Flashcards in Chap 161-163 ALI + Compartment Syndrome Deck (39):
What is Compartment Syndrome?
Increased intracompartmental pressure impairs tissue perfusion (ICP)
What are the major two causes of CS and what are examples of each?
CS 21% of acute ischemia
IR causes muscle tissues injury, interstitial edema. Oxygen free radicals increase permeability
Arterial occlusion initiates IR
Fasciotomy for blunt 11%, penetratig 30%
Venous outflow obstruction
Phelgmesia cerulea dolens, harvesting of deep veins from thigh
Rapid increase in compartment pressure
Tibia or forearm most common cause of ortho
Muscle swelling, bleeding
Anterior compartemenr and flexor compartement most prone
Comminuted fracture more likely to result in CS
Extra of large volumes, or caustic medications. Punctures in coagulopathic patients
What is secondary compartment syndrome?
CS with no overt evidence of trauma
diffuse microvascular permeability from trauma induced systemic inflammatory response syndrome combined with massive fluid resuscitation
What are clinical findings of CS?
pain on passive movement elicits pain
loss of 2 point discrimination
absence of clinical findings
Numbness interweb space (ant)
What pharmacological interventions can decrease CS?
they reduce oxygen free radicals and reduce impact of schema-reperfusion
What are two different techniques in fasciotomy?
Single vs double incision
Describes each surgical approach for fasciotmy.
Lateral incision over fibula from neck to 3-4cm above lateral malleolus
Sc flap anterior direction to access anterior and lateral compartments
Posterior flap to access superficial posterior compartment
Flexor hallucis longus identified and dissected off fibula in subperiosteal plane
Fascial attachement of PT to the fibula is incised to open deep post compartment. Most do not perform a fibulectomySingle-incision
Lateral incicions over intermuscular spetum b/w ant and lat compartements, apporx 4cm lateral to crest of the tibia. anterior and lateral compartments.
Medial aspect of leg incision 1-2cm posterior to the tibia, for posterior decompression incision over gastroc, for deep compartment divide soleal attachments off tibia and incise fascia
What are advantages/disadvantages for each surgical technique of fasciotomy?
potential injury to perineal nerve
but two large incision have high morbidity
Describe technique for thigh fasciotomy.
Incision on lateral thigh. Start just distal to intertrochanteric line and extending distal to lateral epicondyle
Iliotibial band exposed and incised longitufinally to decomp anteriror
Vastus lat reflected medially to exposed lateral IM septum which is then incised
Medial usually does not need decomp
Incision over adductor muscle group
What are different was of closing fasciotomies?
dradual dermal apposition
What are complications of CS?
neuro deficits 5-35%
what complications are related to myonecrosis?
What are complications for missed CS?
50% require amp
after 3-4 days decompression not indicated b/c myonecrosis too high
What is chronic compartment syndrome?
exercise induced pain and tightness of the lower legs esp ant compartment
within 20-30 mins abates 15-30mins
What are pressure criteria for diagnosis of chronic compartment syndrome?
1 resting ICP >15mmHg
2 ICP >30mmhg 1-2 mins after completion of exercise
3 ICP >20mmhg 5 mins after completion of exercise
one or more for diagnosis
What is tx for chronic CS?
avoidance of inciting factors
What muscles are in the anterior compartment?
enclosed by the crural fascia
extensor digitorum longus
extensor hallucis longus (mid-distal)
peroneus tertius (very distal)
What muscles are in the superficial posterior compartment?
medial sural cutaneous nerve
What muscles are in the deep posterior compartment?
flexor digitorum longus
flexor hallucis longus
What muscles are in the lateral compartments?
superficial peroneal nerve
What is the techniques for closed fasciotomies for compartment syndrome?
Close the skin
What are causes of acute limb ischemia.
thrombi post MI
aortic mural thrombi
occlusion of graft
What is the most common cause? The most common site?
What is the earliest sign of ALI?
then muscle weakness
muscle tenderness sign advanced ischemia
When does irreversible muscle loss occur?
What are the five Ps?
What is the classification of ALI?
no sensory loss, no muscle weakness. positive A, V doppler signals
IIa marginally threatened
salvageable is treated promptly
minimal sensory loss, no muscle weakness. inaudible A. audible V
IIb immediately threatened.
Salvageable with immediate revasc. sensory loss more then toes with rest pain, mild-mod muscle weakness. inaudible A, audible V.
major tissue loss or permanent nerve damage inevitable.
sensory profoundly anesthetic, profound paralysis, inaudible A and V.
What is the presentation of aortic occlusion.
mottled to above inguinale ligament
What is the mortality associated with acute aortic occlusion?
close to 100% if embolic
in-situ thrombosis usually has collateral
What are the causes of acute aortic occlusion?
thrombosis of atherosclerotic aorta
thrombosis of small abdo aneurysm
What is the treatment for acute aortic occlusion?
if embolic, bilat transfer embolectomies
otherwise extra-anatomical bypass
What are contra-indications to lysis?
active bleeding disorder
GI bleed within 10d
CVA within 6 months
intracranial/spinal surgery within 3 months
head injury within 3 months
What class schema can lysis be considered
What is the cause of UE ischemia?
What is the natural hx?
50% have late complications if left untreated (contracture, amputation)
What is presenting symptoms of UE ALI?
usually cold and numb rather then pain.
What are amputation, mortality and limb salvage rates for LE ALI?
15%, 20%, 70% at 2 years.
What structures can be injured during a fasciotomy?
common superficial and deep perineal nerve
SV and nerve
What are relative indications for fasciotomy?
Combined arterial and venous trauma
Phlegmatic cerulea dolens
Tense compartment after crush or fracture