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    Compartment Syndromes: Robert M. Harris, MD

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    Satrio Bangun Negoro
    The document discusses compartment syndrome, including its definition, historical context, pathophysiology, diagnosis, treatment with fasciotomy, and considerations for different body areas like the leg and forearm. Compartment syndrome is caused by elevated tissue pressure within a closed fascial space and can lead to permanent tissue damage if not treated urgently with a fasciotomy.

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    Compartment Syndromes: Robert M. Harris, MD

    Uploaded by

    Satrio Bangun Negoro
    5 views31 pages
    The document discusses compartment syndrome, including its definition, historical context, pathophysiology, diagnosis, treatment with fasciotomy, and considerations for different body areas like the leg and forearm. Compartment syndrome is caused by elevated tissue pressure within a closed fascial space and can lead to permanent tissue damage if not treated urgently with a fasciotomy.

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    G04-Compartment Syndrome

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    The document discusses compartment syndrome, including its definition, historical context, pathophysiology, diagnosis, treatment with fasciotomy, and considerations for different body areas like the leg and forearm. Compartment syndrome is caused by elevated tissue pressure within a closed fascial space and can lead to permanent tissue damage if not treated urgently with a fasciotomy.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    5 views31 pages

    Compartment Syndromes: Robert M. Harris, MD

    Uploaded by

    Satrio Bangun Negoro
    The document discusses compartment syndrome, including its definition, historical context, pathophysiology, diagnosis, treatment with fasciotomy, and considerations for different body areas like the leg and forearm. Compartment syndrome is caused by elevated tissue pressure within a closed fascial space and can lead to permanent tissue damage if not treated urgently with a fasciotomy.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 31

    Compartment

    Syndromes

    Robert M. Harris, MD
    Compartment Syndrome
    Definition
    • Elevated tissue pressure within a closed fascial
    space
    • Reduces tissue perfusion
    • Results in cell death
    • Pathogenesis
    – Too much inflow (edema, hemorrhage)
    – Decreased outflow (venous obstruction, tight
    dressing/cast)
    Compartment Syndrome
    Historical Review
    • Late complications of ischemic contracture
    – Volkmann, 1881
    • Ischemia of forearm
    venous stasis leading
    to irreversible contracture
    – Ellis, 1958; Seddon, 1966
    • Lower extremity
    • Retrospective reviews
    – Advised the early recognition of the syndrome and
    fasciotomies of the affected limbs
    Compartment Syndrome
    Pathophysiology
    • Normal tissue pressure
    – 0-4 mm Hg
    – 8-10 with exertion
    • Absolute pressure theory
    – 30 mm Hg - Mubarak
    – 45 mm Hg - Matsen
    • Pressure gradient theory
    – < 20 mm Hg of diastolic pressure – Whitesides
    – McQueen, et al
    Compartment Syndrome
    Tissue Survival

    • Muscle
    – 3-4 hours - reversible changes
    – 6 hours - variable damage
    – 8 hours - irreversible changes
    • Nerve
    – 2 hours - looses nerve conduction
    – 4 hours - neuropraxia
    – 8 hours - irreversible changes
    Compartment Syndrome
    Etiology

    • Fractures-closed and open • Exertional states


    • Blunt trauma • GSW
    • Temp vascular • IV/A-lines
    occlusion • Hemophiliac/coag
    • Cast/dressing • Intraosseous IV(infant)
    • Closure of fascial • Snake bite
    defects • Arterial injury
    • Burns/electrical
    Compartment Syndrome
    Diagnosis
    • Pain out of proportion
    • Palpably tense compartment
    • Pain with passive stretch
    • Paresthesia/hypoesthesia
    • Paralysis
    • Pulselessness/pallor
    Compartment Syndrome
    Differential diagnosis

    • Arterial occlusion

    • Peripheral nerve injury

    • Muscle rupture
    Compartment Syndrome
    Pressure Measurements

    • Suspected compartment syndrome


    • Equivocal or unreliable exam
    • Clinical adjunct
    • Contraindication
    – Clinically evident compartment
    syndrome
    Compartment Syndrome
    Pressure Measurements
    • Infusion • Arterial line
    – manometer – 16 - 18 ga. Needle
    – saline (5-19 mm Hg higher)
    – 3-way stopcock – transducer
    (Whitesides, CORR – monitor
    1975)
    • Stryker device
    • Catheter – Side port needle
    – wick
    – slit wick
    Compartment Syndrome
    Pressure Measurements
    • Arterial line
    – Zero at the
    level of the
    affected limb
    Compartment Syndrome
    Pressure Measurements
    • Needle
    – 18 gauge
    – Side ported
    • Catheter
    – wick
    – slit wick
    • Performed within 5
    cm of the injury if
    possible-
    Whitesides,
    Heckman Side port
    Compartment Syndrome
    Emergent Treatment

    • Remove cast or dressing


    • Place at level of heart
    (DO NOT ELEVATE to optimize
    perfusion)
    • Alert OR and Anesthesia
    • Bedside procedure
    • Medical treatment
    Compartment Syndrome
    Surgical Treatment
    • Fasciotomy - prophylactic release
    of pressure before permanent
    damage occurs. Will not reverse
    injury from trauma.
    • Fracture care – rigid
    stabilization
    – Ex-fix
    – IM Nail
    Compartment Syndrome
    Indications for Fasciotomy
    • Unequivocal clinical findings
    • Pressure within 15-20 mm hg of DBP
    • Rising tissue pressure
    • Significant tissue injury or high risk pt
    • > 6 hours of total limb ischemia
    • Injury at high risk of compartment
    syndrome
    • CONTRAINDICATION - Missed CS (>24-
    48 hrs)
    Fasciotomy Principles
    • Make early diagnosis
    • Long extensile incisions
    • Release all fascial compartments
    • Preserve neurovascular structures
    • Debride necrotic tissues
    • Coverage within 7-10 days
    Compartment Syndrome
    Forearm Anatomy

    • Anatomy-3 compartments
    – Mobile wad-BR,ECRL,ECRB
    – Volar-Superficial and deep flexors, Pronator
    teres, Supinator
    – Dorsal-Extensors
    Forearm Fasciotomy

    • Volar-Henry approach
    – Include a carpal tunnel
    release
    • Release lacertus
    fibrosus and fascia
    Forearm Fasciotomy
    • Protect median nerve,
    brachial artery and
    tendons after release
    • Consider dorsal
    release
    Compartment Syndrome
    Leg Anatomy
    • 4 compartments
    – Lateral: Peroneus longus and brevis
    – Anterior: EHL, EDC, Tibialis anterior,
    Peroneus tertius
    – Posterior-Gastrocnemius, Soleus
    – Deep posterior-Tibialis posterior, FHL, FDL
    Leg Fasciotomies
    • Generous skin
    incisions
    – medial
    – lateral
    • Release completely all
    4 fascial
    compartments
    • Beware of
    neurovascular
    structures to prevent
    iatrogenic injury
    Fasciotomy: Medial Leg

    Gastroc-soleus

    Flexor digitorum
    longus
    Fasciotomy: Lateral Leg

    Intermuscular septum

    Superficial peroneal nerve


    Compartment Syndrome
    Thigh
    • Lateral to release
    anterior and
    posterior
    compartments
    Vastus lateralis
    • May require medial
    incision for
    adductor
    compartment

    Lateral septum
    Compartment Syndrome
    Foot
    • Four major compartments
    • Multiple layers
    • Careful exam with any swelling
    • Clinical suspicion with certain mechanisms
    of injury
    – Lisfranc fracture dislocation
    – Calcaneus fracture
    Compartment Syndrome
    Foot Fasciotomies
    • Dorsal incision-to
    release the
    interosseous, central
    and lateral
    compartments
    • Medial incision-to
    release the medial
    compartment
    Compartment Syndrome
    Other Areas
    • Can occur anywhere in the body
    • Hand-dorsal incisions, thenar, hypothenar
    • Arm-lateral incision
    • Buttock-posterior (Kocher) approach
    • Abdominal- with the Trauma surgeons
    Interim Coverage Techniques

    • Simple absorbent dressing


    • Semipermeable skin-like
    membrane
    • Vessel loop “bootlace”
    • Sutures progressively
    tightened in ensuing days
    • “VAC” (Vacuum Assisted
    Closure)
    Aftercare
    • Wound is not closed at initial surgery
    • Second look debridement with consideration for
    coverage after 48-72 hrs
    – Limb should not be at risk for further swelling
    – Pt should be adequately stabilized
    – Usually requires skin graft
    – DPC possible if residual swelling is minimal
    • Goal is to obtain definitive coverage within 7-10
    days
    – DPC/STSG/flap if nerves, vessels, bone exposed
    Compartment Syndrome
    Medical-Legal
    • Most frequent cause of litigation

    • 1992-average award $225K-Hennepin


    County, Minn.
    • Medical health care providers
    • Lawyers
    • Mass media
    Questions

    Return to
    General Index

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