Chapter 102 - Compartment syndrome and its management Flashcards
Poiseuille’s Law
F = pi r^4 deltaP / 8nL F = capillary blood flow r = radius of capillary deltaP = pressure gradient pre-capillary arteriole to post-capillary venule
Matson’s critical closing pressure theory
Capillaries collapse after this pressure Disproven by Hartsock
Hartsock dynamic pressure ICP-MAP cutoff for likely capillary collapse
25.5 +/- 14 mmHg
Dynamic intracompartmental pressure threshold for 1) healthy tissue 2) injured tissue
MAP - ICP 1) < 30 mmHg 2) < 40 mmHg
Usual cutoff used for pressure threshold
MAP - ICP < 40 mmHg DBP - ICP < 10 mmHg
Causes of compartment syndrome
1) ischemia reperfusion 2) trauma 3) venous outflow obstruction (needs extensive multilevel DVT) 4) hemorrhage 5) fractures 6) crush injuries 7) iatrogenic
Mechanism of ischemia reperfusion leading to compartment syndrome
1) muscle injury 2) increase microvascular permeability 3) efflux of plasma protein 4) interstitial edema
Papalambros risk factors of compartment after limb ischemia
1) prolonged > 6 houors 2) younger age 3) insufficienct collaterals 4) hypertension 5) acute course of occlusion 6) poor backbleeding from distal vessels
Rate of fasciotomy after different type of vascular trauma
1) Arterial: 29.5% 2) Venous: 15.2% 3) Combined arterial + venous: 31.6% 4) Popliteal artery injury: 61%
Rate of fracture-induced compartment syndrome
1-29%
Risk factors associated with fractures that predispose compartment syndrome
1) anterior compartment of leg 2) flexor compartment of arm 3) communited fracture (means higher energy of injury)
Mechanism that crush injuries cause compartment syndrome
1) direct muscle injury 2) ischemia reperfusion 3) large volume crystalloids
Iatrogenic causes of compartment syndrome
1) extravasation of IV 2) bleeding 3) compression
Secondary compartment syndrome define
1) no direct trauma 2) diffuse microvascular permeability due to trauma-induced SIRS 3) massive fluid resuscitation
Clinical presentation of compartment syndrome
1) pain out of proportion 2) Pain with passive motion of muscles in compartment 3) paresis/parasthesia 4) tense compartment
How good is clinical presentation in terms of positive predictor and negative predictor for compartment syndrome
Poor positive predictor 11-15% Great rule out test 97-98%
Normal range of compartment pressures
< 10-12 mmHg
When to measure compartment pressure
1) equivocal cases 2) unconscious patient 3) pediatric patient
Causes of hand compartment syndrome
1) crush 2) fracture
Number of compartments in the hand
10
Thigh compartment syndrome cuase
Blunt trauma, crush, contusions
Which thigh compartment most likely to get compartment syndrome
Anterior
Gluteal compartment syndrome causes
1) hypogastric ligation or embolization 2) hip arthroplasty 3) prolonged compression
Symptoms of gluteal compartment syndrome
1) rhabdomyolysis 2) renal failure 3) sciatic nerve palsy
Mars protocol for first aid to hypoxic cells
1) maintain normal BP 2) remove constricting bandages 3) maintain limb at heart level 4) O2 supplement
Systemic sequelae presentations - elevation in these molecules
1) hyper K 2) myoglobin 3) PO4 4) CPK
Effects of myoglobinuria
1) nephrotoxic/ renal vasoconstriction 2) tubular casts 3) heme cytotoxic effects
Treatment of myoglobinuria
1) crystalloid 2) Mannitol 3) bicarb
Treatment goals of myoglobinuria
pH > 6.5
Role of HD in treatment myoglobinuria
minimal molecule too big for HD
Contraindication to fasciotomy
1) non-viable tissue 2) crush injury
Most common nerve injury in fasciotomies
superficial peroneal
Course of the superficial peroneal nerve
Branch from common at proximal fibular head descend in lateral compartment in intermuscular septum
Failure rate of subcutaneous fasciotomy with minimal skin incision
12%
Full fasciotomy length of incision
12-20 cm
Two incision technique fo LE fasciotomy
Ant/lat 1) between figular shaft and tibial crest 2) 4 cm lateral to crest is septum 3) raise skin flap 4) terminate fasciotomy 5cm from fibular head Post 1) skin incision 2 cm posterior to tibia 2) avoid saphenus nerve 3) cut gastroc fascia 4) cut soleus attach to tibia 5) cut fascia over flexor and posterior tibialis
Single incision technique
Start with typical ant/lateral incision 2) develop posterior subcutaneous flap 3) accss fascia to superficial posterior 4) dissect flexor hallucis longus off fibula 5) mobilize peroneal neurovascular bundle posteriorly 6) incise into deep posterior compartment
Thigh compartments
1) anterior 2) posterior 3) medial
Contents of the anterior thigh compartment
1) sartorius 2) quadriceps 3) innervate by femoral nerve
Contents of the posterior thigh compartment
1) biceps femoris 2) semimembranosis 3) semitendonosis 4) innervate by sciatic nerve
Contents of the medial thigh compartment
1) Pectineus 2) obturator externus 3) Gracilis 4) adductors 5) innervate by obturator nerve
Decompressing thigh compartments
1) lateral thigh intertrochanteric line down to lateral epicondyle 2) cut IT band 3) reflect vastus lateralis medially 4) enter intermuscular septum Incision on adductor muscle group to decompress medial compartment
Gluteal compartment decompression
Each of the 3 muscles have own fascial compartment so incise into each
Foot compartments
1) Medial 2) lateral 3) superficial 4) calcaneal 5) interosseous muscles each have one
Foot decompression
1) longitudinal dorsal incision along medial part of 2nd metatarsal 2) longitudinal dorsal incision along lateral 4th metatarsal
Upper extremity forearm compartments
1) Volar 2) lateral 3) extensor
Henry’s Volar fasciotomy
1) Single curvilineal incision proximal to ACF medial to bicep tendon 2) cross ACF crease 3) extend to radial side of forearm 4) incise each muscle of deep flexor 5) extend from lateral epicondyle to wrist between extensor carpi radialis brevis and extensor digitorium communis
Compartments of the hand
total 10 1) hypothenar 2) thenar 3) adductor pollicis 4) 4 dorsal interosseous 5) 3 volar interosseous
Releasing hand compartments
Longitudinal incision to release carpal tunnel +/- some interosseous
Post-fasciotomy mortality
11-15%
Post-fasciotomy major amputation
5-21%
Post-fasciotomy wound complication
4-38%
Post-fasciotomy neuro deficit
7-36% especially in forearm
Late complications of fasciotomies
1) impaired sensation 77% 2) tethered tendon 7% 3) recurrent ulceration 13% 4) venous insufficiency due to lack fo calf pump 47% 5) late amputation 7.5%
Consequence of delaying treatment in compartment syndrome > 12 hours
93% neuropathy 50% amputation
Voklmann contracture define
ischemic muscles fibrosis Treat with contracture and joint release
Chronic exertional compartment syndrome (CECS) classic signs
1) exercise-induced 2) young 20-30’s 3) athlete/runner 4) 20-30 min onset 5) 15-30 min resolve after resting
Chances of bilateral exertional compartment syndrome
82%
Differential of chronic exertional compartment syndrome
1) fascial hernia 2) medial tibial syndrome 3) claudication with popliteal entrapment
Pedowitz criteria for CECS ICP
Pain with exercise + 1 of: 1) rest ICP > 15 2) ICP > 30 post exercise in first 1-2 min 3) ICP > 20 even 5 min post exercise
Treatment of CECS exertional compartment Different ways
1) Only treat anterolateral compartment 2) transverse incision 3) fasciectomy
Outcome of CECS treatment (exertional compartment)
83% success at 2 years with symptom resolution
Indications for treatment compartment syndrome with fasciotomy
