLORATION MUST EXTEND DEEPLY TO THE FLEXOR DIGITORUM PROFUNDUS WHICH SUSTAINS THE MAXIMUM DEGREE OF NECROSIS. THE MEDIAN NERVE SHOULD BE FREED. IF PERIPHERAL PULSES ARE NOT RESTORED THE BRACHIAL ARTREY MUST BE INSPECTED AND DECOMPRESSED.

51. THE SURGICAL WOUND IS LEFT OPEN UNTIL THE SWELLING SUBSIDES AND SECONDARY CLOSURE IS DONE LATER. THE EXTREMITY IS SUPPORTED IN A SPLINT IN A FUNCTIONAL POSITION. LATER DYNAMIC SPLINTING AND EXERCISES PREVENT DEFORMITY.

52. THANK YOU….!!!