DONE BY :ASIM MAKHDOM 25/Nov/2008 ORTHOPEDIC H.O

Volkmann contracture : Richard vonVolkmann (documented nerve injury and subsequent contracture from CS following supracondylar fracture. That injury remains known as Volkmann contracture.) Approximately 50 years after vonVolkmann, Jepson described ischemic contractures in dog hind legs resulting from limb hypertension after experimentally induced venous obstruction

in the 1970s, the importance of measuring intracompartmental pressures became apparent.

Compartment syndrome (CS) is a limb- threatening and life-threatening condition observed when perfusion pressure falls below tissue pressure in a closed anatomic space

Pressure perfusion until no oxygen is available for cellular metabolism.

Tissue perfusion is determined by measuring capillary perfusion pressure (CPP) minus the interstitial fluid pressure (TP=CPP-IFP) (Normal cellular metabolism requires 5-7mmHg oxygen tension )

this is easily maintained with the CPP averaging 25 mm Hg and interstitial pressure 4-6 mm Hg SO intracompartmental pressures greater than 30 mm Hg are generally agreed to require intervention

At this point, blood flow through the capillaries stops no oxygen ischemic injury release of chemical mediator

depends on both the diagnosis and the time from injury to intervention… complete recovery of limb function if fasciotomy was performed within 6 hours

The traditional 5 Ps (ie, pain, paraesthesia, pallor, poikilothermia, pulselessness) are not diagnostic of CS. Literature warns that, with the exception of pain and paraesthesia, these traditional signs are not reliable, and the presence or absence of them should not affect injury management

Importantly, note that these symptoms assume a conscious patient who did not suffer any additional injury that hinders sensory input (eg, spinal cord injury

-Long bone fracture -High-energy trauma -Penetrating injuries (eg, gunshot wounds, stabbings) - Often cause arterial injury, which can quickly lead to CS -Venous injury - May cause CS (do not be misled by palpable pulses) Crush injuries

1- simple venipuncture in an anticoagulated patient 2- MINOR TRUMA

passive stretching of the muscles, is the earliest clinical indicator of CS

SENSORY EXAM THEN MOTOR EXAMPLE deep peroneal nerve

1- metabolic profile 2- creatinine/ urine myoglobin 3- serum myoglobin 4- PT /PTT 5- urine analysis

1_x-ray 2_u/s to rule out other diff

the most helpful test and should be done ASAP

1_ oxygen mask 2_ don’t elevate the affected limb more than 35 cm arterial pressue by 23 mmHg and no change in the ICP 3_hydaration 4_fasciotomy(definitive therpy)

Delta-p is a measure of perfusion pressure (diastolic blood pressure minus intracompartmental pressure). Originally used in dogs, delta-p measurements of less than 30 mm Hg were used by McQueen (1996) for fasciotomy. As a result, several patients with intracompartmental pressures of 40 mm Hg or greater were observed because the delta-p was greater than 30 mm Hg. Criteria were used in 116 patients without sequelae. The converse also is true, since patients with intracompartmental pressures less than 30 mm Hg but with high delta-p values have developed CS.

- Permanent nerve damage - Infection - Loss of limb - Death - Cosmetic deformity post fasciotomy

Really we should apply this to all discharged pt.