Arm Pump Elimination System Book
Compartment syndrome often involves the calf following blunt trauma or fracture 21,22 . It may also result from muscle strain injury and associated swelling and hematoma (Fig. 29). Compartment syndrome without muscle injury has been described in the anterior compartment of the lower leg in soccer players 127 . Increased pressure within fascial compartments leads to capillary circulatory compromise with ischemia to the musculature and nerves, and progress to tissue necrosis if left untreated. While typically a clinical diagnosis confirmed with pressure measurements, MR may be used to evaluate the extent of involvement but should not delay intervention in emergency cases. Findings in the acute setting include increased T2 signal with muscle enlargement, edema, or both 10 . Compartment syndrome can also be chronic, as a result of neoplasm or associated with exercise (Fig. 30). MRI before and after exercise may demonstrate increased T2 signal in the compartment of concern 128-131 ....
There is a high incidence of associated injuries accompanying closed tibial shaft fractures, including compartment syndrome, arterial and neurological injury. Twenty per cent of fractures have an associated knee ligament injury. A bifocal fracture may involve the tibial plateau or ankle in 5 of cases. In other cases the fracture may extend from the diaphysis to intra-articular regions. Pathological fractures due to metastatic spread are rare however, metabolic bone disease may manifest as a tibial fracture. Stress fractures, even in the young, are recognized. The popliteal artery and trifurcation are tethered by the anterior tibial artery passing through the interosseus membrane, and are more susceptible to injury with displaced fractures around the proximal diaphyseal-metaphyseal junction. The peroneal nerve is prone to injury from an associated fracture of the proximal fibula. Compartment syndrome is most common in the leg.
Laparoscopic surgery has become very popular for the treatment of severe obesity. Obesity can be distributed in either an android fashion, primarily within the abdominal area or centrally as seen primarily in male patients, or in a gynoid manner, in the hips and buttocks, peripherally as seen primarily in female patients. Many of our severely obese female patients have both peripheral and central obesity. We have found that central obesity is associated with a significant increase in intra-abdominal pressure and this pressure is as high or higher than the pressure seen in patients with an acute abdominal compartment syndrome (Fig. 5.1). Data support the finding that this increase in intra-abdominal pressure is associated with a number of obesity related co-morbidity problems leading to the development of a chronic abdominal compartment syndrome . These co-morbidities include obesity hypoventilation syndrome with its high cardiac filling pressures, gastroesophageal reflux disease,...
Forearm fractures are the second most common open fracture. Clinical examination should include the elbow and wrist, and full neurovascular assessment. The earliest signs of compartment syndrome are palpable tension in the soft tissues and pain on passive finger movement.
The leg is the most common site for compartment syndrome, following a closed tibial shaft fracture, but elevated pressure may follow open fractures and IM nailing. The four compartments in the leg (anterior, lateral, posterior and deep posterior) must all be released. The anterior compartment is the most frequently involved. 2. The forearm may develop compartment syndrome following trauma or surgery, especially when the deep fascia has been closed. A supracondylar fracture of the distal humerus may also be associated with compartment syndrome, when the circulation has been interrupted. Classically the volar compartments are affected. The forearm is decompressed through a longitudinal volar incision, zigzagged across the wrist into the palm, to include release of the carpal tunnel. It is uncommon to need to release the dorsal compartments through a second dorsal approach. The same approach to wound care is required. 3. The hand and foot may develop compartment syndrome, following...
This is required to debride the wound and assess the extent of soft tissue damage. The wound margins should be excised, damaged subcutaneous tissue removed and the muscle inspected. Muscle should be assessed for viability and excised if appropriate. Deep fascia should be incised to accommodate subsequent oedema and soft tissue swelling, to prevent the onset of compartment syndrome. The wound should be irrigated with a generous volume of saline, ideally pulsed lavage. In the presence of a fracture, a minimum of 9 l should be used. The wound is packed with gauze and dressed.
Exertional (chronic) compartment syndrome. This malady represents a common cause of leg pain in young persons. It is caused by a transient increase in muscular compartment pressure in response to exercise. The anterior and lateral compartments of the leg are most commonly involved.
Most isolated fractures are managed by closed reduction in a long leg cast. Close follow-up and cast changing or wedging is required to prevent loss of reduction. Wedging maybe required in the first 3 weeks. Operative management is indicated in open fractures, compartment syndrome, neurovascular injuries, failure of closed management, and possibly in polytrauma victims. Compartment syndrome is occasionally recognized.
Union rates in I, II and IIIA injuries are almost comparable to closed fractures. Delayed bone union should be treated by exchange IM nailing and bone grafting, which is required in about 10 of all cases, but more commonly for IIIC injuries. The period to union is greater, and infection or non-union rates as high as 50 or more in IIIB and IIIC fractures. Compartment syndrome reportedly occurs in 20 of open injuries.
Axial T2 image showing large soleus hematoma and lower extremity enlargement with muscle edema consistent with clinical finding of compartment syndrome (arrow). Fig. 29. Axial T2 image showing large soleus hematoma and lower extremity enlargement with muscle edema consistent with clinical finding of compartment syndrome (arrow). Fig. 30. Patient with chronic compartment syndrome as a result of a large hemangioma seen on these post contrast axial T1-weighted images (arrow). Fig. 30. Patient with chronic compartment syndrome as a result of a large hemangioma seen on these post contrast axial T1-weighted images (arrow). Treatment of muscle herniations, especially when asymptomatic, is conservative, although fasciotomy may be performed for cosmetic reasons. Fascial repair is no longer performed as this may result in compartment syndrome 133 . Herniation may rarely result in muscle necrosis as a result of strangulation 10 .
Hematoma may result from direct trauma associated with contusion or related to myotendinous injury and subsequent bleeding. MRI and ultrasound helps assess size and location and determine if it is intermuscular or intramuscular in nature. Large hematomas may result in compartment syndrome or significant pain and aspiration may be needed.