Managment of compartment syndrome. pptx

This presentation is made on topic management of compartment syndrome. Presentation include detailed discussion regarding diagnosis and management of compartment syndrome

1. MANAGEMENT OF COMPARTMENT SYNDROME BY dr. Shahzain ali Rotational P.g DOST UNIT II LUMHS

2. OBJECTIVES DEFINATION PATHOPHYSIOLOGY CAUSES CLINICAL FEATURES DIANOSTIC TOOLS COMPLICATIONS MANAGEMENT

3. DEFINATION COMPARTMENT SYNDROME IS DEFINED AS RAISED INTERSTIT I AL PRESSURE IN A CLOSED OSTEOFACIAL COMAPRTMENT THAT RESULTS IN MICROVASCULAR COMPR OMISE AND LOSS OF VIABILITY OF THE TISSUES WITHIN THAT SPACE.

4. PATHOPHYSIOLOGY IT INVOLVES WHEN THE PRESSURE WITHIN A CLOSED OSTEO-FASCIAL MUSCLE COMPARTMENT RISES ABOVE A CRITICAL LEVEL. THIS CRITICAL LEVEL IS THE TISSUE PRESSURE WHICH COLLAPSES THE CAPILLARY BED AND PREVENTS LOW-PRESSURE BLOOD FLOW. NORMAL TISSUE PRESSURE IS 0-10 MM HG. THE CAPILLARY FILLING PRESSURE IS ESSENTIALLY DIASTOLIC ARTERIAL PRESSURE. WHEN TISSUE PRESSURE APPROACHES THE DIASTOLIC PRESSURE, CAPILLARY BLOOD FLOW CEASES.

5. THE CRITICAL MEASUREMENT IS MUSCLE PERFUSION PRESSURE (MPP), IT IS THE DIFFERENCE BETWEEN DIASTOLIC BLOOD PRESSURE (DBP) AND MEASURED INTRAMUSCULAR TISSUE PRESSURE. (MPP HAS ALSO BEEN CALLED "DELTA P"​ SIGNIFICANT MUSCLE NECROSIS CAN OCCUR IF DELTA PRESSURE IS LESS THAN 30 MM HG FOR LONGER THAN 8 HOURS.

6. VICIOUS CYCLE

7. COMMON SITES ANTERIOR & DEEP POSTERIOR COMPARTMENTS OF LEG . VOLAR COMPARTMENT OF FOREARM . OTHER AREAS ARE BUTTOCK , THIGH , SHOULDER , HAND , FOOT & ARM .

8. CAUSES DUE TO DECREASE IN COMPARTMENT SIZE : TIGHT DRESSING / CAST. LOCALISE EXTERNAL PRESSURE : LYING ON LIMB. DUE TO INCREASE OF COMPARTMENT CONTENTS : BLEEDING : FRACTURE , VASCULR INJURY & BLEEDING DISORDER . CAPPILARY PERMEABILITY : ISCHEMIA , TRAUMA , BURNS , INTENSE EXERSICE , SNAKE BITE . MUSCLE COMPARTMENT SYNDROME OCCURS MOST COMMONLY AFTER HIGH-ENERGY LIMB INJURIES.

9. INCIDENCE Type of Fx % of ACS Incidence all ages Incidence <35 Tibial diaphysis 36% 4.3% 5.9% Distal radius 9.8% 0.25% 1.4% Forearm diaphysis 7.9% 3.1% 3.2%

10. CLINICAL FEATURES THE CLASSIC FEATURES OF ISCHAEMIA ARE FIVE Ps : 1. PAIN 2. PARESTHESIA 3. PALLOR 4. PARALYSIS 5. PULSELESSNESS

11. IN COMPARTMENT SYNDROME THE ISCHEMIA OCCURS AT CAPPILARY LEVEL , SO PULSES MAY STILL BE FELT & SKIN MAY NOT BE PALE. THE EARLIEST OF CLASSIC FEATURE IS SEVERE PAIN , OR BURSTING SENSATION , AND THIS MAY BE THE ONLY FEATURE SEEN. THE MOST IMPORTANT SIGN IS PAIN OUT OF PROPORTION TO THAT OF INJURY.

12. BECAUSE OF VARIABILITY OF CLINICAL SIGNS & SYMPTOMS SENSITIVITY OF CLINICAL FINDINGS ARE LOW. IN ESTABLISHED MUSCLE COMPARTMENT SYNDROME, THE HYPOXIC MUSCLE WILL BECOME NECROTIC WITHIN HOURS AFTER 6-8 HOURS OF INADEQUATE MUSCLE PERFUSION PRESSURE EXTENSIVE MUSCLE NECROSIS IS LIKELY.

13. DEVICES TO MEASURE COMPARTMENT PRESSURES         1. HAND HELD COMPARTMENT PRESSURE MONITOR :

14. 2. WHITESIDES TECHNIQUE :

15. Complications NERVE DAMAGE FOOT DROP RHABDOMYOLYSIS RENAL FAILURE INFECTION VOLKMANN CONTRACTURE AMPUTATION (LIMB LOSS) In delayed cases, where there is already extensive muscle death, dermato-fasciotomy has a high risk of infection of the dead tissue, septicaemia and, in some cases, death

16. TREATMENT OPTIMAL THERAPEUTIC APPROACH IS IMMEDIATE FASCIOTOMY IN THE OPERATING ROOM. INDICATED IN ABSOLUTE COMPARTMENT PRESSURE > 30 MM HG OR DELTA PRESSURE < 30 MM HG. REGARDLESS OF THE SPECIFIC COMPARTMENT INVOLVED, ALL COMPARTMENTS IN THE AFFECTED EXTREMITY SHOULD HAVE FASCIOTOMY PERFORMED.

17. INITIAL MANAGEMENT SPLITTING OF CAST & UNDERLYING PADDING CAN DECREASE COMPARTMENT PRESSURE BY AS MUCH AS 50% TO 85 % . ANY CIRCULAR CONSTRICTIVE BANDAGES SHOULD BE RELEASED . PLACING THE LIMB AT LEVEL OF HEART , PRODUCES HIGHEST LEVEL OF ARTERIOVENOUS GRADIENT .

18. ELEVATION OF LIMB DECREASES ARTERIAL INFLOW WITHOUT SIGNIFICANTLY INCREASE VENOUS OUTFLOW , THUS INCREASING LOCAL ISCHEMIA. IF SYMPTOMS DONOT RELIEVED IN 60 MINUTES THAN AGAIN MEASURE PRESURE , IF PRESSSURE IS INCREASED THAN FASCIOTOMY IS INDICATED. FASCIOTOMY AFTER 12 HOURS HAS WORST RESULTS.

19. FASCIOTOMY OF COMPARTMENT SYNDROME OF LEG NEED OF FASCIOTOMY IS VARIED WIDELY ACCORDING TO MECHANISM OF INJURY : 42 % IN COMBINED VASCULAR INJURY WITH TIBIA FRACTURE . 9 % IN FIRE ARM INJURY . 2 % IN CLOSED TIBIA FRACTURES . LESS THAN 1 % IN RTA CASES .

20. FASCIOTOMY TECHNIQUES MOST COMMONLY USED TECHNIQUES ARE : 1. SINGLE INSICION PERIFIBULAR FASCIOTOMY . THE SINGLE IS USED WHEN SOFT TISSUES ARE NOT EXTENSIVELY DISTORTED , WHICH IS RARE CASE . 2. THE DOUBLE INSICION FASCIOTOMY . THE DOUBLE INSCISION IS GENERALLY SAFER AND MORE EFFECTIVE .

21. SINGLE INCISION parafibular 4-compartment dermato-fasciotomy ( MATSEN METHOD ) THIS TECHNIQUE AVOIDS A MEDIAL INCISION, AND RELEASES THE POSTERIOR COMPARTMENTS, AS WELL AS ANTERIOR AND LATERAL COMPARTMENTS THROUGH A SINGLE LATERAL INCISION A) AN INCISION IS MADE FROM THE FIBULAR NECK TO THE LATERAL MALLEOLUS. B) THE LATERAL COMPARTMENT (LC) IS OPENED.

22. C) RETRACTING THE ANTERIOR SKIN EXPOSES THE FASCIA OF THE ANTERIOR COMPARTMENT (AC), WHICH IS OPENED, WITH CARE BEING TAKEN TO AVOID THE SUPERFICIAL PERONEAL NERVE (SPN).

23. D) THE POSTERIOR SKIN IS RETRACTED TO EXPOSE THE FASCIA OF THE SUPERFICIAL POSTERIOR COMPARTMENT (SPC), WHICH IS OPENED.

24. E) THE LATERAL COMPARTMENT IS RETRACTED ANTERIORLY. THE SOLEUS IS RELEASED FROM THE FIBULAR SHAFT AND IS RETRACTED POSTERIORLY, EXPOSING THE FASCIA OF THE DEEP POSTERIOR COMPARTMENT (DPC), WHICH IS OPENED.

25. DOUBLE INCISION FASCIOTOMY (MUBARAK & HARGENS METHOD) ANTERIO MEDIAL RELEASE : Posteromedial Incision The two posterior compartments are approached through a single longitudinal incision in the lower leg, two centimeters behind the palpable posteromedial edge of the tibia.

26. AFTER REACHING THE FASCIA, UNDERMINE ANTERIORLY TO THE POSTERIOR TIBIAL MARGIN, IN ORDER TO AVOID THE SAPHENOUS VEIN AND NERVE. THE DEEP POSTERIOR COMPARTMENT HERE IS SUPERFICIAL AND READILY ACCESSIBLE. THE FASCIA OF THE DEEP POSTERIOR COMPARTMENT IS CAREFULLY OPENED DISTALLY AND PROXIMALLY, UNDER THE BELLY OF THE SOLEUS MUSCLE, PAYING SPECIAL ATTENTION TO THE POSTERIOR TIBIAL NEUROVASCULAR BUNDLE.

27. THROUGH THE SAME INCISION, THE FASCIA OF THE SUPERFICIAL POSTERIOR COMPARTMENT IS OPENED WIDELY, TWO CENTIMETERS POSTERIOR AND PARALLEL TO THE INCISION IN THE FASCIA OF THE DEEP COMPARTMENT.

28. ANTEROLATERAL INCISION THE ANTERIOR AND LATERAL COMPARTMENTS ARE APPROACHED THROUGH A SINGLE LONGITUDINAL INCISION ON THE OUTER ASPECT OF THE LEG, TWO CENTIMETERS ANTERIOR TO THE FIBULAR SHAFT AND LONG ENOUGH TO EXPOSE THE WHOLE LENGTH OF THE COMPARTMENTS. THE INCISION LIES APPROXIMATELY OVER THE ANTERIOR INTERMUSCULAR SEPTUM THAT DIVIDES THE ANTERIOR AND LATERAL COMPARTMENTS AND ALLOWS EASY ACCESS TO BOTH.

29. A SMALL INCISION IS MADE IN THE FASCIA OF THE ANTERIOR COMPARTMENT, MIDWAY BETWEEN THE SEPTUM AND THE TIBIAL CREST. THE FASCIA IS OPENED PROXIMALLY AND DISTALLY, RESPECTING ANY VISIBLE SUPERFICIAL NERVE.

30. The lateral compartment fasciotomy is in line with the fibular shaft. Directing the scissors towards the lateral malleolus helps avoid the superficial peroneal nerve as it exits from the fascia in the distal third of the leg near the septum and courses anteriorly. Look for this nerve, which may be branched, and protect it

31. WOUND CLOSURE MANAGEMENT OF FASCIOTOMY WOUNDS INCLUDES : 1. SPLIT THICKNESS SKIN GRAFT ( APPROX 50 % CASES ) 2. PRIMARY CLOSURE. 3. HEALING BY SECONDARY INTENTION

32. 4. ALTERNATE IS DELAYED PRIMARY CLOSURE BY VESSEL LOOP SHOE LACE TECHNIQUE . ​ ​ 5. VACCUM ASSISTED DRESSING IS USED TO REDUCE POST OPERATIVE EDEMA . ​

33. POST OPERATIVE CARE IT IS IMPORTANT TO SPLINT THE FOOT AND ANKLE IN A NEUTRAL, OR DORSIFLEXED, POSITION TO MAINTAIN A PLANTIGRADE FOOT, PARTICULARLY IF ANY MUSCLE DAMAGE HAS OCCURRED AND CONTRACTURES MAY DEVELOP. THIS CAN BE DONE WITH A WELL-PADDED PLASTER BACK-SLAB, OR WITH EXTENSION OF AN EXTERNAL FIXATOR TO THE FOOT. MAINTAIN TOE MOBILITY WITH PASSIVE STRETCHING. CONSIDER K-WIRE TOE FIXATION, IF FLEXION CONTRACTURES ARE DEVELOPING.

34. BCQ’s

35. 1. PATHOPHYSIOLOGY OF COMPARTMENT SYNDROME? A. HAPPENS AT MAJOR ARTERY. B. HAPPENS AT MINOR ARTERY. C. HAPPENS AT MAJOR VEIN. D. HAPPENS AT MINOR VEIN . E. HAPPENS AT CAPILLARY LEVEL .

36. ANSWER (E)      HAPPENS AT CAPILLARY LEVEL .

37. 2. An orthopedic resident is asked to measure compartment pressure in a trauma patient. The diastolic BP is 80 mmHg, and the measured anterior compartment pressure is 55 mmHg. What is the appropriate interpretation? A. Pressure is normal B. Observe for 6 hours C. Perform fasciotomy D. Apply a cast E. Repeat in 2 hours

38.    (C)         Perform fasciotomy ANSWER

39. 3. A 25-year-old male presents to the emergency department after a motorcycle accident resulting in a closed tibial shaft fracture. Six hours post-injury, he complains of severe pain in his anterior lower leg, which worsens with passive toe dorsiflexion. On examination, the anterior compartment feels tense, and he reports numbness in the first dorsal web space of the foot. His pulses are palpable. What is the most likely diagnosis? A. Deep vein thrombosis B. Anterior compartment syndrome C. Tibial nerve injury D. Posterior compartment syndrome E. Peroneal nerve injury

40. ANSWER    (B)         Anterior compartment syndrome

41. 4. A 22-year-old female presents with untreated anterior compartment syndrome for 12 hours after a severe leg injury. She now has foot drop and loss of sensation on the dorsum of her foot. Question: Which anatomical structure is most likely permanently damaged in this case? A. Femoral nerve B. Deep peroneal nerve C. Tibialis anterior  D. Saphenous nerve E. Tibial nerve

42. ANSWER (B)         Deep peroneal nerve

43. 5. A 40-year-old male is diagnosed with acute anterior compartment syndrome following a tibial fracture. His symptoms include severe pain, swelling, and inability to dorsiflex the foot. The orthopedic surgeon is consulted. Question: What is the definitive treatment for this patient’s condition? A. Leg levation B. NSAIDs C. Ice application D. Emergency fasciotomy E. Physical therapy

44. ANSWER    (D)       Emergency fasciotomy

45. 6. A 10-year-old boy is seen 2 weeks after a cast was removed for a supracondylar fracture. His parents report that he cannot fully extend his fingers, and the wrist is held in flexion. There is also noticeable wasting in the forearm. What is the most likely diagnosis? A. Volkmann’s ischemic contracture B. Ulnar nerve palsy C. Tendon rupture D. Compartment syndrome of hand E. Brachial plexus injury

46. ANSWER  (A)      Volkmann’s ischemic contracture