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Musculoskeletal 2 > Compartment Syndrome > Flashcards

Compartment Syndrome Flashcards

1
Q

Define compartment syndrome

A
  • an elevation of the interstitial pressure in a closed osteofascial compartment that results in microvascular compromise
  • if left untreated will cause tissue damage
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2
Q

Which compartments are most commonly involved?

A
  • those with relatively noncompliant fascial or osseous structures
  • MC are especially the anterior compartment of the leg and the volar compartment of the forearm
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3
Q

2 classifications of compartment syndrome

A
  1. acute compartment syndrome (ACS)

2. chronic compartment syndrome (CCS)

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4
Q

Sites of ACS

A
  • can develop anywhere a skeletal muscle is surrounded by a substantial fascia
  • may occur in foot, leg, thigh, buttocks, lumbar paraspinous muscles, hand, forearm, arm and shoulder
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5
Q

How many compartments are in the foot?

A

9

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6
Q

How many compartments are in the leg?

A

4 (anterior, lateral, superior & deep posterior)

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7
Q

How many compartments are in the hand?

A

4

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8
Q

How many compartments are in the thigh?

A

3 (anterior, posterior, and medial)

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9
Q

How many compartments are in the forearm?

A

4 (superior &deep volar, dorsal, mobile wad of Henry)

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10
Q

What is the first step in ACS pathophys??

A
  1. develops after prolonged elevated intra-compartmental pressure, which results from either externally applied or internally expanding pressure forces.
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11
Q

What is the second step in ACS pathophys?

A
  1. increased tissue pressure will decrease capillary blood flow leading to local tissue necrosis caused by O2 deprivation
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12
Q

What is the third step in ACS pathophys?

A
  1. the elevated intra-compartmental pressure increases the local venous pressure leading to narrowed arteriovenous perfusion gradient and compartment tamponade, resulting (if uncontrolled) in nerve injury and muscle ischemia
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13
Q

What is the formula for local blood flow?

A

LBF = Pa - Pv / R

Pa = arterial pressure
Pv = venous pressure
R = resistance
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14
Q

Considerations for patients requiring splints

A
  1. pre-splint neurovascular status
  2. post-splint neurovascular status
  3. patient education on how to frequently check neurovascular status
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15
Q

Etiology of ACS

-External Restriction of Compartment Size

A
  • casts
  • tight dressings
  • splints
  • lying on limb for long period
  • MAST
  • burn eschar
  • closure of fascial defect
  • lithotomy position
  • malfunctioning pneumatic boot
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16
Q

Etiology of ACS

-Internal Increase in Compartment Volume

A

**factures

MC in adults:

  • closed and open tibial shaft fx
  • distal radial fx

MC in children

  • radial head or neck fx
  • supracondylar fx
  • forearm fxs
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17
Q

Etiology of ACS

-hemorrhage

A

due to vascular injury

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18
Q

Etiology of ACS

-coagulopathy

A
  • hemophilia
  • ASA overdose
  • thrombolytics
  • heparin infusion
  • sickle cell disease or trait
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19
Q

Etiology of ACS

-muscle edema

A
  • severe exercise
  • crush injury
  • trauma, alcohol, or drug-induced
  • trauma with or without fx
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20
Q

Etiology of ACS

-surgically related

A
  • knee arthroscopy
  • tibial osteotomy without drainage
  • after epidural anesthesia
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21
Q

Other etiology of ACS

A
  • Massive crystalloid infusion
  • Ruptured Backer’s cyst
  • Muscle hypertrophy (androgens)
  • Rhabdomyolysis
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22
Q

Other etiology of ACS

-cont

A
  • Intracompartmental fluid infusion (interosseosus infusion )
  • Capillary leak syndrome
  • Intra-arterial injections of sclerosing agents
  • Post –ischemic reperfusion
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23
Q

Clinical evaluation of ACS

-history

A
  • Pain out of proportion to that expected with the injury***
  • Severe pain at rest
  • Hyperesthesia or paresthesia
  • Presence of a causing factor
  • Mechanism of injury (long bone fx, high-energy trauma, penetrating injuries, crush injury)
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24
Q

Clinical evaluation of ACS

-physical exam

A
  • Tightness of the involved compartment (tense)
  • Pain with Passive stretching of those muscles passing through the compartment
  • Hyperesthesia or paresthesia
  • N.B. Paralysis, pallor or absent arterial pulse are late findings
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25
Q

What are the 6 P’s of compartment syndrome?

A
  1. PAIN
  2. PALLOR
  3. PARESTHESIAS
  4. PULSELESSNESS
  5. PARALYSIS
  6. POIKILOTHERMIA - cool feeling of the skin
26
Q

If Pt complains of pain, what compromise do you need to determine??

A

**neural compromise

  • sensory nerves begin to lose conductive ability, followed by motor nerves
  • some nerves may reveal effects of increasing pressure others

(e.g. in the anterior compartment of the lower leg, the deep peroneal nerve quickly will be affected and sensation in the 1st web space may be lost)

27
Q

The diagnosis of ACS may be delayed in…

A
  • patients with multiple injuries or altered consciousness
  • in children, in whom physical findings cannot be accurately documented
  • in patients with altered neurological function caused by vascular injuries, peripheral nerve injury, continuous epidural anesthesia or tourniquet palsy
28
Q

Although there is controversy, what mmHg do some surgeons use as cutoff criteria for ACS?

A
  • 30 mmHg (in normotensive pt)
  • or when the ICP rises to a level 10 to 30 mmHg below the diastolic BP (in hypotensive pt)

**cutoff for performing fasciotomy

29
Q

How should compartment pressure be measured?

A
  • as close to the fracture site as possible

- measured in all compartments

30
Q

What is the diff dx for ACS?

A
  • Cellulitis
  • DVT
  • Gas gangrene
  • Necrotizing fasciitis
  • Peripheral vascular injury
  • Rhabdomyolysis
31
Q

How can ICP be measured in ACS?

A
  • stryker hand-held
  • slit catheter
  • wick catheter
  • fiberoptic transducer (Camino catheter)
32
Q

When an ACS is suspected, which procedures can be used to decrease the likelihood of development of a full-blown ACS?

A
  • removal of the possible cause (i.e. release of tight dressings or circular constrictive bandages, splitting of casts, removal of MAST, cut the webril)
  • correction of coagulopathy
    (i. e. vitamin K and FFP (fresh frozen plasma) to reduce Warfarin)
  • positioning of the limb at the level of the heart
33
Q

Management of ACS

A
  • Cooling the limb
  • Treat systemic hypotension shock
  • Hyperbaric oxygen (still experimental)
  • Use of mannitol (still experimental)
34
Q

If symptoms don’t resolve in 30 to 60 min after appropriate treatment…

A

pressure measurement should be repeated, and, if equivocal, fasciotomy is indicated

35
Q

What is the definitive treatment for ACS?

A

**FASCIOTOMY

  • procedure is done without a tourniquet, each potentially limiting envelope is opened over the entire length of the compartment, all muscle groups should be soft to palpation at the end of the procedure
  • muscle debridement should be kept to a minimum
36
Q

Is the skin closed after decompression?

A

there is no immediate closure, skin is packed open with bulky dressing

37
Q

What is the care after decompression?

A

sterile dressing (saline soaks), splinting the limb in functional position

38
Q

When should you return to the OR with ACS?

A
  • for 2nd look in 2-5 days where any necrotic material is debrided
  • if no evidence of necrosis, the skin is loosely closed
39
Q

Next step if closure is not accomplished.

A

the debridement is repeated after another 72- h interval, after which skin closure or skin grafting can be performed

40
Q

Management of ACS

-skeletal fixation

A

external fixation, plates, and/or IM nailing can all be applied at time of initial surgical decompression

41
Q

Management of ACS of the Leg

-3 approaches

A
  1. Fibulectomy – a radical procedure and rarely, if ever, is indicated
  2. Single incision fasciotomy – may be useful if the soft tissue of the limb is not extensively distorted
  3. Double – incision four compartment fasciotomy: is safer and more effective and generally should be used
42
Q

What affects prognosis of ACS?

A

it can be excellent to poor, depending on how quickly ACS is diagnosed and treated and whether or not complications develop

43
Q

Complications of ACS

-myonecrosis definition

A
  • happens after an ischemic insult of an 8 hours or more duration
  • Rx fasciotomy + debridement of the muscles + neurolysis may lead to myoglobinuria and eventually renal failure
44
Q

Complications of ACS

-myonecrosis tx

A

diuresis ( by mannitol, diuretics or IV fluids ) should be prompted to increase the tubular flushing and eliminate the proteinaceous material

45
Q

Complications of ACS

-Volkmann contracture definition

A
  • the residual limb deformity that over wks to mos follows untreated ACS or ischemia from arterial injury
  • it may occur in the upper or lower extremities
  • MC following humeral (supracondylar) or femoral shaft fxs
46
Q

Complications of ACS

-Volkmann contracture pathogenesis

A

prolonged ischemia ——— myonecrosis —— fibroblastic proliferation —— contraction of the cicatrix —- myotendinous adhesion formation.

47
Q

Complications of ACS

-Volkmann contracture tx

A
    • non-surgical (physiotherapy & bracing of the involved joints)
    • surgical (contracture release, nerve compression release, amputation or reconstruction with tissue transfers)
48
Q

Other complications of ACS

A
  • Neurovascular injury
  • Infection
  • Amputation
  • Rhabdomyolysis
  • Myoglobinuric renal failure
  • Death
49
Q

When should prophylactic fasciotomy be performed?

A

prophylactic fasciotomy of the forearm or leg should be performed if arterial ischemia has been present for > 4 –6 h

50
Q

When should prophylactic fasctiotomy be considered?

A

whenever an open tibia fx is debrided or a tibial osteotomy is performed

51
Q

Chronic Compartment Syndrome is also known as…

A

exertional CS, recurrent CS and subacute CS

52
Q

What induces CCS?

A

Exercise –induced pain

*occur mainly in the lower limb

53
Q

What is typical CCS patient?

A

young (20-30s) athlete (long distance runner) or military recruits pushed past normal limits of functional tolerance

54
Q

Pathophysiology of CCS

A
  • not yet fully understood
  • probably occurs from increased muscle relaxation pressure during exercise, which causes decreased muscle blood flow, leading to ischemic pain and impaired muscle function
55
Q

Physical Exam in CCS

A
  • may reveal tenderness over the musculature involved in the compartment
  • bilateral involvement is common (up to 82% )
  • fascial hernias (39% in one of the studies)
56
Q

Diagnosis of CCS

A

Intracompartmental testing is the hallmark of diagnosis:

  1. Pre-exercise resting pressure of 15 mm Hg or more.
  2. Pressure of 30 mm Hg 1 minute after the exercise.
  3. Pressure of 20 mm Hg or more 5 minutes after the exercise.
57
Q

DDx of CCS

A
  • Periostitis
  • Entrapment of the superficial peroneal nerve
  • Tendinitis of the posterior tibial tendon
  • Stress fracture of tibia
  • Intermittent claudication
58
Q

Work-up of CCS

A

Plain x-rays: will show 90% of stress fx

Bone scan:

  • diffuse uptake - periostitis
  • localized uptake-stress fx

Tinel test: may be positive in superficial peroneal nerve entrapment

NCS: could be helpful

MRI: promising results reported

59
Q

Non-operative tx of CCS

A
  • NSAIDs
  • electrostimulation
  • massage
  • muscle relaxants
  • ultrasound
  • cessation or significant reduction of athletic activities
60
Q

Surgical tx of CCS

A
  • Single incision fasciotomy

- Double incision fasciotomy

61
Q

After CCS surgery…

A
  • early ROM exercises are encouraged
  • WBAT on crutches is allowed on POD#1
  • light jogging is allowed at 2-3 weeks if no swelling or tenderness

Musculoskeletal 2 (14 decks)

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