DONE BY :ASIM MAKHDOM 25/Nov/2008 ORTHOPEDIC H.O.
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Transcript of DONE BY :ASIM MAKHDOM 25/Nov/2008 ORTHOPEDIC H.O.
COMPARTMENT SYNDROME
DONE BY :ASIM MAKHDOM25/Nov/2008
ORTHOPEDIC H.O
Background
Volkmann contracture : Richard vonVolkmann. 1872 (documented nerve injury and subsequent contracture from CS following supracondylar fracture. That injury remains known as Volkmann contracture.) Approximately 50 years after vonVolkmann, Jepson described ischemic contractures in dog hind legs resulting from limb hypertension after experimentally
induced venous obstruction
in the 1970s, the importance of measuring intracompartmental pressures became
apparent.
Definition
Compartment syndrome (CS) is a limb-threatening and life-threatening condition observed when perfusion pressure falls below tissue pressure in a closed anatomic space
Location
maintain a high level of suspicion when dealing with complaints of extremity pain
Pathophysiology
Pressure perfusion
until no oxygen is available for cellular
metabolism .
Tissue perfusion is determined by measuring capillary perfusion pressure (CPP) minus the interstitial fluid pressure (TP=CPP-IFP)
(Normal cellular metabolism requires 5-7mmHg oxygen tension)
this is easily maintained with the CPP averaging 25 mm Hg and interstitial pressure 4-6 mm Hg SO
intracompartmental pressures greater than
30 mm Hg are generally agreed to require intervention
At this point, blood flow through the capillaries stops
no oxygen ischemic injury
release of chemical
mediatorIncreased ICP
Decreased PHNerve injury
Muscle necrosis
myoglobin
RF Death
Frequency
Mortality/Morbidity
depends on both the diagnosis and the time from injury to intervention… complete recovery of limb function if fasciotomy was
performed within 6 hours
SEX
HX
The traditional 5 Ps (ie, pain, paraesthesia, pallor, poikilothermia, pulselessness) are not diagnostic of CS. Literature warns that, with the exception of pain and paraesthesia, these traditional signs are not reliable, and the presence or absence of them should not affect injury management
Importantly, note that these symptoms assume a conscious patient who did not suffer any additional injury that hinders sensory input (eg, spinal cord injury
Determine the mechanism of injury.
-Long bone fracture -High-energy trauma
-Penetrating injuries (eg, gunshot wounds, stabbings) - Often cause arterial injury, which can quickly lead to CS
-Venous injury - May cause CS (do not be misled by palpable pulses)
Crush injuries
Anticoagulation therapy
1- simple venipuncture in an anticoagulated patient
2- MINOR TRUMA
Physical EXAM
passive stretching of the muscles, is the earliest clinical indicator of CS
SENSORY EXAM THEN MOTOR EXAMPLE deep peroneal nerve
(Etiology and diff)
lab
1- metabolic profile 2- creatinine/ urine myoglobin
3- serum myoglobin4- PT /PTT
5- urine analysis
imaging
1_x-ray2_u/s to rule out other diff
Compartment pressure measurement
the most helpful test and should be done ASAP
MANAGEMENT
1 _oxygen mask2 _don’t elevate the affected limb more
than 35 cm arterial pressue by 23 mmHg and no change in the ICP
3_hydaration 4_fasciotomy(definitive therpy)
when the fascitomy؟؟applied
Delta-p
Delta-p is a measure of perfusion pressure (diastolic blood pressure minus intracompartmental pressure). Originally used in dogs, delta-p measurements of less than 30 mm Hg were used by McQueen (1996) for fasciotomy. As a result, several patients with intracompartmental pressures of 40 mm Hg or greater were observed because the delta-p was greater than 30 mm Hg. Criteria were used in 116 patients without sequelae. The converse also is true, since patients with intracompartmental pressures less than 30 mm Hg but with high delta-p values have developed CS .
Complications
-Permanent nerve damage
-Infection -Loss of limb -Death
-Cosmetic deformity post fasciotomy
prognosis
Patient education
Patient education
Really we should apply this to all discharged pt .
THANKS FOR EVERY ONE