Classification of myofascial compartment syndrome

Many are interested: "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 buttock, hip, shoulder, waist and back area.

The compartment syndrome is a set of changes,provoked by increased pressure in a limited area of ​​the body. Depending on what was caused by increased pressure inside the tissues, it is customary to isolate the acute or chronic form of the disease.

Causes of pathology development

As the most common causes of the development of the disease are:

• fracture;
• the vastness of the disorder of soft tissues;
• violation of the integrity of blood vessels;
• compression of the limb with positional compression;
• improperly applied plaster bandage;
• burn;
• lengthy traumatic surgeries.

In medicine, mention is made of cases of injection into a vein or artery of liquids under pressure, as well as bites of poisonous snakes.

A high risk of pathology exists andwith the introduction of drugs that dilute the blood, and in general with a violation of blood coagulability. Iatrogenic causes, inattention to unconscious patients are also possible.

Chronic form of the syndrome

The compartment syndrome accepts chroniccharacter in the case of long-term repeated physical exertion. It is also associated with increased pressure in the tissues in the calf region. Intensive physical loads that exceed the limits of the acceptable limit, provoke an increase in muscle volume to 20%, which causes compression in the corresponding segment. The syndrome is often diagnosed in professional runners.

Pathophysiological basis

Pathophysiology of the syndrome is due to localhomeostasis of tissues under the influence of injuries, increased pressure inside tissues and muscle cases, decreased blood flow in the capillaries, violations of venous outflow of blood, and then of the arterial influx. In the final analysis, tissue necrosis develops due to a lack of oxygen.

Symptomatology

Symptoms of compartmental syndrome occurring inacute form, expressed in rapidly increasing edema, which is determined by palpation (the degree of density of the affected area is determined). Also, there are bubbles, there are painful sensations with passive movement of the muscle (flexion and extension of the foot), sensitivity is lost.

It should be noted that the most striking feature of thispathology, as a compartment syndrome, is pain, the level of which indicates the intensity of damage. Often, it can not be stopped even after the introduction of painkillers.

This symptom is also characteristic of gas gangrene.

Basic forms of compartment syndrome

The compartmental syndrome can occur in two forms: abdominal and myofascial (local ischemia syndrome with increased pressure).

Myofascial form is characterized by a decreaseperfusion of muscles, ischemia, necrosis and development of contracture. The reasons for increasing the level of pidfascial pressure lie in post-traumatic hematoma, edema of inflammatory nature, positional contraction, progressive tumor.

Myofascial compartment-syndrome is diagnosed through physical examination.

The following metrics are taken into account:

• time elapsed after receiving an injury before admission to the clinic;
• time since the onset of swelling;
• rate of swelling increase (within 6-12 hours after injury);
• term of application of a tourniquet and prevention of ischemia (removal of a tourniquet for a short time).

The pain is of a deep, pulsating nature. They are more intense than with normal damage, they are not stopped by immobilization of the damaged area and analgesics in conventional doses.

Pain occurs when the muscle that has undergone damage is passively stretched. This changes the position of the fingers.

Method for measuring pressure inside tissues

How is the compartment syndrome identified? Diagnosis of pathology is carried out using the method Whiteside (1975), which allows to measure the interstitial pressure.

It involves the use of:

• a system including a mercury manometer;
• a three-way valve;
• Needles for injection, the diameter of which is not less than 1 mm;
• tube systems;
• a 20 ml syringe.

At present, to determine the pidfascialpressure devices are used that conduct long-term monitoring. The results are compared with the cardiac output. The pressure in the myofascial limb space should not exceed 10 mm Hg. Art. The presence of compartmental syndrome is established if the index of pidfascial pressure exceeds the critical mark by 40 mm Hg. Art. and below the diastolic. Its increase within 4-6 hours can trigger the onset of ischemia.

Classification of the myofascial form

• Distal segment of limbat feeling warm. On the main arteries, the pulse is preserved. The index of subfascial pressure is 40 mm Hg. Art. below diastolic.
• Average lesion - skin on a damaged areathe limb has a lower temperature than on the healthy one. Hyperesthesia or anesthesia of the limb fingers is noted. The pulse is palpable slightly. The subfascial pressure is the same as the distal one.
• Severe defeat - the pulse of the main arteries is not probed. Anesthesia of the fingers is noted. Subfascial pressure is higher than diastolic pressure.

Differential diagnosis

The compartment syndrome should be distinguished from damage to the main vessels, presence of arterial thrombosis, damage to the nerve trunks from clostridial and nonclostridial myositis.

Differentiated diagnostics should be conducted in accordance with a number of criteria:

• presence of pulsation;
• swelling;
• lack of sensitivity in the limb;
• intoxication of blood;
• increase in the level of leukocytes;
• index of pidfascial pressure.

Lesion of the muscles of the forearm

Muscles in the forearm region are divided byfascia on three osteo-fascial cases: lateral in the region of the ray muscle, anterior (muscles responsible for flexion of the fingers) and posterior (muscles involved in the extension of the fingers).

If the patient can not unbend his fingers, then a diagnosis such as anterior compartment-forearm syndrome is established. If the patient can not bend his fingers, then the back case is struck.

Defeat of the calf muscles

The calf muscles are divided by fascia into four osteo-fascial cases:

• lateral (fibular muscles);
• front (responsible for extension of the foot);
• posterior (superficial soleus muscle);
• posterior deep (responsible for flexion).

If the patient is unable to bend the foot andfingers, and the attempt of such an action causes him acute pain, then we can talk about the presence of anterior compartment syndrome, and if he can not unbend his fingers, then this is a rear view.

Abdominal form

The normal index of pressure in the abdominal regionThe cavity depends on the body weight and is approximately equal to zero. The abdomen is a reservoir for a liquid in which the pressure on the surface and in all regions is the same. Intra-abdominal pressure can be measured in any part of the abdomen.

What are the risk factors for the development of the syndromeabdominal hypertension? The main cause is intestinal paresis, numerous injuries, urgent laparotomy in a patient who receives intensive infusion therapy. This leads to an increase in the volume of fluid in the abdominal region.

In many patients after surgery in the abdominal region, the pressure in the cavity increases by 3-13 mm Hg. Art. without any clinical signs

With abdominoplasty, the pressure inside the abdomen becomes higher by 15 mm Hg. that provokes the development of abdominal compartment syndrome.

At an index of 25 mm Hg. Art. and more there is a failure in the bloodstream along the large vessels in the peritoneal region, which leads to kidney failure and a disturbance in the work of the heart and blood vessels.

The pressure in the abdominal region is above 35 mm Hg. Art. can provoke complete cardiac arrest.

How is the abdominal compartment syndrome manifested?

The abdominal abdominal syndrome manifests itself in superficial hindered breathing and a decrease in cardiac output. There is also a diuresis, blood saturation.

In medicine, there are four types of hypertension in the peritoneum:

• 1st degree - pressure index 12-15 mm Hg. Art.
• The 2nd degree is a pressure index of 16-20 mm Hg. Art.
• The third degree is a pressure index of 21-35 mm Hg. Art.
• 4th degree - a pressure indicator above 35 mm Hg. Art.

Methods for measuring peritoneal pressure

As a rule, the pressure in the abdomen is measuredthrough the bladder. A well-stretched wall acts as a passive conductor for intra-abdominal pressure if the volume of fluid in the peritoneum does not exceed 50-100 ml. With a large volume, the pressure of the muscles of the bladder influences the measurement.

Therapy for abdominal syndrome

How is the compartmental syndrome stopped? Treatment involves correction or elimination of causes (removal of compression linen, high position of the head of the bed, sedatives). Oxygen therapy is performed, in which a nasogastric tube is used.

To prevent decompensation of hemodynamics, blood saturation with oxygen is restored and coagulation is optimized. Pressure monitoring inside the peritoneum and other functions is also shown.

The compartmental syndrome in abdominal surgery is eliminated by means of decompression laparostomy. The catheterization of the bladder is performed to increase the volume of the peritoneum.

Main measures for conservative treatment

With conservative treatment the following measures are carried out:

• the squeezing of the affected area is eliminated(removal of bandages, plaster langets, weakening of the skeleton tract, location of the affected limb on one level with the heart, which prevents the development of ischemia);
• optimizes blood circulation, eliminates spasms in the vascular region and increased coagulation;
• blood rheological indicators improve;
• Anesthetics are used (analgesics based on narcotic substances, as well as non-narcotic substances);
• puffiness is removed;
• acidosis is stopped.

If conservative treatment does not bring the expectedresults, the level of subfascial pressure is higher than the critical mark, muscle tone and swelling are observed, then operative intervention (application of decompression fasciotomy) is indicated. It can be of a curative and preventive nature.

What is decompression fasciotomy?

Decompression fasciotomy is a surgicalan intervention aimed at preventing and stopping the compartmental syndrome. To surgery resorted to damage to the artery and veins of the shoulder. It also removes the compartment-medial component of the elbow joint, the consequences of injuring the pit of the elbow and arteries and veins under the knee. Fasciotomy is mostly performed on the lower limbs.

Indications for preventive fasciotomy

The main indications are:

• presence of venous insufficiency;
• damage to the artery under the knee;
• unsuccessfully completed reconstruction of the arteries;
• later the reconstruction of the arteries;
• marked swelling of the soft tissues of the limb.

Carrying out a medical fasciotomy

The operation is performed in patients with a pronounced subfascial pressure revealed during the study. The figure is above 30 mm Hg. Art. are classified as pathological.

The increase in subfascial pressure is an absolute indicator for conducting a medical operation.

The main symptoms for such a surgical intervention are the following symptoms:

• presence of paresthesias;
• painful sensations with passive limb movements;
• Presence of a paralysis at preservation of a nerve;
• decreased peripheral pulse.

Warning

Do not perform such surgery in the area of ​​the hip or shoulder. "Mannitol" and antibiotics are prescribed only at the discretion of the doctor.

Fasciotomy is an operation that can cause andcomplications (infection, chronic pain, the presence of paresthesias, 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 Area

Surgical intervention to eliminate such a pathology, as a compartment-syndrome of the forearm, involves the use of local anesthesia. The incision is from the epicondyle to the wrist area. The fascia opens above the flexor muscle in the elbow area. It is displaced medially. The superficial muscle responsible for flexion is displaced laterally. The fascia dissects above the deep flexor. The fascia of each muscle is opened by a longitudinal incision.

If necessary, the volaric incision is supplemented with a dorsal incision. The living muscle immediately swells. There is a response hyperemia.

Unviable muscle (usually this isthe flexor located in the depth) is colored yellow, which is characteristic of necrosis. The fascia does not close. The cutaneous wound is sutured without tension. If the implementation of such manipulation is impossible, then the cutaneous wound is left in the open under the bandage.

For dressings, antiseptic agents or sorbents are used. Further water-emulsion ointments are used.

Secondary sutures are applied five days aftersurgical intervention. Sometimes the wound remains open for a month. In some cases, additional laxative incisions or different types of plastic surgery are used to close the wound.

Technique of fasciotomy on the hand

The operation involves performing a longitudinalcut in the tenor area of ​​the first metacarpal bone. This incision is parallel to the fifth wrist bone. In this case, the projection of the ulnar nerve does not intersect. Decompression of the interosseous muscles is performed from individual incisions on the back of the hand.

Conduction of fasciotomy on the shin

The abdominal joint syndrome is eliminated by surgical intervention with local anesthesia.

If the patient is difficult to bend the foot and fingers because of acute pain, then we can judge the presence of anterior compartment syndrome. If he can not unbend his shin, then this is the rear compartment-shin syndrome.

To open all the cases, resort to two or three longitudinal cuts on the shins, which are 15 cm in length. If necessary, the fascia cut may have a Z-shaped shape.

If the circulation in the foot does not improvefor a few minutes, the medial incision is deepened, and the sheath, located behind, is opened by means of scissors. The incision of this fascia is not performed with a scalpel, since the posterior tibial artery and the tibial nerve can be damaged.

The incision of the fascia remains open. If possible, the wound on the skin is sutured without tension. If stitching is not possible, the wound remains open under the bandage. Secondary sutures are usually applied after 5 days.

The technique of performing the operation on the foot

This operation assumes the presence of fouraccesses. Two dorsal incisions are made along the 2nd and 4th metatarsal bones, through which four gaps between the bones and the central case in the foot are opened. Another couple of incisions are done laterally and medially. They open the cases.

An operation performed prior to necrosis of muscle tissue,has a high degree of efficiency. On the third day after decompression, swelling decreases, and it becomes possible to suture the wound. If decompression has revealed necrosis of muscle tissue, then removal of the dead region is indicated. The final compression in this case is postponed for a week.

Prognosis of the disease

The prognosis of the disease is in a directdependence on timely treatment and full implementation of surgical intervention. If the pain stops, there are disorders of a neurological nature, then, as a rule, it indicates the irreversibility of pathological changes. Further implementation of necroctomies and other procedures is not able to save the limb, its amputation is shown. In order not to bring the situation to extremes, it is recommended that all measures be taken in a timely manner to prevent the development of the compartmental syndrome.