Compartment syndrome Flashcards
Compartment syndrome
Local Bloodflow - (Pa-Pv)/R decreases
increased compartement pressure - venous outflow obstruction - increased capillary permeability - increased compartment pressure - decreased arterial flow - decreased tissue oxygenation
Derangements of energy stores with depletion of ATP, disturbancde in myocyte ion hemostasis, Ca2+ overload, neutral proteases and phospholipases and other degenerative enzymes - leads to membrane phospholipid damage, mycyte lysis, toxic intracellular chemicals into extracellular environment, microvascular damage, increase of compartment pressure
causes can be:
- increases compartment content
- decreased compartement / extremity volume
diagnosis
irresible condition after 4-6 hours, period is shorter if there is a crush component
5 P’s
pain, pale, paraesthesia (c-fibers are most sensite to hypoxia), paralysis, pulselessness
passive stretching increases pain
hard skin and shiny (compartment full at 30-40 mmHg)
the diagosis is very difficult from clinical setting - low sensitivity of right diagnosis - better is pressure measurement (stryker) - in doubt immediate surgery
basis science
pressure in the volar forearm 0-8mmHg, interosseus 15mmHg
classified:
- acute incipient compartment syndrome
early period - compartement develop below critical pressure - reversible
- acute establishe CS - reversible
pressurization less than 8 hours - reversible
- acute established CT - irreversible
pressurization greater than 8 hours - cellular death - surgery useful to save tissue
4.late established CS
nonvialbility tissue before replacement begins - pressure elevation for more than 8 hours
- Volkmann’s ischemic contracture
replacement of muscle with fibrous fibers - contracture and nerve dysfunction
- chronic exertional CS
special form - recurrent, transient increases in compartmental tissue pressures, usually during exercises, resulting in transient neurologic symptoms and pain, symptoms resolve with rest
treatment I
acute phase
fasciotomy with carefully respect to the anatomy - if possible use a tourniquet -
S-type skin over the volar forearm - fascitomy to all 3 compartments (volar, dorsal and mobile wad) - maybe subseperated - carpal tunnel - hypothenar and thenar - dorsal 2 incisions for the hand (interosseus usually 2 compartments) - if necessary midline incision to the fingers (not to the palm - necrosis - dorsal of cleland ligament) - incision proximal to the brachium with lateral insicion crossing the elbow (lacertus!!!) - two compartments dorsal and anterior - maybe incision of the deltoid muscle
look for arteries which are thrombose - vein repair - maybe nerve release - prophylactic fasciotomy of every major replantation
wound closure with skin graft, artifical skin (syspuderm, epigard), shoe band closure over vessel loop and wound clamps
prophylactic antibiotics for infection, second look in the OR in 12-24h, maybe intensive unit care, resuscitation, protection of the kidney (crush syndrome)
mannitol as a free radical scavenger (reducing ischemia-reperfusion injury) and hyperosmolar capabilities (recucing tissue edema)
splinting and elevation above the heart for venous drainage and reduce swelling
treatment II
intermediate stage
be careful - bad condition of the skin with purulent blsters, loss of epidermis and contused areas - any surgery in this case leads to infection
waiting about 4-6 weeks will improvement of skin condition - ischaemic injury lead to whole loss of muscle - crush injury maybe leads to survive of the proximal part which can be used for reconstruction
further surgery not befor 3 month - yellow, friable ischemic tissue can still be easily removed - early enough to save nerves before irreversible entrapment
postop:
early active range of motion is important after fasciotomy - maybe lymphatic drainage (fasciotomy after 3-4 hours) - 4-5 muscle strength and S4 sensory can be expected
after 4-5 hours there will be necrotic tissue - pale colour in contrast to other tissue, uncontructible tissue with mechanical stimulation - resection of the whole necrotic tissue - before interval fo reconstruction - dynamic splinting, passive stretching, electrical stimulation
inital fasciotomy with pressure about 30-40mmHg or in doubt - compartment pressure less than 20mmg of diastolic blood pressure
treatment III
chronic stage: Volkmann’s contracture
Classification of contracture
Tsuge’s classification:
mild - FDP and maybe FPL
moderate - all flexors
severe - flexors and extensors
holden’s classification:
Holden’s I contracture distal to the injury - Holden’s II contracture on the level on the injury
mild-contracture - grade I
skin release, Z-plasty, tendon lengthening, maybe joint release, tendon transfer FDP to FDS
moderate-contracture - grade II
Z-plasty, tendon lengthening, tendon transfer (BR to FPL, ECRL to FDP), muscle slice and neurolysis (there are 5 types of nerve lesions in Volkmann’s contracture)
Type I
nerve in continuity - normal perfusion
external neurolysis
Type II
nerve in continuitiy - ischemic perfusion
external and internal neurolysis
Type III
nerve in continuitiy, fascicles remain ischemich after neurolysis
segmental excision and interfascicular nerve grafting
Type IV
nerve in continuity, but thinner due scar
segmental excision and interfascicular grafting
Type V
nerve disrupted with neuromal formation
neuroma excision and interfascicular nerve grafting
outcome: S3-4 sensory in type 1 and 2 - type 3-5 - protective sensation can be achieved
severe-contracture - grade III
free functional muscle transfer (latissimus or gracilis - gracilis with less soft tissue coverage - restore 10 - 40% of grip strength)
correction of bone and joint deformities
Holden’s I mild
long and ring finger usually contracted - maybe little and index finger - PL and PQ maybe involved
Holden’s I moderate
all flexors - intrinsic-minus deformity - sensory disturbances
Holden’s I severe
all flexors, partial or total involvement of extensors and occasionally intrinsics with severe grade of contracture - median and ulnar nerve involved - forearm has a woody consistency - intrinsic minus (MP hyperextension - PIP flexion)
Holden’s II direct contractures by direct trauma
Holden’s II mild
only trauma region affected - partially necrotic muscle bellies - direct trauma of nerves and soft tissue - proximal forearm portion is protected - intrinsic minus - no fixed contractures of the fingers
Holden’s II moderate
soft tissue at the site of the injury scarred and contracted - both nerves and all flexors are involved - neuralgies, paresthesias and sometimes dystrophic changes at the fingertips, intrinsic-minus - proximal part remains intact
Holden’s II severe
entire extremity is usually atrophic and severely contracted distal to the injury site
