Next up is Dr. Milan Stevanovic from USC who is an extremely talented surgeon and tremendous teacher who will speak to us about fasciotomies for compartment syndrome. Good afternoon ladies and gentlemen, thanks for a very difficult job guys that you have. So today my charge is to talk about treatment of the compartment syndrome and tell you how we do that to avoid day in court because that's the nerve injury, the second most difficult problem that we are facing. Etiology of the compartment syndrome are usually decreased in compartment size where a tight cast of dressing results in compression of the compartments. This five year old kid autistic was restrained, fortunately six hours later we found that he had a compartment syndrome, released everything and I saw a kid about a year and a half later with excellent functional outcome. So he doesn't cooperate well. It's not the same with this young girl of six years who had a small tip injury of the fingers and coban dressing and seven days later end up with a problem like this. Not only decrease the compartment size but also increase compartment volume can be seen very often. Two years old girl with rubber band was put around the wrist, next morning was seen in emergency room so everything was released and she has excellent functional outcome. This can be also seen in patient who never had any trauma, just had a blood draw with formation of the hematoma or some blood dyscrasia patient like this young kid with hemophilia problem. So clinical diagnosis we know that pain is the most useful clinical sign and the pressure and all P's are in adults like pale or paresthesia but all come later on when compartment is developed. However, in pediatric patients we agree with the next coming president that really A is not the P's. It's anxiety, agitation, and algesia that you have to be careful with. I cannot say that the defining moment whether a patient will be taken to war or not is the pressure of the tissue but sure is one of the components that we consider. So this is how many compartments over 20 you have on the upper extremity. So I'll just show you that we use for the treatment extensile approach starting from the medial side above the elbow going on the radial side of the carpal tunnel. We also would like to release all the compartments of the hand including the fingers because we think the hemotomy is very important that not many surgeons consider because you don't have the muscles there. So dissecting all these compartments we do the dorsal approach for the straight line for the extensors and for the tenar and hypotenar muscles. That's the line incision that we make. It is important that the carpal tunnel should be included in this extensile approach and you can extend the carpal tunnel as much as the metacarpophalangeal joints to release all the three or internal muscle of war that you have in the hand. It's important to release all the fascia of the superficial extended as you can see here. Actually, we like to do episiotomy of the muscles to release the fascia of the muscles. The most common compartment that was missed here is the deep compartment. Get to the deep compartment of the ulnar side where you push aside the flexor carpe dialis and you also have a ulnar artery, ulnar nerve. So after releasing all of these fascias, you be sure that this muscle will be safe. Otherwise, if muscle are swollen and you don't release all the fascia on the top of the muscles, you're really looking very fast changes of the muscle fibers. Sometimes we need to extend especially the kids with supracondylar fractures more proximally. You be sure that brachial artery and the median nerve are patent. You can also release the compartment of the biceps muscle as you can see here. So the median nerve should be free and be sure that you expect that the brachial artery as well as median nerve just were entering the superficialis arch. That's the common place where muscle nerve will be affected. Distally as you see here, we'll be sure we're releasing the carpal tunnel not to cut the motor branch. On just straight incision on the dorsal side, you can release all mobile wall and on the ulnar side incision for a hypotenar muscles, we allowed you about two to half inch incision to completely release all the fascia from the muscles on the hypotenar area. As well as on the tenar area, we prefer to have an incision next to the first metacarpal. Don't forget ever to release the first dorsal interosseous as well as the IAD doctor to the thumb. As far as the dorsal intrinsic muscles of the hand, we did two incisions between second and third metacarpal as well as between the fourth and fifth metacarpal will give you enough room that you can release all these muscles from the dorsal side. Try to save the veins because important this patient has good outflow. As far as the dermatomy of the thumb, we like to do this on the lateral side, radial side and release not only the skin but also releasing the Grayson and the ligament or Cleveland ligament to be sure the pedicle is not compressed because the mistake will be made if you don't do that. So we have now incision for the small and ring finger on the radial side which is reverse for the index finger and middle finger. They should be on the ulnar side because you don't like to have an incision on the pinch side of the fingers. So if you treat patients like this, 69 years old, severe crash injury, almost no circulation, systole, forearm fracture as you can see here. We release everything from the dorsal side. The forearm will be released as we previously said with incision like this and if you cannot close the skin, just feel everything inside. Cover with a skin graft and this is nine months later, full function, full flexion, full extension. Unfortunately, this young fellow who is 380 pounds who was slept on the hand over the night. I saw him about four weeks ago. We released all this hand. He is a diabetic patient and despite that, he already has a significant impairments of the human hand. Why is it important to do dermatomy? Because this patient had a four-finger dermatomy but the surgeon considered the thumb is not really indicated and look later on, this patient end up with distal, losing the distal phalanx of the thumb. So finally, at the end, neonatal compartment syndrome is more commonly seen and Sentinel notes should be treated emergency to the OR. As you can see here, the compartment progressed very fast and this fellow even didn't know how to do dermatomy for the fingers but was able to save this hand and forearm. So in summary, you have to recognize the condition that lead to compartment syndrome. The certain clinical signs have high risk and when compartment syndrome is present, please treat this promptly. Thank you. Milan, Milan, before you go, Milan, do you do digital in all patients now? All patients that have a swelling of the fingers, digital dermatomy should be done. Only if they have swollen fingers. Thanks. That was terrific. Always a great speaker, Milan.

compartment syndrome

fasciotomies

decreased compartment size

increased compartment volume

clinical signs