1. Dr Shrenik M Shah Shrey hospital Ahmedabad

2. Definition Definition: Increased tissue pressure compromises the circulation within the enclosed space of fascial compartments  the blood supply to the soft tissuesis impaired  irreversible muscle and nerve damage resulting in fibrosis and contracture. Most common in forearm and hand, can occur in arm and finger arm is divided into 2 fascial compartments, the fore- arm into 3, the hand into 10, and the finger into 2 compartments.

3. Anatomy of Arm compartments

4. Compartments of forearm & hand

5. Pathogenesis = Vicious circle compartment pressure  blood flow to soft tissues-ischemia  necrosis Blood flow is dependent on venous/ arteial/ local interstitial pressure Tissue ischemia  increased capillary permeability  intramuscular edema  increased tissue presssure  decreases blood flow and oxygen transport  more tissue damage

6. pathophysiology critical level is that tissue pressure which collapses the capillary bed and prevents low-pressure blood flow through the capillaries and into the venous drainage. Normal tissue pressure is 0-10 mm Hg. The capillary filling pressure is essentially diastolic arterial pressure. When tissue pressure approaches the diastolic pressure, capillary blood flow ceases.

7. Pathogenesis -2 Compartment volume Compartment contents Tight casts and dressing burn eschar, limb lengthening or applica- tion of traction, increased external pressure on limb from prolonged weight [lying on limb or entrapment under a weight] bleeding—arterial or venous injury, anticoagulation, trauma, reperfusion injury, edema, infiltrated infusion, snakebite, infection, high-pressure injection

8. Natural history Functional changes occur in muscle after 2 to 4 hours Hypoxia to nerves causes paresthesia and hypoesthesia within 30 minutes of ischemia irreversible nerve damage may not occur until 12hours permanent neural deficit tissue necrosis growth arrest Volkmann contracture wet gangrene

9. How do we go about? Detailed history Evaluate possible causes- trauma and others Pain out of proportion Single or multiple compartments Tense,swollen and tender compartment Pain on passive stretch of the muscle Paresthesias /motor weakness Pallor and pulselessness are late finding Obtunded/ sedated patient-measure comp pressure

10. Imaging / pressure measurement Clinical exam- high degree of suspicion X rays/ arterial injury- doppler/ arteriography Immediate fasciotomy Obunded/ sedated patient- measure comp pressure Finger compartment syndrome -only clinical diag. Arm –measure pressure in biceps and triceps( avoid radial nerve) Forearm-measure all compartments-median, ulnar, superficial branch of radial and post interosseus nerve are at risk Pressure-30-45 mm Hg( 30mm less than diastolic BP) Hand-15-20 mm Hg

11. Decompression of the arm Choice of incision depends on need for # fixation. Take care to completely decompress the skin and fascia. Do not injure superficial nerves. Débride any devitalized muscle. Do not close the fascia. Close the skin loosely or leave it open at the initial procedure.

12. Decompression of the forearm

13. Hand compartment syndrome

14. Hand compartments- decompression Avoid sensory branches of radial and ulnar nerves Preserve dorsal veins Release dorsal compartment and then go volar thru dorsal interosseous Release adductor thru incision over 2 nd metacarpal Wounds are left open Hand in bulky splint in intrinsic plus position ( MCP 70*, IP extended)

15. Decompression of the finger

16. Post op care 2 nd look at 48-72 hours Serial debridements until no devitalised tissue Delayed primary closure of skin or STG If significant tissue loss with exposed tendon/nerve or bone then flap coverage Wound coverage asap to avoid infection, dessication and amputation.

17. Illustrative Case Young male worker at a factory sustained air compressor injury while learning to work. Sustained open # Tibia upper third and both hand injury. Right hand minor injury Left hand had # metacarpal and proximal phalanx of fifth ray Haemodynamically stable

20. X RAY

23. Fasciotomy with carpal tunnel release

24. Hand and forearm fasciotomies

25. Follow up

26. Follow up at 7 wks