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Compartment Syndrome
Compartment Syndrome
Compartment Syndrome
Compartment syndrome: Interstitial tissue pressures within osteofascial compartments are elevated to sustained, non-physiologic pressures. Can be caused by fractures, soft tissue injury, compression, arterial injury, reperfusion, snakebites, electrical burns, infections, hematologic disorders, tourniquets, casts or dressings, intraoperative positioning, or even exercise.
Pathophysiology: increased compartment pressures → venous outflow obstruction
→
increased capillary permeability
→
further increase in compartment pressures
→
arterial obstruction and decreased tissue oxygenation
→
reversible and then irreversible ischemia
Anatomic compartments
◊
Brachium: Deltoid (anterior, middle, and posterior); anterior; and posterior
◊
Antebrachium: Dorsal; volar; and mobile wad
◊
Hand: Carpal tunnel / distal ulnar tunnel; thenar; hypothenar; dorsal and palmar interosseous; and digital
Diagnosis is made clinically – pain with passive stretch (or pain out of proportion), paresthesias (subjective numbness
→
hypesthesias to light touch
→
motor weakness
→
anesthesia), pallor, paralysis, and pulselessness
◊
Differential diagnosis: Arterial insufficiency (will not have pain), acute carpal tunnel syndrome, nerve lacerations (typically will not have pain or swelling)
Objective testing
◊
Needle manometry, indwelling wick catheter, slit catheter, or Stryker hand-held manometer
◊
Abnormal if absolute value is over 40 mm Hg, or if within 30 mm Hg of the diastolic blood pressure. Normal pressure is 0-
12 mm Hg.
◊
Indicated in patients who are unreliable or uncooperative, unresponsive / obtunded, or with neurologic deficits from
other conditions.
Treatment – Emergent surgical decompression / fasciotomies
◊
Debride nonviable / devitalized structures
◊
Decompress subcompartments and perform epimysiotomy to maximize tissue viability
◊
Use caution when closing skin primarily
◊
Forearm
♦
Volar incision (Henry approach) is used to release lacertus fibrosus, pronator quadratus, deep flexors, and carpal tunnel.
♦
Dorsal incision is also longitudinal to mid-distal third; preserve extensor retinaculum.
◊
Hand
♦
Carpal tunnel release
♦
Two dorsal longitudinal incisions (index-long and long-ring) to release septae between dorsal and palmar interossei
♦
Longitudinal incision on radial thumb (thenar compartment) and ulnar hand (hypothenar compartment)
♦
Release adductor pollicis through incision perpendicular to skin crease of thumb-index web space
◊
Digits
♦
Index, long, and ring through ULNAR midaxial incision
♦
Thumb and small fingers through RADIAL midaxial incision
Post-op: Elevate extremity, consider functional orthosis and early ROM, and return to OR at 48 hours for re-evaluation and repeat debridement. Multiple debridements may be needed before closure.
Late diagnosis – see irreversible ischemic changes. Surgery may not be indicated in subacute phase (risk of infection).
Summary
Availability:
On-Demand
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