Many are interested in: "Compartment syndrome - what is it?" This pathology can be observed in all areas where the muscles are surrounded by strong fascia - this is the area of the buttocks, thighs, shoulders, lower back and back.
Compartment syndrome is a set of changes provoked by an increase in pressure in a limited area of the body. Depending on what provoked an increase in pressure inside the tissues, it is customary to single out an acute or chronic form of the disease.
Causes for the development of pathology
The most common causes of the development of the disease are:
- fracture;
- extensive soft tissue disorder;
- violation of the integrity of blood vessels;
- compression of the limb during positional compression;
- incorrectly applied plaster cast;
- burn;
- long traumatic operations.
In medicine, cases of injection of liquids under pressure into a vein or artery, as well as bites from poisonous snakes are mentioned.
A high risk of developing pathology exists with the introduction of blood thinning drugs, and in general withblood clotting disorder. Iatrogenic causes, inattentive attitude towards unconscious patients are not excluded.
Chronic form of the syndrome
Compartment-syndrome becomes chronic in the case of long-term repetitive physical activity. It is also associated with an increase in pressure in the tissues in the shin area. Intense physical activity that exceeds the permissible limit provokes an increase in muscle volume up to 20%, which causes compression in the corresponding segment. Compartment syndrome is often diagnosed in professional runners.
Pathophysiological basis
The pathophysiology of the syndrome is due to local tissue homeostasis under the influence of trauma, increased pressure inside the tissues and muscle sheaths, reduced blood flow in the capillaries, impaired venous outflow of blood, and then arterial inflow. Ultimately, tissue necrosis develops due to lack of oxygen.
Symptomatics
Symptoms of compartment syndrome, occurring in an acute form, are expressed in rapidly increasing swelling, which is determined by palpation (the degree of density of the affected area is established). Bubbles also appear, pain is noted during passive movement of the muscle (flexion and extension of the foot), sensitivity is lost.
It should be noted that the most striking sign of such a pathology as compartment syndrome is pain, the level of which indicates the intensity of damage. Often it is not possible to stop it even after the introductionnarcotic painkillers.
This symptom is also characteristic of gas gangrene.
Basic forms of compartment syndrome
Compartment syndrome can occur in two forms: abdominal and myofascial (local ischemia syndrome against the background of increased pressure).
Myofascial form is characterized by reduced muscle perfusion, ischemia, necrosis and development of contracture. The reasons for the increase in the level of pidfascial pressure lie in post-traumatic hematoma, inflammatory edema, positional compression, and progressive tumor.
Myofascial compartment syndrome is diagnosed by physical examination.
The following indicators are taken into account:
- time from injury to hospital admission;
- time since the appearance of puffiness;
- puffiness increase rate (within 6-12 hours after injury);
- duration of tourniquet application and prevention of ischemia (removal of the tourniquet for a short time).
The pains are deep throbbing. They are more intense than with normal damage, they are not stopped by immobilization of the damaged area and analgesics in conventional doses.
Pain occurs when the injured muscle is passively stretched. This changes the position of the fingers.
Method for measuring intratissue pressure
How is compartment syndrome diagnosed? Diagnosis of pathology is carried out using the Whiteside method (1975), which allowsmeasure interstitial pressure.
It suggests the use of:
- system including mercury manometer;
- three-way valve;
- injection needles with a diameter of at least 1 mm;
- tube systems;
- 20 ml syringe.
Currently, devices that conduct long-term monitoring are used to determine pidfascial pressure. The results obtained are compared with an indicator of cardiac pressure. The pressure in the myofascial space of the limb should not exceed 10 mm Hg. Art. The presence of compartment syndrome is established if the index of pidfascial pressure exceeds the critical mark by 40 mm Hg. Art. and below diastolic. Its increase within 4-6 hours can provoke ischemia.
Classification of myofascial shape
- Slight lesion - the distal segment of the limb is warm when felt. On the main arteries, the safety of the pulse is noted. The indicator of subfascial pressure at 40 mm Hg. Art. below diastolic.
- Medium lesion - the skin on the damaged area of the limb has a lower temperature than on a he althy one. There is hyperesthesia or anesthesia of the fingers of the limb. The pulse is weakly palpable. Subfascial pressure is the same as distolic.
- Severe defeat - the pulse of the main arteries is not palpable. Anesthesia of the fingers is noted. Subfascial pressure higher than diastolic.
Diagnostication
Compartment syndrome should be distinguished from damage to the main vessels, the presence of arterial thrombosis, damage to the nerve trunks from clostridial and non-clostridial myositis.
Differentiated diagnosis should be carried out in accordance with a number of criteria:
- presence of ripple;
- puffiness;
- lack of sensation in limb;
- blood poisoning;
- increased white blood cell count;
- pidfascial pressure indicator.
Forearm muscle injury
The muscles in the forearm are divided by fascia into three osseous-fascial compartments: lateral in the region of the radial muscle, anterior (muscles responsible for finger flexion) and posterior (muscles involved in finger extension).
If the patient cannot extend his fingers, then a diagnosis is made such as the anterior compartment syndrome of the forearm. If the patient cannot flex the fingers, then the back sheath is affected.
Shin muscle injury
The muscles of the lower leg are divided by fascia into four bone-fascial cases:
- lateral (peroneal muscles);
- front (responsible for foot extension);
- posterior (superficial soleus);
- rear deep (responsible for bending).
If the patient is unable to flex the foot and fingers, and the attempt to do so causes him acute pain, then we can talk about the presence of the anterior compartment syndrome, and if he cannot straighten the fingers, then this is the rear view.
Abdominal shape
Normal pressure in the abdominal cavity depends on body weight and is approximately zero. The abdomen is a reservoir for fluid, in which the pressure on the surface and in all areas is the same. Intra-abdominal pressure can be measured anywhere in the abdomen.
What are the risk factors for developing abdominal hypertension syndrome? The main reason is intestinal paresis, numerous injuries, urgent laparotomy in a patient who receives intensive infusion therapy. This leads to an increase in the volume of fluid in the abdomen.
In many patients after surgery in the abdomen, the pressure in its cavity increases by 3-13 mm Hg. Art. without any clinical signs
With abdominoplasty, the pressure inside the abdomen increases by 15 mm Hg. Art., which provokes the development of abdominal compartment syndrome.
At 25 mm Hg. Art. and more there is a failure in the blood flow through large vessels in the peritoneum, which leads to kidney failure and disruption of the heart and blood vessels.
Pressure in the abdomen above 35 mm Hg. Art. can cause complete cardiac arrest.
How does abdominal compartment syndrome manifest?
The abdominal compartment syndrome manifests itself in superficial labored breathing and a decrease in cardiac output. The presence of diuresis, blood saturation is also noted.
In medicine, there are four types of hypertension in the peritoneum:
- 1st degree - pressure indicator12-15 mmHg st.
- 2nd degree - pressure indicator 16-20 mm Hg. st.
- 3rd degree - a pressure indicator of 21-35 mm Hg. st.
- 4th degree - a pressure indicator above 35 mm Hg. st.
Methods for measuring pressure in the peritoneal region
Typically, pressure in the abdomen is measured through the bladder. A well-stretched wall acts as a passive conductor of intra-abdominal pressure if the volume of fluid in the peritoneum does not exceed 50-100 ml. With a large volume, the measurement is affected by the tension of the bladder muscles.
Therapy for Abdominal Syndrome
How is compartment syndrome treated? Treatment involves correcting or eliminating the causes (removal of compression underwear, high position of the head of the bed, sedatives). Oxygen therapy is carried out, in which a nasogastric tube is used.
To prevent hemodynamic decompensation, blood oxygen saturation is restored and coagulation is optimized. Monitoring of intraperitoneal pressure and other functions is also indicated.
Compartment syndrome in abdominal surgery is eliminated by decompression laparostomy. Bladder catheterization is carried out to increase the volume of the peritoneum.
Basic measures for conservative treatment
With conservative treatment, the following activities are carried out:
- compression of the affected area is eliminated (removal of bandages, plaster splints, weakening of the traction of the skeleton, locationof the affected limb at the same level as the heart, which prevents the development of ischemia);
- optimizes blood circulation, eliminates spasms in the vascular area and increased coagulation;
- improved blood rheology;
- painkillers are used (analgesics based on narcotic substances, as well as non-narcotic drugs);
- puffiness is removed;
- acidosis stops.
If conservative treatment does not bring the expected results, there is a level of subfascial pressure above the critical level, muscle tone and swelling are observed, then surgery is indicated (use of decompression fasciotomy). It can be curative or preventive.
What is a decompression fasciotomy?
Decompression fasciotomy is a surgical intervention aimed at preventing and relieving compartment syndrome. The operation is resorted to in case of damage to the artery and veins of the shoulder. It also eliminates the compartment syndrome of the medial component of the elbow joint, the consequences of injury to the fossa of the elbow and arteries and veins under the knee. Fasciotomy is mostly performed on the lower extremities.
Indications for prophylactic fasciotomy
The main indications include:
- presence of venous insufficiency;
- damage to the artery under the knee;
- failed reconstruction of the arteries;
- late holdingarterial reconstruction;
- pronounced swelling of the soft tissues of the limb.
Performing therapeutic fasciotomy
The operation is performed on patients with pronounced subfascial pressure, identified during the study. The indicator is above 30 mm Hg. Art. classified as pathological.
Increase in subfascial pressure is an absolute indicator for a medical operation.
The main indicators for such a surgical intervention are the following symptoms:
- presence of paresthesia;
- pain during passive limb movements;
- presence of paralysis with intact nerve;
- decreased peripheral pulse.
Caution
This operation should not be performed on the hip or shoulder area. Mannitol and antibiotics are prescribed at the discretion of the doctor.
Fasciotomy is an operation that can cause complications (infection, chronic pain, paresthesia, swelling, osteomyelitis). It should be noted that they appear infrequently, but the probability still exists. Therefore, a careful examination of the patient is required before the intervention.
Decompression fasciotomy in the forearm
Surgical intervention to eliminate a pathology such as forearm compartment syndrome involves the use of local anesthesia. The incision is made from the epicondyle to the wrist area. The fascia is opened over the flexor muscle in the elbow area. It moves medially. Superficial muscle responsible for flexionmoves laterally. The fascia is dissected above the deep flexor. The fascia of each muscle is opened with a longitudinal incision.
If necessary, the volar incision is supplemented with a dorsal one. Live muscle immediately swells. Her response hyperemia is observed.
The non-viable muscle (usually the flexor located in depth) is colored yellow, which is characteristic of necrosis. The fascia is not sutured. The skin wound is sutured without tension. If such a manipulation is not possible, then the skin wound is left open under a bandage.
For dressings, antiseptic agents or sorbents are used. In the future, water-emulsion ointments are used.
Secondary sutures are placed five days after surgery. Sometimes the wound remains open for a month. In some cases, additional laxative incisions or various types of plastic surgery are used to close the wound.
Technique for fasciotomy on the hand
The operation involves making a longitudinal incision in the area of the tenor of the first metacarpal bone. Such an incision is made parallel to the fifth carpal bone. In this case, the projection of the ulnar nerve does not intersect. Interosseous muscle decompression is performed from separate incisions on the back of the hand.
Fasciotomy on the lower leg
Shin compartment syndrome is eliminated by surgery using local anesthesia.
If the patient has difficulty bending the foot and fingers due to acute pain, thencan be judged on the presence of the anterior compartment syndrome. If he cannot straighten the lower leg, then this is the posterior compartment syndrome of the lower leg.
To open all cases, resort to two or three longitudinal incisions on the lower leg, the length of which is 15 cm. If necessary, the incision of the fascia can be Z-shaped.
If the blood circulation in the foot has not improved after a few minutes, then the medial incision is deepened, and the case located at the back is opened with scissors. The incision of this fascia is not performed with a scalpel, as it can damage the posterior tibial artery and tibial nerve.
The fascia incision remains open. If possible, the wound on the skin is sutured without tension. If suturing is not possible, the wound is left open under a dressing. Secondary sutures are usually placed after 5 days.
Technique for foot surgery
This operation requires four accesses. Two dorsal incisions are made along the 2nd and 4th metatarsals, through which the four spaces between the bones and the central sheath in the foot are exposed. A couple more incisions are made laterally and medially. They open the cases.
An operation carried out before muscle tissue necrosis has a high degree of efficiency. On the third day after decompression, swelling decreases, and wound closure becomes possible. If during decompression necrosis of muscle tissue was detected, then removal of the dead area is indicated. The final compression in this case is delayed for a week.
Disease prognosis
Forecastdisease is directly dependent on timely therapy and the full implementation of surgical intervention. If the pain stops, neurological disorders appear, then this, as a rule, indicates the irreversibility of pathological changes. Further implementation of necrectomy and other procedures is not able to save the limb, its amputation is indicated. In order not to bring the situation to an extreme, it is recommended to take all measures in a timely manner that are aimed at preventing the development of the compartment syndrome.
