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SYNDROME(S)
• Acute compartment
syndrome
• « Volkmann’s
syndrome »
• Chronic exertion
syndrome: mostly sport
induced
HISTORICAL REVIEW
• Richard von Volkmann described the conditions of
irreversible contractures of the flexor muscles of the hand
because of ischemic processes occurring in the forearm.
Prolonged
pressure in
comatous
patients
PATHOPHYSIOLOGY
Diminution
of muscle
perfusion
Tourniquet
Arterial injury
PATHOPHYSIOLOGY
Muscular
(and nerve)
ischemia
PATHOPHYSIOLOGY
extravasation
of cellular fluid
= oedema
Increase pressure
Decreased
AV
pressure
gradient
PATHOPHYSIOLOGY
Increase
pressure
extravasation Diminution
of cellular fluid of muscle
= oedema perfusion
Muscular
(and nerve)
ischemia
Increase
pressure
extravasation Diminution
of cellular fluid of muscle
= oedema perfusion
Muscular
(and nerve)
ischemia
Vaillancourt C et al. Acute compartment syndrome: how long before muscle necrosis occurs? CJEM 2004;6(3):147–54
Sheridan GW, Matsen FA. Fasciotomy in the treatment of the acute compartment syndrome. JBJS Am 1976;58:112–5.
HOW TO MAKE AN EARLY DIAGNOSIS ?
• Think of it ! be afraid of it !
• Physical examination
• Ancillary tools
Bhattacharyya T, Vrahas MS. The medical-legal aspects of compartment syndrome. J Bone Joint Surg Am 2004;86-A:864–
PHYSICAL EXAMINATION: THE 6 P’S RULE
• Pain:
• Out of proportion
• « Crescendo pain », nor responsive to
analgesia
• On passive stretch of the muscles within
the compartment
• Paresthesiae (loss of sensation is a late
sign)
• Paralysis (late sign - muscle weakness is
more sensitive)
• Pallor:
• Pulselessness (very late sign)
• Poikilothermia : affected limb feels cooler Independently each sign
has a poor prognostic
value (< 20%)
Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma 2002;
16: 572-7.
Griffiths DL. Volkmann’s ischaemic contracture. Br J Surg 1940; 28:239 –260.
FOR HAND COMPARTMENT SYNDROME
• Thenar eminence:
• Hypothenar eminence:
• Tense compartment,
• Phlyctenulae in mirror,
• In children:
• Anxiety + increasing
analgesic requirement is a
very reliable indicator of
compartment syndrome.
Hand
PRESSURE MEASUREMENTS
• Absolute pressure: threshold is 30 mm
Hg
isonitril scintigraphy ? ☛ No
Whitesides TE, Haney TC, Morimoto K, Harada H. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop
Relat Res 1975; 113: 43-51.
McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br
1996; 78: 99-104
LIMITATIONS
• 38 physicians
Large TM, Agel J, Holtzman DJ, et al. Interobserver variability in the measurement of lower leg compartment pressures. J Ortho
Trauma 2015;316–21.
TREATMENT
• Protective measures:
• Thenar, hypothenar,
adductor pollicis, dorsal
interosseous (n = 4), volar
interosseous (n = 3).
• Incision begins and ends along the ulnar border of forearm and
is located along the radial border of mid forearm.
• Incise fascia/epimysium
longitudinally if muscles look
pale and tense after
fasciotomy
Chandraprakasam T, Kumar RA. Acute compartment syndrome of forearm and hand. Indian J Plast Surg. 2011; 44(2): 212–218.
TECHNICAL DIFFICULTIES
Chan PSH, Steinberg DR, Pepe MD, Beredjiklian PK. The significant of the three volar spaces in forearm compartment syndrome:
A clinical and cadaveric correlation. J Hand Surg 1998;23A:1077–81.
Nwakile I et al. A single volar incision fasciotomy will decompress all three forearm compartments: A cadaver study. Injury
2012;43:1949–1952
DORSAL INCISIONS
• Proximal landmark is approximately 4 cm
distal to the lateral epicondyle.
• In adults:
Kanj WW, Gunderson MA, Carrigan RB, et al. Acute compartment syndrome of the upper extremity in children: diagnosis,
management, and outcomes. J Child Orthop 2013;7(3):225–33.
Brostom LA, Stark A, Svartengren G. Acute compartment syndrome in forearm fractures. Acta Orthop Scand 1990;61: 50-53.
Ouellette EA, Kelly R. Compartment syndrome of the hand. J Bone Joint Surg 1996;78A:1515-1522.
IF UNTREATED ?
• Muscle necrosis,
• Ischaemic contracture,
• Infection,
Kalyani BS, Fisher BE, Roberts CS, et al. Compartment syndrome of the forearm: a systematic review. J Hand Surg Am 2011;36(3):
535–43.
CONCLUSION
• Early diagnosis ☞ Think of it