Dr. Anshu

Sharma

COMPARTMENT SYNDROME &

VOLKMANN’S ISCHAEMIC

CONTRACTURE

DEFINATION

COMPARTMENT SYNDROME IS DEFINED AS

AN ELEVATION OF THE INTERSTITAL

PRESSURE IN A CLOSED OSTEOFASICAL

COMPARTMENT THAT RESULTS IN A

MICROVASCULAR COMPROMISE.

COMPARTMENT WITH RELATIVELY

NONCOMPLIANT FASICAL OR OSSEOUS

STRUCTURES ARE INVOLVED ESPECIALLY

THE ANTERIOR AND DEEP POSTERIOR

COMPARTMENTS OF LEG AND THE VOLAR

COMPARTMENT OF FOREARM.

ANATOMY AND

PATHOPHYSIOLOGY

THE PATHOPHYSIOLOGY OF COMPARTMENT

SYNDROME INVOLVES AN INSULT TO NORMAL

LOCAL TISSUE HOMEOSTASIS THAT RESULTS IN

INCREASED TISSUE PRESSURE

DECREASED CAPILLARY BLOOD FLOW

LOCAL TISSUE NECROSIS DUE TO OXYGEN

DEPRIVATION

Increased compartment pressure

Increased venous pressure

Decreased blood flow

Decreases perfusion

MUSCLE ISCHEMIA

4 hours - reversible damage

8 hours - irreversible changes

4-8 hours - variable

EXPERIMENTAL EVIDENCES SUGGESTS THAT

SIGNIFICANT MUSCLE NECROSIS CAN OCCUR

IN PATIENT WITH NORMAL BLOOD FLOW IF

INTRACOMPARTMENTAL PRESSURE IS

INCREASED TO MORE THAN 30mm HG FOR

LONGER THAN 8 HOURS.

CLASSIFICATION ON THE BASIS OF

CAUSE OF INCREASED PRESSURE

AND DURATION OF SYMPTOMS

ACUTE

CHRONIC

ACUTE COMPARTMENT

SYNDROME

CAUSES:

FRACTURES

SOFT TISSUE TRAUMA

ARTERIAL INJURY

LIMB COMPRESSION DURING ALTERED

CONSCIOUSNESS

ANTICOAGULANTS

CLINICAL EVALUATION

PHYSICAL SIGNS

• TIGHTNESS OF THE INVOLVED

COMPARTMENT

• PAIN WITH PASSIVE MOTION OF THE

MUSCLE

• WEAKNESS OF THE MUSCLE

THE MOST IMPORTANT SIGN IS THE PAIN OUT

OF PROPORTION TO THAT EXPECTED OF

INJURY.

HYPESTHESIA OR PARESTHESIA SHOULD BE

EVALUATED BY TESTING WITH PIN PRICK,LIGHT

TOUCH AND 2 POINT DISCRIMINATION.

THE DIAGNOSIS OF COMPARTMENT

SYNDROME MAY BE DELAYED IN PATIENTS

WITH MULTIPLE INJURIES,ALTERED

CONSCIOUSNESS AND IN CHILDREN.

5P’S

PAIN OUT OF PROPORTION TO THAT OF

INJURY

PALLOR

PULSELESSNESS

PARAESTHESIA

PARALYSIS

BECAUSE OF THE VARIABLITY OF CLINICAL

SIGNS AND SYMPTOMPS THE POSITIVE

PREDICTIVE VALUE ARE LOW HOWEVER THE

SPECIFICITY AND NEGATIVE VALUES ARE HIGH

IF COMPARTMENT SYNDROME IS SUSPECTED

AND AN ADEQUATE EXAMINATION CAN NOT BE

PERFORMED PRESSURE LEVEL SHOULD BE

MEASURED

DEVICES FOR MEASURING

PRESSURE IN COMPARTMENT

SYNDROME

ARTERIAL LINE MANOMETER

WHITESIDES THREE WAY STOPCOCK

APPARATUS

WICK MONITOR

ULTRASONOGRAPHY TO MEASURE

SUBMICROMETER DISPLACEMENT OF

FASCIA WALL

HOWEVER PREASURE MEASURMENTS

SHOULD NOT BE USED AS FIRST LINE FOR

FASCIOTOMY

METHOD OF MEASURING

LARGE BORE NEEDLE IS INSERTED INTO

THE COMPARTMENT AND IS CONNECTED TO

A FLUID FILLED ASSEMBLY WITH THE MANO

METETR.

THE MILIMETERS OF MERCURY PRESSURE

NECESSARY TO OVERCOME THE

RESISTANCE WHEN ATTEMPTING TO INJECT

THE FLUID INTO THE COMPARTMENT IS

NOTED.

IF TISSUE PRESSURE APPROACHES THE

RANGE WITHIN 10mmHG TO 20mmHG OF THE

DIASTOLIC PRESSURE,CESSATION OF BLOOD

FLOW IS EMINENT.

WHEN TISSUE PRESSURE REACHES 40mmHG

TO 50mmHG MUSCLE THREATNING

COMPRESSION AND ISCHEMIA ARE PRESENT.

A PRESSURE OF 30mmHG OR GREATER MAY BE

USED AS A CRITERIA FOR FASCIOTOMY.

TREATMENT

IF COMPARTMENTAL PRESSURE IS GREATER

THAN 30MMHG IN THE PRESENCE OF

CLINICAL FINDINGS IMMIDIATE FASCIOTOMY

IS INDICATED

IN PATIENTS WITH MAJOR DISRUPTION OF

ARTERIAL CIRCULATION OF MORE THAN

FOUR HOURS FASCIOTOMY SHOULD BE

PERFORMED AT THE TIME OF INITIAL

SURGERY

IN INSOLATED LIMB INJURIES SPLITTING OF

THE CAST AND UNDERLYING PADDING CAN

DECREASE THE PRESSURE AS MUCH AS 50 TO

85 % .

PLACING THE LIMB AT THE LEVEL OF HEART

PRODUCES THE HIGHEST AV GRADIENT.

IF THE SYMPTOMS DON’T RESOLVE WITHIN 30

TO 60 MINUTES AND CONDITION REMAINS THE

SAME THEN FASCIOTOMY SHOULD BE DONE.

IF FASCIOTOMY IS DONE WITHIN 25 TO 30 HOURS PROGNOSIS IS GOOD

LITTLE OR NO RETURN OF FUNCTION IS EXPECTED IF TREATMENT IS DELAYED

NO BENEFIT FROM FASCIOTOMY HAS BEEN REPORTED AFTER 3RD OR 4TH DAY

IF FASCIOTOMY IS DONE LATE THAN SEVERE INFECTIONS HAVE BEEN REPORTED

ACUTE COMPARTMENT

SYNDROME OF THIGH

IT IS ASSOCIATED WITH HIGH LEVELS OF

MORBIDITY

IN ONE STUDY OF 23 PATIENTS WITH ACUTE

THIGH COMPARTMENT SYNDROME 4

PATIENTS REQUIRED AMPUTATION

COMMON CAUSES

BLUNT TRAUMA WITH OR WITHOUT

FRACTURES

VASCULAR INJURIES

BURNS

TOURNIQUET USE

SURGERY

MUSCLE OVERUSE

QUADRICEPS TENDON RUPTURE

THE THIGH IS DIVIDED INTO 3 DISTINCTIVE

COMPARTMENTS

1. ANTERIOR

2. MEDIAL

3. POSTERIOR

Compartments

Anterior

Medial

Posterior

Deep

Superficial

EDL

FDLTP

Gastroc

Soleus

TA

EHL

FHL

Peroneu

s

ANTERIOR COMPARTMENT

QUADRICEPS MUSCLE GROUPS

SARTORIUS

FEMORAL NERVE AND ITS SENSORY

BRANCH

SAPHENOUS NERVE

FEMORAL ARTERY AND VEIN

MEDIAL COMPARTMENT

ADDUCTOR MUSCLES GROUP

PROFUNDA FEMORIS

OBTURATOR ARTERY

OBTURATOR NERVE

POSTERIOR COMPARTMENT

BICEPS FEMORIS

SEMIMEMBRANOSUS

SEMITENDINOSUS

ARTERIAL BRANCHES OF PROFUNDA

FEMORIS

SCIATIC NERVE

MOST COMMON SIGNS OF THIGH

COMPARTMENT SYNDROME ARE PAIN AND

INCREASED THIGH CIRCUMFRENCE AS

COMPARED TO OPPOSITE SIDE.

WEAKNESS OF THE INVOLVED THIGH MUSCLES

AND SENSORY OR MOTOR DEFICITS IN THE

ANATOMICAL DISTRIBUTION OF NERVE CAN

HELP TO DETERMINE WHICH AREA IS

INVOLVED.

FASCIOTOMY FOR ACUTE

COMPARTMENT SYNDROME OF

THIGH

PREPARE AND DRAPE THE THIGH IN A

STERILE FASHION EXPOSING THE LIMB

FROM ILIAC CREST TO THE KNEE JOINT.

MAKE A LATERAL INCISION BEGINNING JUST

DISTAL TO THE INTER TROCANTRIC LINE

AND EXTENDING TO LATERAL EPICONDYLE

USE SUBCUTANEOUS DISSECTION TO EXPOSE

THE ILIOTIBIAL BAND AND THEN MAKE A

STRAIGHT INCISION IN LINE WITH THE SKIN

INCISION THROUGH THE ILIOTIBIAL BAND

REFLECT THE VASTUS LATERALIS OF LATERAL INTERMUSCULAR SEPTUM

MAKE 1.5 CM INCISION IN THE LATERAL INTER MUSCULAR SEPTUM AND EXTENDING IT PROXIMALY AND DISTALLY THE LENGTH OF INCISION

AFTER THE ANTERIOR AND POSTERIOR COMPARTMENT HAVE BEEN RELEASED MEASURE THE PRESSURE OF THE MEDIAL COMPARTMENT IF THE PRESSURE IS ELEVATED MAKE A SEPARATE MEDIAL INCISION TO RELEASE THE ADDUCTOR COMPARTMENT.

ACUTE COMPARTMET

SYNDROME OF LOWER LEG

MOST COMMON CAUSES ARE TIBIAL

FRACTURES

SECOND MOST COMMON CAUSE IS BLUNT

SOFT TISSUE INJURY

TREATMENT SINGLE INCISION PERIFEBULAR

FASCIOTOMY- IF THE SOFT TISSUE OF THE LIMB IS NOT EXTENSIVELY DISTORTED

DOUBLE INCISION FASCIOTOMY – IT IS SAFER AND MORE EFFECTIVE

IF THE DIFFERENCE BETWEEN COMPARTMENT PRESSURE AND PREOPERATIVE DIASTOLIC BP IS GREATER THAN OR EQUAL TO 30mm HG POSTERIOR COMPARTMENT ARE NOT RELEASED.

DOUBE INCISION

FASCIOTOMY

MAKE A 20 TO 25CM INCISION IN THE

ANTERIOR COMPARTMENT CENTERED HALF

WAY BETWEEN THE FIBULAR SHAFT AND

THE CREST OF TIBIA.

MAKE A TRANSVERSE INCISION TO EXPOSE THE

LATERAL INTERMUSCULAR SEPTUM AND IDENTIFY THE

SUPERFICIAL PERONEAL NERVE JUST POSTERIOR TO

SEPTUM

USING SCISSOR RELEASE THE ANTERIOR

COMPARTMENT PROXIMALY AND DISTALY IN LINE WITH

ANTERIOR TIBIAL MUSCLE

PERFORM FASCIOTOMY OF THE LATERAL

COMPARTMENT PROXIMALLY AND DISTALLY IN LINE

WITH THE FIBUALR SHAFT

MAKE A SECOND LONGITUDINAL INCISION 2CM

POSTERIOR TO THE POSTERIOR MARGIN OF

TIBIA AND IDENTIFY THE FASCIAL PLANES

RETRACT THE SAPHENOUS VEIN AND NERVE

ANTERIORLY

MAKE A TRANSVERSE INCISON TO IDENTIFY

THE SEPTUM AND RELEASE THE FASCIA

MAKE ANOTHER FASCIAL INCISON OVER THE FLEXOR

DIGITORUM LONGUS MUSCLE AND RELEASE THE

ENTIRE DEEP POSTERIOR COMPARTMENT

AFTER RELEASE IF INCREASED TENSION IS EVIDENT

RELEASE IT OVER THE EXTENT OF MUSCLE BELLY.

DELAYED PRIMARY CLOSURE

CHRONIC EXERTIONAL

COMPARTMET SYNDROME

IT IS DEFINED AS REVERSIBLE ISCHEMIA

SECONDARY TO A NONCOMPLIANT

OSTIOFASCIAL COMPARTMENT THAT IS

UNRESPONSIVE TO THE EXPANSION TO

MUSCLE VOLUME THAT OCCOUR WITH

EXERCISE

DIFFERENTIAL DIAGNOSIS

MEDIAL TIBIAL STRESS SYNDROME

STRESS FRACTURE

TENOSYNOVITIS

PERIOSTITIS

DVT

NERVE ENTRAPMENT SYNDROME

LUMBOSACRAL RADICULOPATHY

NUROGENIC CLAUDICATION

POPLITEAL ARTERY ENTRAPMENT SYNDROME

VASCULAR CLAUDICATION

INFECTION

MYOPATHY

TUMOR

CLINICAL EVALUATION

A TYPICAL PATIENT IS COMPETITIVE

RUNNER 20 TO 30 YRS OLD WHO DESCRIBES

EXERCISE INDUCED PAIN AND A FEELING OF

TIGHTNESS THAT BEGINS AFTER 20 TO 30

MINUTES AFTER RUNNING AND PAIN

USUALLY RESOLVES AFTER 15 TO 30

MINUTES OF CESSATION OF EXERCISE

TREATMENT

NON OPERATIVE

REST

ANTI INFLAMATORY MEDICATION

STRETCHING AND STRENTHNING OF

INVOLVED MUSCLES

OPERATIVE

o DOUBLE MINI INCISION FASCIOTOMY FOR CHRONIC

ANERIOR COMPARTMENT SYNDROME

o SINGLE INCISION FASCIOTOMY FOR CHRONIC

ANTERIOR AND LATERAL COMPARTMENT SYNDROME

o DOUBLE INCISION FASCIOTOMY FOR CHRONIC

POSTERIOR COMPARTMENT SYNDROME

VOLKMANN’S ISCHEMIC

CONTRACTURE

IT IS DEFINED AS ISCHEMIC NECROSIS OF

THE STRUCTURE CONTAINED WITHIN THE

VOLAR COMPARTMENT OF THE FOREARM

USUALLY FOLLOWING A SEVERE INJURY

ABOVE THE ELBOW OR DIRECTLY IN THE

FOREARM.

ETIOLOGY

IN THE CHILD UNDER 10 YEARS

SUPRACONDYLAR FRACTURE OF HUMERUS

IS THE MOST COMMON PRECIPITATING

FACTOR.

CONTUSION OR CRUSH INJURY OF

FOREARM

CLINICAL PICTURE

AT FIRST SEVERE,DEEP PAIN DEVELOPS IN

THE FOREARM.

THE VOLAR ASPECT OF THE FOREARM IS

SWOLLEN,RED,WARM AND TENSE TO

PALPATION.

THE FINGERS ARE HELD IN FLEXION AND

ATTEMPT TO EXTEND THE FINGER

INTENSIFIES THE PAIN.

INITIAL NERVE INVOLVMENT IS EVIDENCED

BY DIMINISHED SENSATION IN THE

AUTONOMOUS SENSORY ZONE OF THE

AFFECTED NERVE.

THE MOST COMMON NERVE INVOLVED IS

MEDIAN NEVE.

COMPLETE GLOVE ANESTHESIA DURING THE

EARLY STAGE IMPLIES EXTREME ISCHEMIA.

ADVANCED NERVE DEFICIET RESULTS IN

PARALYSIS OF NOT ONLY FLEXOR BUT ALSO

THE INTRINSIC MUSCLES OF HAND.

WITH IN THE FUE DAYS PAIN AND SWELLING

SUBSIDES AND FOREARM DEVLOPS A WOODEN

INDURATION.

TREATMENT

IF POSSIBLE SURGICAL DECOMPRESSION

SHOULD BE DONE BEFORE THE

PERIPHERAL PULSATIONS ARE LOST.

WHEN TISSUE PRESSURE APPROACHES THE

LEVEL OF DIASTOLIC BLOOD PRESSURE

SEVERE IRRETRIEVABLE MUSCLE NECROSIS

IS IMINENT AND THE COMPARTMENT

SHOULD BE OPENED BY FASCIOTOMY.

SURGICAL EXPLORATION MUST EXTEND

DEEPLY TO THE FLEXOR DIGITORUM

PROFUNDUS WHICH SUSTAINS THE MAXIMUM

DEGREE OF NECROSIS.

THE MEDIAN NERVE SHOULD BE FREED.

IF PERIPHERAL PULSES ARE NOT RESTORED

THE BRACHIAL ARTREY MUST BE INSPECTED

AND DECOMPRESSED.

THE SURGICAL WOUND IS LEFT OPEN UNTIL

THE SWELLING SUBSIDES AND SECONDARY

CLOSURE IS DONE LATER.

THE EXTREMITY IS SUPPORTED IN A SPLINT IN

A FUNCTIONAL POSITION.

LATER DYNAMIC SPLINTING AND EXERCISES

PREVENT DEFORMITY.

THANK YOU….!!!