Compartment Syndrome.PowerPoint Presentation (2).ppt

Clinical compartment syndrome

1. Done by Alaa
PRINCIPLES OF ORTHOPAEDIC &
TRAUMA CARE
COMPARTMENT SYNDROME

2. Learning Outcomes
Define Compartment Syndrome and identify
underlying pathology & the main causes
Explain principles of patient assessment
and provide an evidence base
Identify relevant investigations and the
practitioners role in these
Describe the conservative and surgical treatment
options and the care management
complications

3. Compartment Syndrome is…
‘ … an elevation of the interstitial pressure in a
closed osseofascial compartment that results in micro
vascular compromise’
Mubarak & Hardens (1983, cited Edwards 2004:32)
‘ … a condition in which the circulation and function
of tissues within a closed space are compromised by
an increased pressure within that space’.
Matson (1975, cited Singh, Trikha & Lewis 2005:468)

4. 
Compartment syndrome is a condition in which
increased pressure within one of the body's 
compartments  which contain muscle and nerve.
results in insufficient blood supply to tissue

5. Anatomy revision
Key Compartment
Syndrome sites
4 Lower limb
compartments
3 Thigh compartments
2Forearm compartments

6. Is compartment syndrome acute?

ACUTE
follows traumatic event, commonly fractures, with
worsening symptoms & irreversible tissue damage
within hours

CHRONIC
a recurrent syndrome occurring with exercise or
work (microtrauma or repetitive overexertion).
Symptoms often resolve with rest.

8. fractures

Fracture most commons cause of compartment
syndrome

Fractures of the arm or leg can give rise to severe

ischaemia, even if there is no damage to a major
vessel.

Bleeding, oedema or inflammation (infection)

may increase the pressure within one of the
osseofascial Compartments; there is reduced
capillary flow,

which results in muscle ischaemia,

9. 
after 12 hours or less,

necrosis of nerve and muscle within the
compartment.

Nerve is capable of regeneration but muscle, once
infarcted, can never recover and is replaced by
inelastic fibrous tissue (Volkmann’s ischaemic
contracture).

A similar cascade of events may be caused by
swelling of a limb inside a tight plaster cast.

12. Pathophysiology
Fluid enters fixed volume
compartment
tissue pressure increases,
venous pressure rises
Rise in interstitial
pressure
exceeds the
arterio venous
perfusion gradient
capillary collapse and
muscle/tissue ischemia occur.
Myocyte necrosis produces
osmotically active particles
attracting sufficient fluid to
cause further rise in
intramuscular pressure that
decreases tissue blood flow
thus increasing muscle
ischaemia & cell oedema

13. Single-incision fasciotomy.

14. Diagnosis

History

Clinical exam:the Ps

Compartment pressures

Laboratory tests
CPK
Urine myoglobin

15. Clinical Diagnosis

The six ‘Ps’:
Pressure
Pain
Paresthesia
Paralysis
Pallor
Pulselessness

16. Pain on stretch
Paresthesia
Paresis
(droop foot
Pulse
presentPink color

17. Pressure

Early finding

Only objective finding

Refers to palpation of compartment and its tension
or firmness

18. Pain

Deep , poorly localized and Out of portion to injury

Not reliving by analgesia

Exaggerated with passive stretch

Earliest symptom but inconsistent

Not available in obtunded patient

19. Paresthesia

Early sign
Peripheral nerve tissue is more sensitive than muscle to
ischemia
Permanent damage may occur in 75 minutes

Will progress to anesthesia if pressure not relieved

20. Paralysis

Very late finding
Irreversible nerve and muscle damage present

Paresis may be present early
Difficult to evaluate because of pain

21. Pallor & Pulselessness

Rarely present

Indicates direct damage to vessels rather than
compartment syndrome

Vascular injury more of contributing factor to
syndrome rather than result

22. Compartment Pressure /measurement

When
Confirm clinical exam
Obtunded patient with tight compartments
Regional anesthetic
Vascular injury
some surgeons advocate the use of continuous compartment pressure
monitoring for high-risk injuries (e.g. fractures of the tibia and fibula) and
especially for forearm or leg fractures in patients who are unconscious

Technique
Whiteside infusion
Stic technique: side port needle
Wick catheter
Slit catheter

23. Stryker Stic System

Easy to use

Can check multiple compartments

Different areas in one compartment

25. Pressure measurements should be performed in:
1.both the anterior and the deep posterior compartments
2. at the level of the fracture
3. at proximal and distal locations

26. Increasing Inter Compartmental
Pressure
Normal Inter
Compartmental Pressure
(ICP) = 0-8mmHg

Raised Inter
Compartmental Pressure
(ICP) > 30mmHg basis
for treatment
ICP > 40mmHg = surgical
emergency
Untreated, within 6-10
hours, the outcome of
persistent high
compartmental pressures
is muscle infarction,
tissue necrosis, and nerve
injury

27. TREATMENT

28. Chronic compartment syndrome

in the lower leg can be treated conservatively or
surgically.

Conservative treatment includes

rest, anti-inflammatories, and manual
decompression.

Elevation of the affected limb in patients with
compartment syndrome is contraindicated, as this
leads to decreased vascular perfusion of the
affected region.

29. Ideally, the affected limb should be positioned at
the level of the heart.
The use of devices that apply external pressure to
the area, such as splints, casts, and tight wound
dressings, should be avoided
 If symptoms persist after conservative treatment
compartment syndrome can be treated by a surgery
known as a fasciotomy.

30. Surgery - Fasciotomy
Two-incision
posteromedial
fasciotomy.

31. Acute compartment syndrome

Acute compartment syndrome is a medical
emergency requiring surgical treatment.

The use of devices that apply external pressure to
the area, such as splints, casts, and tight wound
dressings, should be avoided

or must be completely removed

32. 
Elevation of the affected limb in patients with
compartment syndrome is contraindicated, as this
leads to decreased vascular perfusion of the
affected region.

Ideally, the affected limb should be positioned at
the level of the heart

33. fasciotomy

In the case of the leg,

‘fasciotomy means opening all four compartments

through medial and lateral incisions

The wounds should be left open and inspected 2
days later: if there is muscle necrosis, debridement
can be carried out; if the tissues are healthy, the
wounds can be sutured (without tension) or skin-
grafted.

34. Post-op fasciotomy & external fixation

35. Complications
Motor deficits ie foot drop, Volkmann contracture
Infection, with potential amputation
Hyperaesthesia & painful dysesthesia: medication ie phenytoin,
carbamazepine, gabapentin
Recurrent CS, due to scarring - athletes
Systemic complications: acute renal failure, sepsis, Adult
Respiratory Distress Syndrome

36. Compartment syndrome
A picture following surgery for compartment syndrome
Specialty Orthopedics
Symptoms Pain, numbness, pallor, decreased ability to move the affected
limb
[1]
Complications Acute :Volkmann's contracture
[2]
Types Acute, chronic
[1]
Causes Acute: Trauma (fracture,
 
crush injury), following a period of poor
blood flow
[3][4]
Chronic: Repetitive exercise
[1]
Diagnostic method Based on symptoms, compartment pressure
[5][1]
Similar conditions Cellulitis,
 
tendonitis,
 
deep vein thrombosis,
 
venous insufficiency
[3]
Treatment Acute: Timely
 
surgery
[5]
Chronic:
 
Physical therapy, surgery
[1]
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