So we've got compartment syndrome next. It's very, very different. All right, so I need to thank Dr. Hausman for allowing me to build this year's talk off of his last year's talk for compartment syndrome. So all right, compartment syndrome, we all know it's an issue with pressure. But basically, what it comes down to is increased pressure in a compartment relative to the perfusion pressure, which is going to keep all the cells alive. And this can happen three ways. You can either have some condition, like a broken bone that markedly increases the pressure in the compartment. Or you can have something that cuts down on the pressure perfusing, that somebody's hypotensive for some reason. Or you can have external pressure causing this pressure within the compartment, like a very tight cast. But either way, you get this loss of pressure differential. The perfusion gets compromised. Cells get hypoxic. Then they get damaged. And when cells die, they release further cytokines and things that will increase the pressure and cause further problems. So what matters? How much pressure is being applied or is present? Number two, what's the duration? How long has it been there? If you look at the old work from White Sides, four hours of ischemia damaged about 5% of the muscle cells. Eight hours kills them all. And then you need to think about the severity and extent of any soft tissue injury. So our understanding of compartment syndrome has really evolved gradually over time. They've known about it for a long time. So in the 1880s, it was described. In the early 1900s, people described fasciotomies. And then later, we get to the kind of famous five or six P's that describe compartment syndrome. So what incites this? I think we're all familiar with this list, the most common fractures being supercondylar fractures in children or knee dislocations, both of which can cause vascular issues resulting in compartment syndrome, or both one fractures and crush injuries. We just need to maintain a high index of suspicion especially in those cases where there's not a fracture. We don't always think about the poor perfusion as being a contributor. So here's our six P's. Number one is pain. That's always the first one. That's always the one they're gonna lead with in the question stems, the pain with passive extension. Parasthesis would likely come next. It takes a little bit longer for the nerves to get involved. If you're relying on pulselessness or pallor or paralysis, it's way too late. Okay, so here's a question. There was a study on this. Is palpation of hand compartments just by feel sufficient to detect compartment syndrome in the hand? What do you guys think? Yes? No? All right, we got some no's. So the answer was no according to the study in JHS in 2015. And they actually had 17 assessors looking at a cadaver model where they could vary the pressure. And basically, when you just palpated the thenars or hyperthenars, surgeons were fairly poor. We weren't good enough to say that we should rely on it. But using a manometer was much better. Okay, so pressure criteria. I know there was a question on this year's self-assessment about this. I wasn't aware that there was a true consensus answer for this question. But basically, some people have said absolute pressures over 30 or 45 millimeters of mercury within a compartment. Other people have relied more on differential pressures, say getting within 20 to 30 millimeters of the diastolic pressure, or getting within 30 millimeters or so of the mean arterial pressure. But somewhere in this range is the definition. And just so you know, there's no one pressure measuring technique or device that has been proven superior. Okay, so for kids with pediatric compartment syndrome, pain is the most consistent finding, okay? The other things are a little bit harder to discern in terms of paresthesia. Most commonly, we talked about the supracondylar fracture. And you gotta remember the communication barriers because children are almost like an impaired adult sometimes. They don't know how to communicate that their hand is numb, or they may have some of these other things. So you just have to maintain a high index of suspicion. But in the pediatric patient, the elementary school child, it's usually that very uncomfortable child just can't get comfortable. They're requiring more pain meds. Something like this needs to come to mind. Fraser Leversedge in 2011 actually wrote a very nice review paper I'd recommend if you wanted to read some review on this topic. It was in the Journal of Hand Surgery. And kind of described some stages where there's an incipient stage where the pressures are up, but not really at a critical level. And then there's that early acute stage, probably in the first eight hours where if you recognize it, they have a legitimate compartment syndrome. If you release it, we've all done those where you open it up, the muscle, everything's healthy, it just needed to be released. Then there's that acute but non-reversible. Some of those muscle is already starting to get necrotic, maybe not all of it, but some of it. Then there's later issues where people come in a few days later with the compartment syndrome where you have a lot of muscle loss. And then there's the very late Volkman's contracture. And then I think exertional compartment kind of fits into another category altogether. So the treatment, as we all know, is fasciotomies. You just gotta make sure, okay, we got it in the forearm, we got flexors, extensors, and mobile wad. There are some advocates of releasing some more individual muscles that may or may not have sort of extra fascia around them or their own little compartments, such as the ECU or pronator quadratus. And then in the hand, it's always thenar, hypothenar, interossei, and adductor, and then carpal tunnel and the individual fingers if needed. So I think everybody can pick their own incisions they like. I like the one on the top left. I like the nice big curve going medial at the elbow if there is not another wound. The hand compartments, I think most of us probably do something similar to this, at least for the interossei and adductor where you go between the metacarpals to get to them. Post-fasciotomies, the concern is colonization. Pseudomonas has been listed as one of the most common organisms for that. There's multiple ways to try to keep them clean or covered. I think there's a lot of wound vacs nowadays, I know. I kind of like the shoelace trick. I know that doesn't fit on a test, but just giving a little bit of traction to the skin edges, say, underneath a vac. And then there's been recommendations to repeat washout every 48 hours or so with some sort of prompt coverage or closure if possible. For Volkman's contracture, you know, this is far later. You've sort of missed the opportunity to decompress so there's no longer any urgency. And in the hand, we've all seen it with the form issues. You end up with that intrinsic minus characteristic MP hyperextension, PIP flexions. So with Volkman's, often advanced imaging's gonna be used to look for any muscle viability. And then depending on what the nerve symptoms are, there's probably an extensive tenolysis, neuralysis, and then either tendon transfers from ones that are working or free muscle bringing in, I know the tests like to ask a lot about bringing in free gracilis to restore flexion. This is another one that could show up on a test that I think is important for life is the newborn compartment syndrome. This doesn't happen very much. There was one review in Journal of Hand Surgery reviewing the 24 cases that had been published in the 20 years leading up to the year 2000. But basically, these are the kids in the NICU who you get called about with that very swollen, unhealthy looking arm slash hand where they're worried about perfusion, things don't look right, and they often have this little eschar either on the forearm or upper arm that is almost pathognomonic for this sort of in utero compartment syndrome. And really to sort of save the arm or hands, this requires the fasciotomies which usually can be done at the bedside in the NICU when the young children are pretty sedated and not very aware of what's going on. But it's an important one to recognize and I think it's an easy picture to show on a test to say, hey, what's this diagnosis or what needs to be done next? And the answer is fasciotomies. Okay, a couple questions here from the self-assessment exams. So in Volkman's ischemic contracture, which muscles are first affected? I think it's usually the deep flexors as opposed to the more superficial muscles. Oh, this one's a small print. It was a big, long question. But basically, you have a 35-year-old woman with Volkman's contracture. She's a year after therapy. She's got good sensation. She's got active extension. She doesn't have flexion. But they're giving you that she's got near full passive range of motion. So they want to know what's the way to get active flexion back in the hand? So fasciotomy's not the answer. It's too late. Fregrosillus could be. Lengthening flexor pronator muscle origin. Now that might be useful if we have contracture and we need to release to get passive extension, but not to give active flexion. Lengthening the flexor tendons. Again, that helps for contracture, not active flexion. And then motor nerve transfers, it's going to be tough down in the form if the nerves have been actually damaged themselves. So fregrosillus is going to be the answer there. All right, we had a lot of Volkman's questions in the last couple of years. 23-year-old male, six months out from a drug overdose, has these contractures. Has MP joint flexion contractures. They want to know the best surgical procedure. And I think when they're talking about the contractures, you're usually looking for release. And at least for me, then I'm looking for intrinsic muscle release. And I think that the answer on this one ended up being proximal intrinsic release because a distal intrinsic release was not expected to correct the MP joints. So that was part of the STEM giving you where they wanted you to go. So here's kind of the short bibliography of a couple of the articles if you ever wanted to look into it more. But hopefully I'll get you the answers for those few questions on compartment syndrome. Thanks.

compartment syndrome

blood flow

soft tissue injury

Volkman's contracture

surgical procedures