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Prof. Mamoun Kremli AlMaarefa Medical College Compartment Syndrome.

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Presentation on theme: "Prof. Mamoun Kremli AlMaarefa Medical College Compartment Syndrome."— Presentation transcript:

1 Prof. Mamoun Kremli AlMaarefa Medical College Compartment Syndrome

2 Pathophysiology Increasing volume in a closed compartment Pressure increased in compartment Decreasing arteriovenous difference Hypoxia : Muscle necrosis

3 Pathophysiology Compartment pressure Venous outflow Venous pressure Gradient A.V pressure Arterial perfusion Ischemia, tissue necrosis, edema Capillary permeability N=0-4 mmHg > 30 mmHg

4 Pathophysiology Increased compartment pressure: ICP > 30mm Hg ( > 40mm Hg) Delta Pressure: P diast - P comp < 30 mm Hg Related to diastolic blood pressure Worse in shock

5 Causes Fractures Bleeding in closed compartment Soft tissue trauma Bleeding and edema in closed compartment Surgery Post osteotomy (Tibia / Forearm) Circumfrential dressings / casting Does not allow swelling of skin

6 Causes Fractures Bleeding in closed compartment Soft tissue trauma Bleeding and edema in closed compartment Surgery Post osteotomy (Tibia / Forearm) Circumfrential dressings / casting Does not allow swelling of skin

7 Clinical Picture – 5P s Pain: Pain out of proportion of expectation Increased pressure / burst sensation Pain with passive motion / stretch Paresthesia Paralysis Pallor Pulselessness  too late, >8h TREAT

8 Clinical Picture - Look Shiny skin Pallor / or Dusky skin Swelling of compartment

9 Clinical Picture - Look Shiny skin Pallor / or Dusky skin Increased volume Blisters Clear fluid Dusky Bloody worst

10 Clinical Picture - Feel Feels tense Parasthesia Pulse ?

11 Clinical Picture - Move Pain on passive stretch Passive dorsiflexion of ankle (leg) Passive dorsiflexion of wrist (forearm)

12 Diagnosis Diagnosis is clinical: Unrelenting, bursting pain Unreleived by analgesia Swollen compartment Pain on passive stretching Sensory deficit? Pulses always palpable Open fractures DO NOT necessarily decompress an elevated compartment pressure

13 Diagnosis Compartment pressure measurement: NOT a substitute for clinical diagnosis Invaluable in unconscious or anesthetized patients

14 Measuring compar t pressure When is pressure measurement needed? Measure pressure only if: Clinical picture equivocal Altered consciousness Multiple injuries Epidural anesthesia Concomitant nerve injury Children

15 Treatment Medical Surgical

16 Medical Management ABC’s. Correct hypotension Remove circumferential bandages & cast Limb at level of the heart more elevation reduces the arterial inflow Supplemental oxygen administration

17 Medical Management With tight cast, compartmental pressure falls: 30%  when cast is split on one side 65%  when cast is split Bilaterally 75%  with Splitting the inside padding 85 – 90%  complete removal of cast

18 Surgical Management Should not be delayed Fasciotomy Skin and All compartments

19 Fasciotomy Indications: High suspicion Equivocal clinical findings Significant tissue injury Delta pressure (DBP - compartment P.) < 25 mm Hg. Compartment pressure > 30mm Hg. S&S not resolved after 30-60min of appropriate precautions Prophylactic with major corrective osteotomy of the leg & forearm High risk patients

20 High Risk Patients Clinical picture equivocal Altered consciousness Multiple injuries Epidural anesthesia Concomitant nerve injury Children

21 Fasciotomy Principles Long extensile incisions Release all compartments Debride necrotic muscles (4C’s) Preserve neurovascular structures Never close fascia Keep wound open Repeated looks x48h, as needed Coverage within 7-10 days (usually within 3-5 d)

22 Fasciotomy Principles

23 emedicine.medscape.com

24 Fasciotomy Principles

25 Fasciotomy Principles Wound closure: Bulky dressing with a splint “Boot lace” vessel loop closure

26 Fasciotomy Principles Wound closure: Bulky dressing with a splint “Boot lace” vessel loop closure “V.A.C” dressing (Vacuum Assisted Closure)

27 Fasciotomy Principles Wound closure: Bulky dressing with a splint “Boot lace” vessel loop closure “V.A.C” dressing (Vacuum Assisted Closure) Later skin graft / flap: Usually skin graft Flap coverage needed if nerves, vessels, or bone exposed mgur.com

28 Compartment Syndrome Evaluation of muscle viability (4Cs): Color Consistency Contractility Capacity to bleed

29 Treatment - early Color red Consistency normal Capable of bleeding Contracts when pinched ✓

30 Treatment – late Color dark Consistency abnormal Not bleeding No contractions when pinched ✗

31 Contraindication to fasciotomy Confirmed acute compartment syndrome diagnosis for > 48 hours damage cannot be reversed and significant infection rate when dead tissue exposed Already dead muscles, as in crush injuries

32 Complications of untreated C.S. Volckmann’s contracture Muscle weakness Sensory loss Chronic pain Amputation

33 Summary Compartment syndrome is a clinical diagnosis Should not be missed - Disaster Requires urgent treatment “Time” is the most important factor to avoid irreversible complications Do NOT apply circumferential dressings


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