Compartment Syndrome Flashcards
The diagnosis ofcompartment syndromeis primarily a clinical one based on careful history and physical examination
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Compartment pressure greater than 50 mm Hg or within
is considered to be an indication of fasciotomy
F Compartment pressure greater than 30 mm Hg or within
20 to 30 mm Hg of the diastolic blood pressure is considered to be indication for fasciotomy
Fasciotomy in a timely manner is the only management for
compartment syndrome with good outcome expected
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compartment syndrome can occur in any closed space in
the body,even the orbit
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mostly occurs within fibro-osseous space in the upper
and lower extremities
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most common site is the upper extremities
F most common site is the lower leg, followed by the forearm and hand.
Upper arm compartment syndrome
is rare, with few reported cases.
91% of the patients were men in their thirties why?
being more likely to sustain high-energy injuries, the author suggested that less space for muscle swelling of the muscle after injury led to a higher incidence of acute compartment syndrome in young men
The upper arm consists of two compartments around the
humerus: the anterior and posterior compartments . They are divided by the lateral and medial intermuscular septae
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The musculocutaneous nerve and median nerves run through the posterior compartment
F The musculocutaneous nerve and median nerves run through the anterior compartment
why symptoms of radial or ulnar nerve ischemia are
not compartment specific?
F The ulnar and radial nerves travel in one compartment first, and then pass through the intermuscular septum into
another compartment at the level ofdistal third ofthe arm
The muscles in the volar compartments are
usually divided into superficial and deep groups
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The forearm has three major compartments, and the radius, ulna,
and rigid interosseous membrane constitute the stifffloor ofthe compartments
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The deep volar muscles are usually the most severely affected in forearm compartment syndrome,
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The median nerve runs between the superficial
and deep muscles and ends at the carpal tunnel
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The ulnar nerve
is the most commonly affected nerve in forearm compartment syndrome.
F The median nerve
is the most commonly affected nerve in forearm compartment syndrome.
The lateral compartment of the forearm include»»>
Brachioradialis muscle
Radial artery
Extensor carpi radialis muscles (ECRP,ECRL)
The AIN and the deepest portion ofthe flexor muscles are severely damaged when compartment syndrome involves the
deep volar compartment
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The dorsal compartment contains the wrist and finger extensors,
and the motor branch of the radial nerve (posterior interosseous
nerve)
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Course of PIN
ravels obliquely through and into the supinator muscle. then lies in a plane between
the superficial and deep extensor muscles. In the distal forearm, the
PIN lies on the interosseous membrane
The dorsal and lateral forearm compartments along with volar forearm compartment are usually effected together
F also
may develop isolated compartment syndrome
There are at least 10 compartments in the hand divided into five groups: thenar, hypothenar, adductor pollicis, palmar, and dorsal interosseous
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The thenar, hypothenar, adductor pollicis, and
interosseous compartments contain 5 intrinsic muscles of hand
F The thenar, hypothenar, adductor pollicis, and
interosseous compartments contain 14 intrinsic muscles of hand
compartment syndrome can still occur in the finger.
T Although the finger has no muscle, compartment syndrome can still occur in the finger.
The compartments of the finger are considered to
be bounded by skin, and Cleland and Grayson ligaments
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Inadequate tissue perfusion within the compartment is the foundation, and progressive cell death is the final result of compartment syndrome
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The leak
ofthe cellular membrane, especially the endothelium of a capillary results in increased capillary permeability, causing the intravascular fluid to move into the interstitial space
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Skeletal muscle can tolerate up to 4 hours of
ischemia, and can recover partially after 6 hours, but incurs permanent damage after 8 hours
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Nerve conduction function is affected after
5 hour of ischemia
F Nerve conduction function is affected after
1 hour of ischemia
peripheral nerves may undergo irreversible
damage after 4 to 6 hours ofischemia
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Volkmann ischemic contracture is used to term the final
result of tissue ischemia following compartment syndrome,
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What is the crush syndrome?
severe local compartment syndrome can also
arise the systemic manifestations, which is called crush syndrome. Rapid return of toxic muscle products into the circulatory system may lead to renal failure, cardiac failure, respiratory failure, and intravascular coagulation
prolonged limb positioning, can lead to compartment syndrom
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High pressure injection injury, drugs
or contrast medium extravasation can lead to compartment syndrom
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Infections Tenosynovitis of the finger can lead to compartment syndrom
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Muscle overuse can lead to compartment syndrom
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most common cause for compartment syndrome in the extremities
Fractures are the most common cause for compartment syndrome in the extremities
Open fractures do not necessarily prevent compartment
syndrome why?
because the wounds may not open the compartment
completely
patients with open fractures had a higher incidence of fasciotomy than those with closed
fractures
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Radius and/or ulna fractures were the most common
cause of forearm compartment syndrome, followed by supracondylar fractures.
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Hand compartment syndrome can be caused by
multiple metacarpal fractures
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Vascular injury with subsequent reperfusion injury is another
common cause of compartment syndrome
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Continuous bleeding leads to ischemai that lead to oedema A delay in revascularization can aggravate ischemic edema that expands the compartment contents.
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ischemic condition
after intramuscular perforator harvest may decrease pressure tolerance of the compartmental tissue.
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Rarer etiologies of compartment syndrome include muscle
overuse, rhabdomyolysis, and systemic sclerosis.
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Crotalid envenomation, infection, electrical injuries, and
burns have also been considered to cause a cascade of events that leads to the rapid formation of vascular permeability and interstitial edema
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The diagnosis of compartment syndrome is primarily clinical, and
based on patient history, symptoms, and signs
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patient’s history may be the only basis of the diagnosis and
fasciotomy
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The fingers are often placed in extension
position in a forearm compartment syndrome
F The fingers are often placed in flexion
position in a forearm compartment syndrome
in the intrinsic
minus position in a hand compartment syndrome
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Swelling is usually not presented in all cases
F in all the patients
Pain Early and sensitive finding
T Worse as passive stretching ofthe compartmental
muscles
Paresthesia Early sign Very low sensitivity but high specificity
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Paralysis Often indicates the compartment syndrome in an
irreversible stage
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Pallor and
Pulselessness Late symptom always present
F May not presented in a compartment syndrome
All five Ps
are more commonly seen in a primary vascular injury rather than compartment syndrome
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Pain is the early and sensitive finding before onset of ischemia
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passive palmar abduction of the thumb, thus stretching the
abductor pollicis brevis, is associated with a thenar compartment syndrome.
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Paresthesia is another early sign, especially when a sensory nerve
travels in the affected compartment.
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Paralysis= the final stage
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Doppler ultrasound and radiography imaging have been used for diagnosis of compart-ment syndrome.
F Doppler ultrasound and radiography imaging have been used to evaluate the primary injury and identify the amount of tissue edema, but not helpful for diagnosis of compart-ment syndrome.
Chronic compartment syndrome commonly happen in the upper limp
characterized by exercise-induced and rest-relieved pain, and it rarely happens in the upper limbs
Neurological symptoms such as
tingling and hand numbness are not present in chronic compartment
F Neurological symptoms such as
tingling and hand numbness were found in some cases
differential
diagnoses of chronic compartment
Negative findings of physical examination at rest can rule out other differential diagnoses including nerve compression syndrome, vascular claudication, and fascia! herniation
Dynamic compartment pressure measurement is helpful to diagnose chronic compartment syndrome of
the forearm.
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compartment syndrome is suspected, any external pressure including cast, bandage, or sutures should be immediately removed. The limb should be elevated at the level of the heart but not above this level
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When compart-ment syndrome is diagnosed, emergency fasciotomy is the only management with good expected outcomes.
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subcutaneous and endoscopic-assisted fasciotomies have
been reported
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Fasciotomy procedures include
only dividing the skin and fascia to release the compartmental muscles and nerves
F also identifying and excising of nonviable
muscles.
Upper arm fasciotomy is often performed via a medial incision
and a lateral incision
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carpal tunnel decompression is often
performed with forearm or hand fasciotomy
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Exp;oration between the flexor carpi ulnaris and flexor digitorum superficialis
to decompress the median nerve and deep group of flexor muscles.
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Site in releasing the dorsal compartment
For dorsal forearm compartment syndrome, a longitudinal incision is designed on the line between the distal radioulnar joint and the lateral epicondyle
incision is
limited to the middle half of the forearm
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The fascia is then divided and approached between
the extensor digitorum communis and extensor carpi radialis brevis
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The mobile wad can be released via the same incision by mobilization of the incision site
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Two longitudinal incisions are recommended by the authors to
release the forearm compartment
One is along the ulnar edge of
the radius over the flexor muscles, and the other is along the ulnar edge of the ulna over the extensor muscles
All compartments in the hand, necessary to approach
f Although there are more than 10 compartments in the hand,
it is unnecessary to approach all· the compartments
Except carpal tunnel release, hand compartments are usually released by
four incisions
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Finger decompression is performed with a midaxial lateral incision along the noncontact side of the finger to release the Cleland
and Grayson ligaments
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The dissection is carried out
superficial to the flexor sheath
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After fasciotomy, all the incisions are left open to avoid recompression of the compartments
F EXCEPT the incision for carpal tunnel release is closed directly.
vacuum-assisted closure benefit
reduce the relative complications including wound edge necrosis, infection, and neurologic deficit
Delayed primary closure or skin grafting to the open area is performed depending on the wound tension,
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Neurological deficit is the most common complication of the
forearm compartment syndrome.
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