Classification of myofascial compartment syndrome

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 buttock, hip, shoulder, waist and back area.

A compartmental syndrome is a set of changes triggered 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 development exists also with the introduction of drugs that dilute the blood, and in general with the violation of blood coagulability. Iatrogenic causes, inattention to patients who are unconscious, are not excluded.

Chronic form of the syndrome

The compartmental syndrome takes on a chronic character in the case of prolonged 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 permissible border, cause the increase in muscle volume to 20%, which causes squeezing in the corresponding segment. The syndrome is often diagnosed in professional runners.

Pathophysiological basis

The pathophysiology of the syndrome is caused by local homeostasis of tissues under the influence of injuries, increased pressure inside tissues and muscle cases, decreased blood flow in the capillaries, violation of venous outflow of blood, and then of the arterial inflow. In the final analysis, tissue necrosis develops due to a lack of oxygen.

Symptomatics

Symptoms of compartmental syndrome, occurring in an acute form, are expressed in rapidly increasing edema, which is determined by palpation (the degree of density of the affected area is established). 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 such a pathology as the compartmental syndrome is pain, the level of which indicates the intensity of the lesion. 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).

The myofascial form characterizes the reduction of 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, edema of inflammatory nature, positional compression, progressive tumor.

Myofascial compartment-syndrome is diagnosed through physical examination.

The following indicators are taken into account:

• Time elapsed after the injury was received before admission to the clinic;
• Time since the onset of swelling;
• Rate of swelling (within 6-12 hours after injury);
• Term of application of the tourniquet and prevention of ischemia (removal of the 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.

The pain occurs with the passive stretching of the muscle that has been damaged. 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, devices that conduct long-term monitoring are used to determine the pidfascial pressure. The results are compared with the cardiac output. The pressure in the myofascial space of the limb 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

• An easy lesion is the distal segment of the limb when feeling warm. On the main arteries, the pulse is preserved. The index of subfascial pressure is 40 mm Hg. Art. Below diastolic.
• Average lesion - the skin on the damaged limb region has a lower temperature than on the healthy one. There is hyperesthesia or anesthesia of the limb fingers. The pulse is palpable slightly. The subfascial pressure is the same as the dystolic pressure.
• 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, the presence of arterial thrombosis, damage to the nerve trunks from clostridial and nonclostridial myositis.

Differentiated diagnostics should be carried out 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

The muscles in the forearm region are divided by fascia into three bone-fascial cases: lateral in the region of the ray muscle, the anterior one (the muscles are responsible for the flexion of the fingers) and the posterior (the muscles participate 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 hit.

Lesion 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 not able to bend the foot and fingers, and the attempt of such an action causes him acute pain, then we can speak about the presence of anterior compartmental 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 region depends on the body weight and is approximately 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 syndrome of abdominal 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 a number of patients after surgery in the abdomen, the pressure in the cavity is increased by 3-13 mm Hg. Art. Without any clinical signs

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

With an indicator of 25 mm Hg. Art. And more there is a malfunction in the bloodstream along large vessels in the peritoneal region, which leads to kidney failure and upsetting of the heart and vessels.

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

How does the abdominal compartment syndrome manifest ?

The abdominal compartment syndrome manifests itself in superficial hindered breathing and a decrease in cardiac output. Diuresis and blood saturation are also noted.

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

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

Methods for measuring peritoneal pressure

As a rule, the 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 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 the 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 dressings, gypsum 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;
• Improve rheological indicators of blood;
• 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 expected results, the level of subfascial pressure above the critical level is noted, 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 surgical intervention aimed at preventing and stopping compartmental syndrome. To surgery resorted to damage to the artery and veins of the shoulder. Also, it eliminates the compartment-syndrome of the medial component of the elbow joint, the consequences of wounding the pits 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 index is higher than 30 mm Hg. Art. Are classified as pathological.

Increase of 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 complications (infection, chronic pain, 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 Area

Surgical intervention to eliminate such a pathology as the compartment-syndrome of the forearm, involves the use of Local anesthesia. The incision is from the epicondyle to the wrist area. The fascia is opened over 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 of her hyperemia.

The non-viable muscle (usually a 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 after surgery. 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 longitudinal incision in the area of the tenor of the first metacarpal bone. This incision is parallel to the fifth wrist bone. 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 lower leg

Compound-shin 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, the length of which is 15 cm. If necessary, the fascia cut may have a Z-shape.

If the blood circulation in the foot does not improve after a few minutes, the medial incision deepens, 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 four accesses. 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 pair of incisions is done laterally and medially. They open the cases.

The operation performed prior to muscle tissue necrosis has a high degree of effectiveness. On the third day after decompression, swelling decreases, and it becomes possible to suture the wound. If decompression 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 directly dependent on timely treatment and full implementation of the surgical procedure. If pain is stopped, neurological disorders appear, then this usually 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 compartment syndrome.