Acute compartment syndrome and volkmann's ischemic contracture
1. Acute compartment syndrome and
Volkmann's ischemic contracture
By Dr /Mustafa Siddig Elmahi
MD orthopedic surgery .
Sudan
29/aug/1439-15/may/2018
3. Historical background & definitions:
Volkmann’s ischemic contracture, described in
1881 by Richard van Volkmann.
In 1888, Petersen for the first time reported
the management of ACS with fasciotomy.
4. Hix cont……
ln 1875, Volkmann described a deformity of the hand
and wrist resulting from an interference of some
nature with the blood supply of the muscles of the
forearm.
5. In his classical article published in1881, Volkmann said
that he believed the affection was due to ischemia
caused by the muscular tissue being deprived of
arterial blood in consequence of which the muscle
perished from want of oxygen.
6. Definitions
Compartment syndrome is defined as a condition in
which a closed compartment’s pressure increases to
such an extent that the microcirculation of the
tissues in that compartment is diminished.
9. Epidemiology
Schwartz et al reported a mortality rate of 47% after
ACS of the thigh .
The average annual incidence of ACS has been
estimated form 1 to 7.3 per 100,000 in USA.
The most common site of ACS is leg followed by
forearm, arm, thigh, foot, gluteal region, hand, and
abdomen. Incidence of ACS in open and closed
fractures is equal .
10. Many surgeons think that open fractures naturally decompress
the compartment and may not be as prone to compartment
syndrome as closed fractures. But the small fascial tears that
usually result from open fractures do not adequately decompress
the compartment.
11. Anatomy
The upper extremity contains about 16 compartments.
The upper arm consists of a flexor (i.e., volar)
compartment and an extensor (ie, dorsal)
compartment.
12. Anatomy cont..
There are four interconnected compartments of the
forearm recognized: the superficial volar compartment
which contains the flexor carpi ulnaris, palmaris
longus, flexor carpi radialis and pronator teres.
The intermediate layer contains flexor digitorum
superficialis only.
The deep volar compartment, which contains flexor
digitorum profundus (FDP), flexor pollicis
longus(FPL) and pronator quadratus.
The dorsal compartment of the forearm is commonly
known as the extensor muscles.
17. Figure 5: The deep dorsal forearm muscles compartment
18. Anatomy cont..
The hand has 10 compartments: hypothenar, thenar, an
adductor pollicis as well as four dorsal interosseous
and three volar interosseous.
The blood supplyof the hand is provided by branches
from the deep and superficial arches which are fed by
the radial and ulnar arteries, respectively .
20. Pathophysiology:
Normal mean interstitial tissue pressure is near zero in
non-contracting muscle. If this pressure becomes
elevated to 30 mmHg or more, small vessels in the
tissue become compressed, which leads to reduced
nutrient blood flow, ischemia and pain.
21. Patho cont..
ACS develops when the intra-compartmental pressure
(ICP) exceeds the venous capillary pressure.
Elevated ICP results in raised pressure at the venous
capillary end and increases hydrostatic pressure,
leading to arteriolar compression .
22. Muscle necrosis occurs after 4 hours of
ischemia which is followed by fibroblastic
proliferation within the muscle infarct .
Heckman et al demonstrated that irreversible
changes to the peripheral nerves and skeletal
muscle occur following 8 hours of complete
ischemia .
23. Con..
Nerve is capable of regeneration but muscle, once
infarcted, can never recover and is replaced by inelastic
fibrous tissue. Peripheral nerves are secondarily
compressed by surrounding necrotic muscle mass. This
neuropathy can also lead to chronic pain, paresthesias
and loss of limb sensibility apart from motor paralysis .
24. Pathophysiology of VIC :
Is a sequela of untreated or inadequately treated
compartment syndrome in which necrotic muscle and
nerve tissue has been replaced with fibrous tissue.
25. Extent of muscle death is dependent on the
duration of ischemia, temperature of the
tissues, and the available residual
microcirculation. Sufficient collateral blood
supply and lower local temperature slows
down the ischemic process .
39. S/S CONT..
The first sign of nerve ischemia is paraesthesia which
is followed by hypoaesthesia, anaesthesia, paresis, and
paralysis .
Sensory assessment should be done by pinprick
testing, light touch, and two-point discrimination in
awakened patients. Motor deficit in the affected limb
can be due to ischemia of nerves and/or muscles or
secondary to pain
41. Diagnosis
Diagnosis of ACS is clinical. The five “P’s” mentioned
in the literature for compartment syndrome are pain,
paralysis, paresthesia, pallor, and pulselessnes.
Though all of the mentioned clinical signs and
symptoms are important clinical findings, mostly all
are not present in every case, and in fact presence of
pulselessness indicates that it is already too late to get
good outcome.
42. The cardinal symptom of ACS in an awake
patient is pain out of proportion. Pain at
rest and with passive stretch is almost
always found in evolving ACS.
43. But if the ACS is already established and ends up in late stage,
pain may not be the clinical finding as the pain receptors and
nerve fibers face ischemic necrosis and death. Moreover, pain can
be absent in regionally anaesthetized patients and sedated and
relaxed patients in intensive care unit (ICU).
44. Be aware….
In unconscious patients most of the clinical findings
cannot be elicited; hence it is necessary to check
compartment pressure by devices .
45. ICP measurement
Matsen et al. used an absolute value of 45mmHg for
diagnosis of ACS and indication for fasciotomy while
30mmHg was used by Mubarak et al .
McQueen and Court-Brown suggested that if the
difference between diastolic blood pressure and ICP
(delta p)was less than 30mmHg, it was highly
suspicious of ACS and needed to be decompressed.
Hypotensive patients with ICPs higher than 20 mmHg
have a high risk of ACS.
47. There is almost complete recovery of limb function
if fasciotomy is performed within 6 hours. Matsen
et al found necrosis after 6 hours of ischaemia. This
is currently the accepted upper limit of viability.
48. Classification of VIC:
The most renowned classification is the one
introduced by Seddon in 1964 and modified by Tsuge
in 1975.
Tsuge divided patients with Volkmann’s ischemic
contractures in three types-mild, moderate, and
severe.
49. Class cont…
Zancolli, in 1975, classification:
Normal intrinsics.
Paralytic intrinsics.
Retracted intrinsic.
Combined type (type IV) .
54. Treatment
Acute compartment syndrome is a medical emergency
requiring immediate surgical treatment. Once the
diagnosis of ACS is established, then the surgical
decompressive fasciotomy should be performed
urgently but a good surgical technique is mandatory.
All dressings should be loosened or removed if
possible.
55. Techniques
There are various techniques of fasciotomy of leg in
the literature, which include single incision fasciotomy
with fibulectomy, single incision fasciotomy without
fibulectomy, and the most common surgical approach
two-incision fasciotomy with anterolateral and
posteromedial incisions.
56. Techniques cont..
In two-incision technique, the anterolateral incision is
made to approach the anterior and lateral compartments. It
is midway between the tibial crest and the fibular head.
Incision starts 5 cm distal to fibular head and extends up to
5 cm proximal to lateral malleolus.
The second incision is posteromedial incision which is
made 2 cm posterior to the medial border of the tibia. This
incision is utilized to release the superficial and deep
posterior compartments and approach the muscles in these
compartments for assessment of viability.
68. Techniques con..
The forearm compartments are not completely
independent of one another as in the leg. Hence individual
compartments do not need to be individually addressed.
Various incision patterns have been described in the
literature, including lazy S shaped and curved incisions.
Volar curvilinear incision is used that allows release of the
lacertus fibrosus proximally and the carpal tunnel distally.
For releasing the dorsal compartment, a longitudinal
incision was made which extends from 4 cm distal to
lateral epicondyle to Lister tubercle .
75. Complications
Infection.
permanent nerve damage,
loss of limb, multi-system organ failure,
rhabdomyolysis, and death.
Crush syndrome , and myoglobin may be released as
the muscle is reperfused after fasciotomy. Early
recognition and aggressive fasciotomy will help to
minimize these adverse outcomes.
76. Treatment of VIC
Assessment of the patient.
Detailed history.
Functional evaluation of the extremity .
The active and passive ROM of all joints of the upper
extremity must be measured.
77. The main goal in the management of
Volkmann contracture is to restore function;
however, normal function of the upper
extremity should not be expected .
83. Objectives
General objective:
To find out the neurological elements in Volkmann’s
ischemic contracture of upper limbs.
Specific objectives:
To identify the injured nerve(s) and to evaluates the
pattern of nerve injuries.
84. Patients and methods
Study design:
Hospital based cross sectional descriptive study.
Study setting :
Soba university hospital 2015-2016
Study population:
patients presented with Volkmann’s Ischemic
contracture to upper limbs.
Inclusion criteria:
Patients less than 16 years old.
patients who had nerve conduction study.
85. Data instruments :
Questionnaire filled directly from pts.
Assessment of nerve conduction study(NCS).
88. 22 of cases (88%) of VIC occurred after TBS.
remaining 3casestreated by doctors.
89. Moderate variety seen in 10 patients (40%).
Severe type seen in 8 patients (32%).
Mild contractures were found in 7 cases
(28%) .
90. No case had been offered
fasciotomy as initial treatment
91. Forearm fractures occurred in 15 patients (60%) .
Supracondylar fractures seen in 7cases (28%).
Hummers fractures seen in 3 cases (12%).
92. Non dominant sides seen in 14 cases (56%).
Dominant side was affected in 11 cases (44%).
93. All of them they had nerves
injuries in different patterns.
94. Median and Ulnar nerves were affected in all patients
(100%).
Radial nerve affected in 15 cases (60%) .
95. Median and ulnar patterns
The median and ulnar axonotamesis seen in 15 cases
(60%) .
median and ulnar neurotamesis seen in 8 patients
(32%) .
While median neurotamesis and ulnar axonotamesis
and median axonontamesis and ulnar neurotamesis
were seen in 1 case each (4%).
96. Radial patterns
Radial axonotamesis seen in 12 cases (80%) .
Radial neurotamesis seen in 3 patients (20%).
97. There was statistical relationship between the clinical
feature of the patients and the NCS results of median
and ulnar nerves (P value of 0.021) while the NCS
results of radial nerve was not matched with the
clinical features of the patients (P value of 0.555) and
this may be due to small number of patients in this
study.
98. CONCLUSIONS
Post-circumferential VIC of the forearm is very
common in our society.
The prevention of this form of iatrogenic disaster is
not easy .
All patients with VIC had nerve injuries.
Median and ulnar nerves are most commonly affected
nerves.
Axonopathies are the most frequent pattern of
injuries.
Moderate variety is the most common type of VIC.
99. Recommendations
Community awareness through health education and
conducting medical camps and seminars might play a
role in decreasing the influence of TBS.
Good training of doctors to insure good handling with
such cases
Early detection and treatment of compartment
syndromes.
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