Compartment Syndrome

- Discussion: - pathophysiology: - compartment syndrome is elevation of interstitial pressure in closed fascial compartment that results in microvascular compromise; - as duration & magnitude of interstitial pressure increase, myoneural function is impaired & necrosis of soft tissues eventually develops; - intracompartmental pressure: - necrosis of tissue may begin at interstitial pressure as low as 30 mm - while others have suggested that it begins at higher level; - w/ periods of hypotension and trauma to limb, interstitial tissue pressure of 30 mm of mercury has been suggested as threshold at which diagnosis of compartment syndrome should be considered; - diastolic pressure: (Whiteside' Theory): - development of a compartment syndrome depends not only on intra-compartment pressure but also depends on systemic blood pressure; - DBP - CP should be greater than 30 - ref: Diastolic blood pressure in patients with tibia fractures under anaesthesia: implications for the diagnosis of compartment syndrome. - Common Sites of Involvement: - compartment syndrome of the upper extremity: - compartment syndrome of forearm: - compartment syndrome of hand and wrist (after crush, hemmorhage, edema); - compartment syndrome of the lower extremity: - compartment syndrome of thigh - compartment syndrome of the leg: - compartment syndrome from tibial frx - chronic compartment syndromes - fasciotomy of leg - anatomy: (4 compartments) - lateral compartment - superfical posterior compartment - deep posterior compartment - anterior compartment - foot compartment syndromes - Exam: - blood pressure (compartment syndrome is potentiated by hypotension); - extreme pain out of proportion to the injury, - pain on passive ROM of the fingers or toes (stretch pain of the involved compartment): - patient will usually hold injured part in a position of flexion to maximally relax the fascia and reduce pain; - pallor of the extremity, - paralysis, - paresthesias (early loss of vibratory sensation); - pulses: - when checking an extremity pulse (such as dorsalis pedis) be sure to occlude the other major artery (posterior tibial artery) so that retrograde flow does not confuse the diagnosis; - alternatively, apply a pulse oximetry monitor to the great toe, and sequentially occlude the posterior tibial and dorsalis pedis pulses; - compare pulses to the opposite non injured side (to rule out vascular injury); - Compartment Pressure Monitoring:

Complications: - reperfusion injury - references: - Mechanisms of Disease: The Role Of Reperfusion-Induced Injury In The Pathogenesis Of The Crush Syndrome. - need to address: - fluid loss - shock - acidosis - hyperkalemia - myoglobinuria - renal failure - consider: - perioperative hydration - mannitol - bicarbonate

Scientific Papers: Fasciotomy After *Trauma* to the Extremities. Pelvic and Lower Extremity Trauma--Symposium: Compartment Syndromes of the Lower Leg. Hyperbaric oxygen reduces edema and necrosis of skeletal muscle in compartment syndromes associated with hemorrhagic hypotension. A comparative study of the tolerance of skeletal muscle to ischemia. Tourniquet application compared with acute compartment syndrome. Compartmental syndrome complicating Salter-Harris type II distal radius fracture. The changes in intramuscular pressure and femoral vein flow with continuous passive motion, pneumatic compressive stockings, and leg manipulations. Simulation of compartment syndrome by rupture of the deep femoral artery from blunt trauma. Ankle and knee position as a factor modifying intracompartmental pressure in the human leg. Quantitation of skeletal-muscle necrosis in a model compartment syndrome. Quantification of intracompartmental pressure and volume under plaster casts. Compartment syndrome as a complication of the Hauser procedure. Intramuscular pressures with limb compression clarification of the pathogenesis of the druginduced muscle-compartment syndrome. A practical approach to compartmental syndromes. Part II. Diagnosis. Skeletal muscle necrosis in pressurized compartments associated with hemorrhagic hypotension. Acute Compartment Syndrome: Update on Diagnosis and Treatment. T.E. Whitesides Jr. MD and M.M. Heckman MD. J Am Acad Orthop Surg. 1996; 4: 209-218. Well-Limb Compartment Syndrome After Prolonged Lateral Decubitus Positioning.

Pathophysiology of Compartment Syndrome

- Discussion: - occurs when pressure in a muscle compartment is > pressure in the capillaries, which leads to progressive muscle ischemia and edema and left untreated can result in infarction of the compartment contents; - ischemia and necrosis of the muscles occur even though the arterial pressure is still high enough to produce pulses; - muscle and nerves can survive for upto 4 hours of ischemia w/o irreversible damage; - nerve kept ischemic for under 4 hours will show neuropraxic damage, whereas after 4 hours, nerves will show irreversible damage; - Whiteside' Theory: - the development of a compartment syndrome depends not only on intra-compartment pressure but also depends on systemic blood pressure; - DBP - CP should be greater than 30 - Causes: - prolonged compression over a compartment (drug over dose) - Intramuscular pressures with limb compression clarification of the pathogenesis of the drug-induced muscle-compartment syndrome. Owen CA. Mubarak SJ. Hargens AR. Rutherford L. Garetto LP. Akeson WH. New England Journal of Medicine. [JC:now] 300(21):1169-72, 1979 May 24. - measured intramuscular pressure by inserting wick catheters into 10 volar forearms and 10 anterior tibial compartments of adult volunteers. - placed the subjects in positions in which victims of drug overdose are commonly found. Intramuscular pressures in the area of direct compression on hard surfaces ranged from 26 to 240 mm Hg, and averaged 101 mm Hg. - fractures (both open and closed) - improper casting of fractures - burns - infiltration of IV medications (chemotherapy) - intra compartment hemorrhage (direct arterial injury, Coumadin, Hemophilia) - tumors - improper positioning of the well leg on the frx table Compartment syndrome in the well leg resulting from fracture-table positioning. Anglen J. Banovetz J. Clinical Orthopaedics & Related Research. (301):239-42, 1994 Apr.

Compartment Syndrome Pressure Monitoring

Discussion: - many surgeon use 30 mm Hg as the cut off for performing fasciotomy; - compartment measurements within 20 mm Hg of diastolic pressure is an indication for fasciotomy (hence DBP - compartment pressure is a relative indicator of tissue perfusion); - compartment pressure measurements should be taken as close to the fracture site as possible (since these will give the highest readings); - influence of vascular injury: (see vascular trauma) - while pulses are usually present in compartment syndromes, the absence of a pulse (eg. from associated fracture or trauma) raises the probability that a compartment syndrome could occur; - for instance loss of the anterior tibial artery following a tibial fracture, places the anterior compartment at high risk for compartment syndrome; - which type of needle is best? - Moed ant Thorderson (1993) compared three methods of measurement methods: (the simple-needle technique, use of the slit catheter, and use of the side-ported needle.) - the side-ported needle appeared to be as accurate as the slit catheter for the measurement of compartment pressures (p = 0.355, 1-beta = 0.9); - the values obtained with use of the simple needle were consistently higher than those obtained with the other two methods (p < 0.001): an average of 18.3 millimeters of mercury higher than the values measured with the slit catheter and 19.3 millimeters of mercury higher than those measured with the side-ported needle; - use of the simple 18-gauge needle is not recommended for this purpose.

Reperfusion Injury / Crush Injury

- See: Compartment Syndrome: - Discussion: - traumatic rhabdomyolysis, or crush syndrome, is consequence of prolonged continuous pressure on the limbs; - it reflects disintegration of muscle tissue & influx of myoglobin, potassium, and phosphorus into the circulation; - syndrome is characterized by hypovolemic shock and hyperkalemia; - these results strongly suggest that free-radical scavengers are beneficial in attenuating or preventing reperfusion-induced injury to ischemic skeletal muscles and consequently to other organs, particularly the kidneys; - these scavengers should be administered before crushed muscles are decompressed or as early as possible during reperfusion in order to prevent irreversible damage to ischemic cells; - Labs: - urine myoglobin; - serum CPK - chemistry panel - Treatment: - fluid requirements: - it is quite common in extensive traumatic rhabdomyolysis for muscles of 75-kg adult to sequester greater/= 12 liters of fluid over 48-hour period (i.e. amount of same order of magnitude as entire volume of extracellular fluid); - if inadequately corrected, this potentially fatal hypovolemia may cause renal ischemia by activating secretion of constrictor hormones, such as angiotensin II, catecholamines, vasopressin, and intrarenal thromboxane; - alkalinization of urine; - bicarbonate: - acetazolamide - medical therapy: - mannitol - scavenger of hydroxyl free radicals, & allopurinol, xanthine oxidase inhibitor & protects against myocardial necrosis; - scavengers also limit tissue injury during ischemia & reperfusion of intestine, the kidney, liver, and island skin flaps; - allopurinol - benzamil - amiloride - KCl-sparing diuretic drug, decreases intracellular sodium concentration & inhibits Na-hydrogen & Na-calcium exchange in many tissues; - renal failure - pathogenesis of renal failure in rhabdomyolysis and the crush syndrome is still not fully understood; - direct toxic effects of myoglobin or products of decomposition; - dehydration is predisposing factor for renal failure; - avoid IV Ca: - unless there is danger of hyperkalemic arrhythmia, infusion of calcium is not indicated; - unless calcium is constantly infused, its administration will correct hypocalcemia only temporarily; most infused calcium is deposited in injured muscles, thus aggravating rhabdomyolysis & causing metastatic calcification; - metastatic calcification: - danger that mild metabolic alkalosis resulting from mannitol-alkaline diuresis therapy may enhance metastatic calcification;

Compartmental syndrome complicating SalterHarris type II distal

radius fracture. Santoro-V; Mara-J Clin-Orthop. 1988 Aug(233): 226-9 Distal radius fractures are common in children, yet complications are rare. A rarely described complication, acute volar compartmental syndrome, occurred in a 15-year-old boy. An accurate physical examination and awareness of the syndrome are essential for diagnosis. Compartmental pressures can be obtained easily and afford a rapid means of corroboration. Once the diagnosis is established, adequate decompression of all involved compartments, including carpal tunnel release, is essential. The literature is unclear regarding the etiology of this complication. There is nothing structurally intrinsic to the distal radius that should lead to a compartmental syndrome. Both the amount of soft tissue damage at the time of fracture and the mode of immobilization (excessive elevation, constricting splint, etc.) are the ultimate determinants of a successful (or unsuccessful) outcome.

Fractures of the Radius and Ulna Menu

- Anatomy: - radius & ulna lie parallel to each other when forearm is supinated; - during pronation radius crosses ulna, rotating on axis that passes from capitulum through the distal end of ulna; - ular side of wrist is supported by TFCC, which articulates w/ both lunate and triquetrium; - ulnar attachment of TFC is to base of ulnar styloid & distally to triquetrum w/ volar ulnocarpal ligaments; - interosseous membrane: - radius and ulna are joined by proximal & distal RU joints & by interosseous membrane, which is directed obliquely downward from radius to ulna; - since ulna does not articulate w/ carpi, direction of interosseous membrane is important in transmission of longitudinal forces from radius to ulna; - Fractures of the Adult Ulna: - Pediatric Ulnar Fracture: - Pediatric Both Bone Forearm Fractures - Monteggia's Fracture - Green Stick Frx - Distal Ulnar Physeal Fractures: - Radiographs: - in the child, it is essential to have 3 views of the elbow: (AP, lateral, and oblique) before a Monteggia frx can be ruled out; - this is especially true in proximal ulnar shaft frx; - references: - Plastic deformation in pediatric fractures: Mechanisms and treatment. Mabrey JD, Fitch RD: J Pediatr Orthop 1989;9:310. - Traumatic plastic deformation of the radius and ulna. Sanders WE, Heckman JD: Clin Orthop 1984;188:58-67.

- Types of Radius Fractures:

- proximal radial fractures: - radial head frx: - radial neck frx: - Distal Radius Fractures: (Synthes Distal Radius Products) - barton's fracture - dorsal - barton's fracture - volar - chauffeur's fracture - colles fracture - intra-articular fractures of distal radius: - pediatric distal radius fracture: - radial shaft fractures: - radial shaft fractures: discussion: - both bone fractures: - galeazzi's fracture:

Adult Ulna Shaft Fracture: - night stick fracture: mechanism: direct trauma w/ forearm used to block blow - stable frx: - diplaced < 50% = Stable; - periosteum & interosseous membrane are intact & act as restraint to rotation; - unstable fracture: - displaced > 50% or > 10-15 deg angulation; - angulation or displacement towards the interosseous membrane is poorly tolerated; - periosteum and interosseous membrane disrupted; - associated injuries: radial head frx or dislocation (see Montegga frx) - non operative treatment: - indicated for fractures in the distal 2/3 of the forearm with less than 10-15 deg angulation and more than 50% to 75% fracture opposition; - well fitted forearm cast or brace which does not interfere with wrist or elbow motion; - expect 50% reduction of forearm pronation or supination while in the brace; - references: - Treatment of ulnar fractures by functional bracing. - The isolated fracture of the ulnar shaft. Treatment without immobilization. - Bracing of stable shaft fractures of the ulna. PA Ostermann et al. J. Orthop. Trauma. Vol 8. 1994. p 245-248. - Early mobilization of isolated ulnar-shaft fractures. - Isolated ulnar shaft fractures. Comparison of treatment by a functional brace and long-arm cast. - Treatment of isolated ulnar shaft fractures with prefabricated functional fracture braces. - The isolated fracture of the ulnar shaft. Treatment without immobilization.

Monteggia's Fracture
- See: - Plating Techniques: - Monteggia Fractures in Children: - Discussion: - Giovanni Monteggia (1814) first described frx of proximal 1/3 of ulna in association w/ anterior dislocation of radial head;

- hence dislocation of radial head w/ frx of proximal 1/3 of ulna is known as Monteggia's deformity. - Mechanism: - proposed mechanisms include direct blow & hyperpronation injuries as well as the hyperextension theory;

- Type I (or extension type) - 60% of cases: - anterior dislocation of radial head (or frx) and fracture of ulnar diaphysis at any level w/ anterior angulation (usually proximal third); - exam: - attempt to palpate radial head (ant, post, or lateral); - PIN palsy is most common in type I frx and may occur in a delayed fashion if the radial head is not promptly reduced; - reduction: - achieved w/ forarm in full supination, & longitudinal traction; - then elbow is gently flexed to > 90 deg to relax biceps; - radial head is gently repositioned by direct manual pressure anteriorly on the bone; - following reduction, radial head will be stable if left in flexion; - angulated ulnar shaft is reduced by firm manual pressure;

- Type II (flexion type) - 15% - posterior or posterolateral dislocation of radial head (or frx); - frx of proximal ulnar diaphysis with posterior angulation; - posterior Monteggia frx is reduced by applying traction to forearm w/ the forearm in full extension; - immobilization is continued until there is union of the ulna; - this ordinarily requires 6-10 wks depending on the age of pt;

- Type III - 20% - lateral or anterolateral dislocation of the radial head; - fracture of ulnar metaphysis; - frx of ulna just distal to coronoid process w/ lateral dislocation of radial head;

- Type IV (5%) - anterior dislocation of the radial head; - frx of proximal 1/3 of radius & frx of ulna at the same level; - Exam: - r/o tear of the annular ligament - associated nerve injury: - paralysis of deep branch of radial nerve is most common; - posterior interosseous nerve may be wrapped around neck of radius, preventing reduction; - note: that patients whose operative treatment is delayed may be found to have a progressive PIN palsy from constant pressure exerted by the dislocated radial head; - spontaneous recovery is usual & exploration is not indicated; - Radiographs: - dislocation of radial head may be missed, eventhough frx of ulna is obvious (need AP, Lateral and Olbique X-rays of elbow) - line drawn thru radial shaft and radial head should align w/ capitellum in any position if the radial head is in normal position - this is esp true on the lateral projection; - apex of angular deformity of ulna usually indicates direction of radial head dislocation; - Reduction: - immobilize the forearm in neutral rotationw/ slight supination, w/ cast carefully molded over lateral side of the ulna at the level of the fracture; - keep elbow flexed ( > 90 deg), to relax biceps, so that full supination can be avoided w/o losing reduction; - Non Operative Treatment: - realize that even w/ successful closed reduction of the ulna (and accompanying reduction of the radial head) that subsequently there may be slow and progressive shortening and angulation; - hence, these patients will require close follow up; - Treatment: - treated by reduction and stabilization of ulna followed by reduction of radial head via supination & direct pressure; - ulnar frx is treated w/ compression plate (esp in proximal third) - medullary nail in this location may not fill the canal and may thus provide less than rigid fixation; - key is to obtain length and alignment, which then allows the radial head to be reduced; - type I, III, and IV lesions are held in 110 deg. of flexion; - type II lesions with posterior dislocations should be maintained in about 70 deg. of flexion for 6 weeks;

- Delayed Dx: - when dx is delayed < 3 months, ORIF is indicated;

- when > 3 months has elapsed, consider non operative treatment because bony ankylosis of the elbow may occur following surgery; - bony ankylosis may be more disabling than the joint instability - in child, a dislocated radial head should never be resected, since it will cause cubitus valgus, prominence of the distal end of the ulna, and radial deviation of the head; - Complications: - PIN or radial nerve palsy from anterior displacement of radial head; - spontaneous recovery is usual & exploration is not indicated; - see: nerve injuries - non union of frx of ulnar shaft - radiohumeral ankylosis - radioulnar synostosis - recurrent radial head dislocation - myositis ossificans;

Radial Shaft Fractures: Discussion

- See: - Anterior Approach to the Radial Shaft: (Henry) - Blount Fracture: Both Bone Forearm Fracture: - Boyd Surgical Approach: - Distal 1/3 of the Radius thru an Anterolateral Incision; - Dorsal Approach (Thompson) : - Galeazzi's Fracture - Proximal 1/3 of the Radius thru the Anterolateral Incision - Approach to the Radius: - when the fracture is in distal half of the bone, expose it thru anterior approach of Henry & apply plate to volar surface; - this defies the principle of applying plate to tension side (dorsal surface); - since the soft tissue coverage on the volar surface is better and bone contour is flat, it is easier to apply plate on volar surface; - when frx is in proximal half, expose it thru dorsal Thompson approach, and apply the plate to the dorsal surface; - radial nerve is less likely to be injured thru this approach than thru the anterior approach; - plate on the dorsal aspect of the proximal radius is also less likely to produce mechanical block to pronation than if applied to the anterior surface; - when frx is in the middle third either approach may be used; - consider applying the plate to side (anterior vs. posterior) which has greater comminution; - Complications: Cadaveric studies (Mathews, 1982) - residual angulation of 10 deg in mid shaft radial frxs or ulna or both will not limit forearm rotation anatomically - loss of rotation is expected w/ residual angles of > 20 deg; - degree of rotatory deformity parallels loss of pronation & supination; - supination losses for mid 1/3 > than for distal 1/3 deformities - compartment syndrome; - synostosis: - uncommon but more common in crush injuries;

Discussion: - extra - articular palmarly displaced distal radius frx; - volar angulation of frx is referred to as "Garden Spade" deformity (reversed Colles Fracture); - hand & wrist are displaced forward or volarly w/ respect to forearm; - frx may be extra articular, intra articular, or be part of frx dislocation of wrist; - Mechanism: - backward fall on the palm of an outstreched hand causing pronation of upper extremity while the hand is fixed to the ground; - Classification: - Type I: extra articular; - Type II: crosses into the dorsal articlar surface; - Type III: enters radiocarpal joint - Volar Barton's Fracture = Smith's type III - both involve volar dislocation of carpus assoc w/ intra articular distal radius component; - Reduction: - frx should be closed reduced by reversing frx deformity w/ longitudinal traction & applying as long arm cast w/ forearm in supination & wrist in neutral; - Non Operative Rx: - if closed reduction is attempted, the wrist should remain in extension; - Surgical Treatment: - ORIF (or External Fixators) is treatment of choice for volar displaced fractures, esp intra articular types II and III; - Ex fix for open Smith's frx is acceptable for wound considerations; - Reduction w/ flouro & supplementary K wires may be needed for Smith's type II frxs, to insure anatomic alignment of radiocarpal joint; - Smith's Type III: Barton's Fracture: - volarly displaced frx of Smith's or volar Barton's type is approached thru volar incision and appication of a buttress plate; - displaced volar spike (Melone type III) may also require volar approach; - incision is made thru proximally extended carpal tunnel incision, w/ reflection of pronator quadratus from radius; - plate is contoured to fit metaphyseal curvature, & distal frag screws are rarely indicated; - during open reduction of distal radius, surgeon needs to examine articular surface reduction of radioscaphoid, radiolunate, and distal radioulnar joints, and treat each appropriately; - there is little indication for primary excision of distal ulna;