Many people are interested in: “Compartment syndrome - what is it?” This pathology can be noted in all areas where the muscles are surrounded by a strong fascia - this is the area of the buttocks, thighs, shoulder, lower back and back.
Compartment syndrome is a combination of changes provoked by increased pressure in a limited area of the body. Depending on what caused the increase in pressure inside the tissues, it is customary to distinguish an acute or chronic form of the disease.
Reasons for the development of pathology
The most common causes of the development of the disease are:
- fracture;
- the extent of soft tissue disorders;
- violation of the integrity of blood vessels;
- limb compression during positional compression;
- improperly applied plaster cast;
- burn;
- long traumatic operations.
In medicine, cases of injection of pressure fluids into a vein or artery are mentioned, as well as bites of poisonous snakes.
A high risk of the development of pathology exists with the introduction of drugs that thin the blood, and in general with a violation of blood coagulation. Iatrogenic causes, inattentive attitude to patients who are unconscious, are not excluded.
Chronic Syndrome
The compartment syndrome takes on a chronic nature in the case of prolonged repetitive physical exertion. It is also associated with increased pressure in the tissues in the lower leg. Intense physical activity, which exceeds the limits of the permissible boundary, provokes an increase in muscle volume up to 20%, which causes compression in the corresponding segment. Compartment syndrome is often diagnosed in professional runners.
Pathophysiological basis
The pathophysiology of the syndrome is due to local tissue homeostasis due to injuries, increased pressure inside the tissues and muscle cases, decreased blood flow in the capillaries, impaired venous outflow of blood, and then arterial flow. Ultimately, tissue necrosis develops due to a lack of oxygen.
Symptomatology
Symptoms of the compartment syndrome, which proceeds in an acute form, are expressed in rapidly increasing swelling, which is determined by palpation (the degree of density of the affected area is established). Bubbles also appear, pain is noted with passive muscle movement (flexion and extension of the foot), sensitivity is lost.
It should be noted that the most striking sign of such a pathology as compartment syndrome is pain, the level of which indicates the intensity of the damage. Often, it cannot be stopped even after the administration of painkillers.
This symptom is also characteristic of gas gangrene.
The main forms of compartment syndrome
The compartment syndrome can occur in two forms: abdominal and myofascial (local ischemia syndrome against the background of increased pressure).
The myofascial form is characterized by a reduction in muscle perfusion, ischemia, necrosis and the development of contracture. The reasons for the increase in the level of pidfascial pressure lie in post-traumatic hematoma, inflammatory edema, positional compression, and progressive tumors.
Myofascial compartment syndrome is diagnosed through a physical examination.
The following indicators are taken into account:
- time elapsed after receiving an injury before admission to the clinic;
- time since the appearance of puffiness;
- the rate of increase in swelling (within 6-12 hours after injury);
- the period of application of the tourniquet and the prevention of ischemia (removal of the tourniquet for a short time).
The pains are deep pulsating in nature. They are more intense than with ordinary damage, they are not stopped by immobilization of the damaged area and analgesics in generally accepted doses.
Pain occurs when passively stretching a muscle that has been damaged. This changes the position of the fingers.
Method for measuring pressure inside tissues
How is compartment syndrome detected? Diagnosis of pathology is carried out using the Whiteside method (1975), which allows measuring interstitial pressure.
It involves the use of:
- a system including a mercury manometer;
- three-way crane;
- injection needles with a diameter of at least 1 mm;
- tube systems;
- 20 ml syringe.
Currently, devices that conduct long-term monitoring are used to determine pidfascial pressure. The results are compared with a heart pressure indicator. The pressure in the myofascial space of the limb should not exceed 10 mm RT. Art. The presence of the compartment syndrome is established if the indicator of pidfascial pressure exceeds the critical mark by 40 mm RT. Art. and below the diastolic. Its increase within 4-6 hours can provoke the occurrence of ischemia.
Classification of myofascial form
- Light lesion - the distal segment of the limb is warm when feeling. On the main arteries, the preservation of the pulse is noted. The index of subfascial pressure at 40 mm RT. Art. below the diastolic.
- Medium lesion - the skin on the damaged area of the limb has a lower temperature than on healthy. Hyperesthesia or anesthesia of the fingers of the limb is noted. The pulse is palpated weakly. Subfascial pressure is the same as dystolic.
- Severe damage - the pulse of the great arteries is not palpable. Finger anesthesia is noted. Subfascial pressure is higher than diastolic.
Differentiation of diagnosis
Compartment syndrome should be distinguished from damage to the main vessels, the presence of arterial thrombosis, damage to the nerve trunks from clostridial and non-clostridial myositis.
Differentiated diagnosis should be carried out in accordance with a number of criteria:
- the presence of ripple;
- swelling;
- lack of sensitivity in the limb;
- blood intoxication;
- increased white blood cell count;
- indicator of pidfascial pressure.
The defeat of the muscles of the forearm
The muscles in the forearm are divided by fascia into three bone-fascial cases: lateral in the area of the radial muscle, anterior (muscles are responsible for flexion of the fingers) and posterior (muscles are involved in extension of the fingers).
If the patient cannot extend his fingers, a diagnosis such as anterior forearm compartment syndrome is established. If the patient cannot bend his fingers, the back case is affected.
Damage to the muscles of the leg
The tibia muscles are divided by means of fascia into four bone-fascial cases:
- lateral (peroneal muscles);
- front (responsible for the extension of the foot);
- back (superficial soleus muscle);
- deep back (responsible for bending).
If the patient is not able to bend the foot and fingers, and an attempt of such an action causes acute pain in him, then we can talk about the presence of the anterior compartment syndrome, and if he can not straighten his fingers, then this is a rear view.
Abdominal form
The normal pressure in the abdominal cavity depends on body weight and is approximately zero. The abdomen is a reservoir for fluid in which the pressure on the surface and in all areas is the same. Intra-abdominal pressure can be measured in any part of the abdomen.
What are the risk factors for developing abdominal hypertension syndrome? The main cause is intestinal paresis, numerous injuries, urgent laparotomy in a patient who receives intensive infusion therapy. This leads to an increase in fluid volume in the abdomen.
In many patients, after surgery in the abdomen, the pressure in his cavity rises by 3-13 mm RT. Art. without any clinical signs
With abdominoplasty, the pressure inside the abdomen becomes 15 mmHg higher. Art., which provokes the development of abdominal compartment syndrome.
With an indicator of 25 mm RT. Art. and more, there is a malfunction in the blood flow in large vessels in the peritoneum, which leads to renal failure and impaired functioning of the heart and blood vessels.
Abdominal pressure above 35 mmHg. Art. can provoke a complete cardiac arrest.
How is the abdominal compartment syndrome manifested?
Abdominal compartment syndrome is manifested in superficial shortness of breath and a decrease in cardiac output. Also there is the presence of diuresis, blood saturation.
In medicine, four types of hypertension in the peritoneum are distinguished:
- 1st degree - a pressure indicator of 12-15 mm RT. Art.
- 2nd degree- an indicator of pressure of 16-20 mm RT. Art.
- 3rd degree - a pressure indicator of 21-35 mm RT. Art.
- 4th degree - an indicator of pressure above 35 mm RT. Art.
Methods for measuring pressure in the peritoneum
Typically, pressure in the abdomen is measured through the bladder. A well-stretched wall acts as a passive conductor of intra-abdominal pressure if the volume of fluid in the peritoneum does not exceed 50-100 ml. With a large volume, the measurement is influenced by muscle tension in the bladder.
Abdominal Therapy
How is compartment syndrome stopped? Treatment involves the correction or elimination of the causes (removal of compression underwear, high position of the head of the bed, sedatives). Oxygen therapy is carried out, in which a nasogastric tube is used.
To prevent decompensation of hemodynamics, oxygen saturation of the blood is restored and coagulation is optimized. Monitoring of pressure within the peritoneum and other functions is also shown.
The compartment syndrome in abdominal surgery is eliminated through decompression laparostomy. Catheterization of the bladder is performed to increase the volume of the peritoneum.
The main measures for conservative treatment
With conservative treatment, the following events are carried out:
- squeezing the affected area is removed (removing dressings, plaster casts, weakening the skeleton extension, the location of the affected limb at the same level with the heart, which prevents the development of ischemia);
- blood circulation is optimized, spasms in the vascular region and increased coagulation are eliminated;
- rheological parameters of blood improve;
- painkillers are used (analgesics based on narcotic substances, as well as non-narcotic drugs);
- puffiness is removed;
- acidosis is stopped.
If conservative treatment does not bring the expected results, a subfascial pressure level above a critical level is noted, muscle tone and swelling are observed, then surgical intervention is indicated (the use of decompression fasciotomy). It can be of a therapeutic and preventive nature.
What is decompression fasciotomy?
Decompression fasciotomy is a surgical intervention aimed at preventing and stopping the compartment syndrome. Surgery is resorted to if the arteries and veins of the shoulder are damaged. It also eliminates the compartment syndrome of the medial component of the elbow joint, the consequences of injuring the fossa of the elbow and arteries and veins under the knee. Fasciotomy is mostly performed on the lower extremities.
Indications for prophylactic fasciotomy
The main indications include:
- the presence of venous insufficiency;
- damage to the artery under the knee;
- unsuccessful reconstruction of arteries;
- late reconstruction of arteries;
- severe swelling of the soft tissues of the limb.
Therapeutic fasciotomy
The operation is performed for patients with pronounced subfascial pressure identified during the study. The indicator is above 30 mm RT. Art. belong to the category of pathological.
An increase in subfascial pressure is an absolute indicator for a medical operation.
The main indicators for such a surgical intervention are the following symptoms:
- the presence of paresthesia;
- pain with passive movements of the limb;
- the presence of paralysis with the preservation of the nerve;
- decrease in peripheral heart rate.
Warning
Such an operation should not be performed in the hip or shoulder area. Mannitol and antibiotics are prescribed only at the discretion of the doctor.
Fasciotomy is an operation that can cause complications (infection, chronic pain, the presence of paresthesia, swelling, osteomyelitis). It should be noted that they appear infrequently, but the probability still exists. Therefore, before the intervention, a careful examination of the patient is required.
Decompression fasciotomy in the forearm
Surgical intervention to eliminate a pathology such as compartment syndrome of the forearm involves the use of local anesthesia. The incision is made from the epicondyle to the wrist. Fascia is revealed over the flexor muscle in the elbow. She moves medially. The superficial muscle responsible for flexion is laterally displaced. Fascia is dissected above the deep flexor. The fascia of each muscle is opened by a longitudinal section.
If necessary, the dorsal incision is supplemented with a volar incision. The living muscle swells immediately. Her response hyperemia is observed.
A non-viable muscle (usually a flexor located in the deep) is colored yellow, which is characteristic of necrosis. Fascia is not sutured. The skin wound is sutured without tension. If the implementation of such manipulation is impossible, then the skin wound is left open under a bandage.
Antiseptic agents or sorbents are used for dressings. In the future, water-emulsion ointments are used.
Secondary sutures are applied five days after surgery. Sometimes the wound remains open for a month. In some cases, additional laxative incisions or various types of plastic surgery are used to close the wound.
Technique of fasciotomy on the hand
The operation involves a longitudinal incision in the tenor area of the first metacarpal bone. This incision is parallel to the fifth carpal bone. In this case, the projection of the ulnar nerve does not intersect. Decompression of interosseous muscles is performed from individual incisions on the back of the hand.
Performing fasciotomy on the lower leg
The tibia compartment syndrome is eliminated by surgical intervention with local anesthesia.
If it is difficult for the patient to bend the foot and fingers due to acute pain, then we can judge the presence of the anterior compartment syndrome. If he can not straighten the lower leg, then this is the posterior compartment-syndrome of the lower leg.
To open all cases, they resort to two or three longitudinal cuts on the lower legs, the length of which is 15 cm. If necessary, the fascia incision may have a Z-shape.
If blood circulation in the foot does not improve after a few minutes, then the medial incision deepens, and through the scissors, the case located at the back is opened. The incision of this fascia is not performed with a scalpel, since it is possible to damage the posterior tibial artery and the tibial nerve.
The fascia incision remains open. If possible, the wound on the skin is sutured without tension. If stitching is not possible, the wound remains open under the dressing. Secondary sutures are usually applied after 5 days.
Technique for the operation on the foot
This operation involves four accesses. Two dorsal incisions are made along the 2nd and 4th metatarsal bones, through which four spaces between the bones and the central case in the foot open. A couple more incisions are made laterally and medially. They open the cases.
An operation performed before necrosis of muscle tissue has a high degree of effectiveness. On the third day after decompression, swelling falls, and wound closure becomes possible. If necrosis of muscle tissue was detected during decompression, then removal of the dead area is indicated. The final compression in this case is delayed for a week.
Disease prognosis
The prognosis of the disease is directly dependent on timely therapy and the full implementation of surgical intervention. If the pain stops, neurological disorders appear, then this, as a rule, indicates the irreversibility of pathological changes. Further implementation of necrectomy and other procedures is not able to save the limb, its amputation is indicated. In order not to bring the situation to extremes, it is recommended that all the measures aimed at preventing the development of the compartmental syndrome be timely performed.