hassan_noaman

أ. د حسان النعمانى

استاذ - رئيس الجامعة - جامعة سوهاج

كلية الطب

العنوان: العنوان الشخصى : ش الجمهورية بسوهاج -عنوان العمل : مبنى الادارة المركزية - الدور الثالث -جامعة سوهاج

31

إعجاب

Hand & Forearm Compartment Syndrome

2018-10-31 02:53:51 |
Introduction
  • Increased osseofascial compartment pressure leads to  decreased perfusion
  • May lead to irreversible muscle and nerve damage
  • May occur anywhere that skeletal muscle is surrounded by fascia, but most commonly
    • leg
    • forearm (details below)
    • hand (details below)
    • foot
    • thigh
    • buttock
    • shoulder
    • paraspinous muscles
  • Pathophysiology
    • local trauma and soft tissue destruction> bleeding and edema > increased interstitial pressure > vascular occlusion > myoneural ischemia
  • Causes
    • trauma
      • fractures (most common)
        • distal radius fractures in adults
        • supracondylar humerus fracture in children
      • crush injuries
      • contusions
      • gunshot wounds
    • tight casts, dressings, or external wrappings
    • extravasation of IV infusion
    • burns
    • postischemic swelling
    • bleeding disorders
    • arterial injury
  • Outcomes
    • may lead to
      • loss of function
      • Volkmann ischemic contracture
      • neurologic deficit
      • infection
      • amputation
Anatomy
  • Forearm compartments 
    • 3 in total
      • volar
        • most commonly affected
      • dorsal
      • mobile wad (lateral)
        • rarely involved
        • muscles
          • brachioradialis 
          • extensor carpi radialis longus 
          • extensor carpi radialis brevis 
  • Hand compartments 
    • 10 in total
      • hypothenar
      • thenar
      • adductor pollicis 
      • dorsal interosseous (x4) 
      • volar (palmar) interosseous (x3) 
Presentation
  • Symptoms 
    • pain out of proportion to clinical situation is usually first symptom
      • may be absent in cases of nerve damage
      • difficult to assess in
        • polytrauma 
        • sedated patients
        • children
  • Physical exam
    • pain w/ passive stretch of fingers 
      • most sensitive finding
    • paraesthesia and hypoesthesia
      • indicative of nerve ischemia in affected compartment
    • paralysis
      • late finding
      • full recovery is rare in this case
    • palpable swelling
      • tense hand in intrinsic minus position 
        • most consistent clinical finding
    • peripheral pulses absent
      • late finding
      • amputation usually inevitable in this case
Evaluation
  • Radiographs
    • obtain to rule-out fracture
  • Compartment pressure measurements post
    • indications
      • polytrauma patients
      • patient not alert/unreliable
      • inconclusive physical exam findings
    • relative contraindication
      • unequivocally positive clinical findings should prompt emergent operative interventionwithout need for compartment measurements
    • threshold for decompression
      • controversial, but generally considered to be
        • absolute value of 30-45 mm Hg
        • within 30 mm Hg of diastolic blood pressure (delta p)
          • intraoperatively, diastolic blood pressure may be decreased from anesthesia
            • if delta p is less than 30 mmHg intraoperatively, check preoperative diastolic pressure and follow postoperatively as intraoperative pressures may be low and misleading 
Treatment
  • Nonoperative
    • indications
      • exam not consistent with compartment syndrome
      • delta p > 30
  • Operative
    • emergent forearm fasciotomies 
      • indications
        • clinical presentation consistent with compartment syndrome
        • compartment measurements with absolute value of 30-45 mm Hg
        • compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
          • intraoperatively, diastolic blood pressure may be decreased from anesthesia
            • must compare intra-operative measurement to pre-operative diastolic pressure
    • emergent hand fasciotomies 
      • indications
        • clinical presentation consistent with compartment syndrome
        • compartment measurements with absolute value of 30-45 mm Hg
        • compartment measurements within 30 mm Hg of diastolic blood pressure (delta p)
          • intraoperatively, diastolic blood pressure may be decreased from anesthesia
            • must compare intra-operative measurement to pre-operative diastolic pressure
Surgical Techniques
  • Forearm
    • emergent fasciotomies of all involved compartments 
      • approach
        • volar incision     
          • decompresses volar compartment, dorsal compartment, carpal tunnel
            • incision starts just radial to FCU at wrist and extends proximally to medial epicondyle
            • may extend distally to release carpal tunnel
        • dorsal incision 
          • decompresses mobile wad
            • dorsal longitudinal incision 2cm distal to lateral epicondyle toward midline of wrist
      • technique
        • volar incision
          • open lacertus fibrosus and fascia over FCU
          • retract FCU ulnarly, retract FDS radially
          • open fascia over deep muscles of forearm
        • dorsal incision
          • dissect interval between EDC and ECRB
          • decompress mobile wad and dorsal compartment
      • post-operative
        • leave wounds open 
          • wound VAC
          • sterile wet-to-dry dressings
        • repeat irrigation and debridement 48-72 hours later
          • debride all dead muscle
          • possible delayed primary wound closure
          • VAC dressing when closure cannot be obtained
            • follow with split-thickness skin grafting at a later time 
  • Hand
    • emergent fasciotomies of all involved compartments
      • approach  
        • two longitudinal incisions over 2nd and 4th metacarpals  
          • decompresses volar/dorsal interossei and adductor compartment
        • longitudinal incision radial side of 1st metacarpal 
          • decompresses thenar compartment
        • longitudinal incision over ulnar side of 5th metacarpal
          • decompresses hypothenar compartment
      • technique
        • first volar interosseous and adductor pollicis muscles are decompressed through blunt dissection along ulnar side of 2nd metacarpal
      • post-operative
        • wounds left open until primary closure is possible
          • if primary closure not possible, split-thickness skin grafting is used
Complications
  • Volkman's ischemic contracture 
    • irreversible muscle contractures in the forearm, wrist and hand that result from muscle necrosis
    • contracture positioning
      • elbow flexion
      • forearm pronation