Compartment syndrome
| Classification according to ICD-10 | |
|---|---|
| T79.6 | Traumatic muscle ischemia |
| R19.8 | Other specified symptoms affecting the digestive system and abdomen |
| M62.2 | Ischemic muscle infarction (non-traumatic) |
| ICD-10 online (WHO version 2019) | |
As compartment syndrome or muscular compression syndrome , the state is defined in which, when closed, skin and soft tissue, an increased tissue pressure leads to the reduction in tissue perfusion, resulting from which neuromuscular disorders or tissue and organ damage. The most common compartment syndrome is the forearm or lower leg . In the intensive care also is abdominal compartment syndrome known as, for example, after a rupture of the aorta may occur.
The compartment syndrome causes damage to the blood vessels , muscles and nerves due to increased pressure in the muscle boxes of the forearm or lower leg (hence the name box syndrome ) . By delimiting the muscle groups through coarse layers of connective tissue ( fascia ), increased pressure leads to circulatory disorders in the corresponding area and thus to nerve and muscle damage. A log syndrome occurs on the lower leg especially in the area of the tibialis anterior log and is then also referred to as tibialis anterior syndrome or tibialis log syndrome . Due to the different types of collagen and different proportions of elastin, there are sometimes also “fascia” that are less elastic. Schünke et al. (2014) write: “The deep flexor box is one of four less stretchable muscle boxes on the lower leg (so-called osteofibrous channels or compartments), which can be the site of a compartment syndrome as a result of vascular injuries” (p. 568).
Epidemiology
Compartment syndrome is the second most common complication in lower leg fractures (after deep vein thrombosis ).
causes
The increase in pressure is caused by bruises or edema that occur when the tissue is subjected to direct or indirect force, for example in the event of an accident (e.g. “ horse kiss ” ). This results in a swelling of the muscle groups limited by fascia, the compartments or boxes. Only the muscle expands, not the fascia, or the fascia only expands to a certain point. This increases the pressure within the muscle boxes on the surrounding vessels and nerves supplying the muscles. The increased pressure leads to a reduced blood flow to the muscles. This poorer supply of blood leads to a decreased metabolism. In the case of an acute compartment syndrome, in the worst case this leads to necrotization, tissue death and neuromuscular damage. In the case of chronic compartment syndrome, the risks are not so high, as the restriction in blood flow is less. As a result, complaints usually only occur under stress and usually without serious consequences.
The compartment syndrome occurs almost exclusively acutely after bone fractures , muscle contusions or during or immediately after excessive exercise (after long marches or in competitive athletes - walkers , medium-distance and marathon runners or triathletes ): The muscle volume increases too quickly. As a result, the fascia surrounding the muscle groups are not yet sufficiently adapted to the increased volume. This also leads to increased pressure in the boxes. In relation to sport as a triggering agent, one speaks of the functional compartment syndrome .
In individual cases, very long (more than 5 hours) operations, e.g. B. in lithotomy position , especially in urology, also in gynecology and in very rare cases in visceral surgery .
Furthermore, cases are known in which the administration of anticoagulants to inhibit blood coagulation have favored the occurrence of a compartment syndrome. Very rarely, an increase in pressure due to bacterial inflammation, e.g. B. as a result of insect bites triggered.
In contrast to the forms mentioned above, the abdominal compartment syndrome is immediately life-threatening for the patient. A distinction is made between a primary and a secondary form. A primary compartment syndrome can arise, for example, in the course of peritonitis , pancreatitis or a mesenteric infarction . The secondary form is due to surgical intervention.
A distinction is made between:
- The acute compartment syndrome
- Chronic compartment syndromes:
- Exertional compartment syndrome
- venous compartment syndrome
Clinic and diagnosis
Painful, hardened muscles → muscle stretching pain → spontaneous muscle pain as a sign of ischemia → sensitivity disorders (late signs). These symptoms are alarm signals, especially if the patient is in a lithotomy position or after trauma. The diagnosis can be made by palpation and - more reliably - a pressure probe in the relevant compartment.
Abdominal compartment syndrome has several consequences. On the one hand, the blood flow back to the heart is impaired and the preload and thus the cardiac output decrease. On the other hand, the patient has breathing problems in the further course, as the increased pressure in the abdominal cavity is passed on via the diaphragm into the thorax and compresses the lungs. This means that higher ventilation pressures are necessary in order to achieve sufficient oxygen saturation in the blood. In addition to local circulatory disorders, the increase in intra-abdominal pressure also causes functional impairment in organs such as the liver , pancreas and kidneys . In the intestine , the impaired blood flow can cause lesions in the intestinal mucosa, which can lead to bacterial infections and peritonitis . Furthermore, there may be insufficient blood supply to the brain. Bladder pressure measurement can be performed to detect abdominal compartment syndrome .
therapy
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In the therapy of compartment syndrome, a distinction must be made between acute and chronic or functional compartment syndrome. In acute compartment syndrome, fasciotomy is the therapy of choice: Relief of the affected compartment by emergency splitting of the muscle boxes (in the case of the lower leg: lateral incision of the tibialis anterior box and the superficial flexor box along the entire length of the lower leg) or in the case of the abdomen Emergency opening of the abdominal cavity ( laparotomy ).
By placing the sutures in place, a wide gap between the wound edges can be avoided and a gradual approach can be prepared. After the swelling has subsided, the wound is usually closed with a secondary suture or split-thickness skin graft. Surgical meshes or flap transplants can be performed in the abdomen.
In the case of chronic or functional compartment syndrome, conservative therapy is used: cooling, elevation and stress reduction on the affected muscles should be used. Exercise should be avoided accordingly. Usually, however, training in the aerobic range with a low heart rate is possible and is also useful for healing the compartment syndrome. The fasciae are better supplied with nutrients due to the improved blood flow to the muscles. As long as no lactate is produced in muscle metabolism through training in the vicinity of the anaerobic area, no symptoms should appear. The training should therefore not have too much strain on the muscles due to a low intensity overall.
Complications
Muscle and nerves
The lack of treatment or even delayed treatment by a few hours leads to permanent damage to the nerves, irreparably damaged by the tissue pressure, and to the tissue that can become necrotic and ultimately fibrotic ; The consequences of this are paralysis or even the loss of the affected limb. A typical Volkmann contracture can develop on the forearm , which is characterized by a stiff joint with flexion in the wrist.
Systemic
Extensive muscle breakdown (rhabdomyolysis) and circulatory disorders result in some harmful metabolic products that can cause serious consequences via the bloodstream, such as kidney failure ; due to the high release of myoglobin , this can lead to death in the worst case.
skin
After splitting the fascia, it may no longer be possible to directly close the edges of the skin. In these cases, a covering with split skin may be necessary.
history
The traumatic compartment syndrome was first mentioned in 1881 by the Halle surgeon Richard von Volkmann . Bernhard Bardenheuer first considered splitting the fascia as a therapy in 1911, but this was only introduced in 1926 by PN Jepson . In 1920 Finochietto researched the compartment syndrome of the upper extremity. However, the current term compartment syndrome was not coined by Reszel and employees of the Mayo Clinic until 1963 .
Compartment syndrome in animals
Compartment syndrome is very rare in veterinary medicine. The most common cause is bleeding into the fascia box; tumors are rarely the trigger.
literature
- M. Oberringer, T. Pohlemann: Compartment syndrome . In: H.-P. Scharf, H. Rüter et al. (Ed.): Orthopedics and trauma surgery . 1st edition. Elsevier - Urban & Fischer, Munich 2009, ISBN 978-3-437-24400-1 , pp. 11-15 .
Individual evidence
- ↑ a b c Alphabetical directory for the ICD-10-WHO version 2019, volume 3. German Institute for Medical Documentation and Information (DIMDI), Cologne, 2019, p. 460.
- ↑ Schünke, M., Schulte, E. & Schumacher, U. (2014). General anatomy and movement system (Prometheus, LernAtlas der Anatomie / Michael Schünke, Erik Schulte, Udo Schumacher; illustrations by Markus Voll, Karl Wesker, 4th, revised and expanded edition). Stuttgart: Georg Thieme Verlag
- ↑ Jörg Jerosch: The functional compartment syndrome in sport ( Memento of the original from December 3, 2013 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 606 kB). In: Journal of Sports Medicine. 4, 2001, pp. 142f.
- ↑ J. Steffens et al: Complications in Urology 2. Springer, 2005, ISBN 3-7985-1543-3 , p. 232. (online at: books.google.de )
- ↑ a b Wolfgang Hach, Jörg D Gruss, Viola Hach-Wunderle, Michael Jünger: VenenChirurgie: Guide for vascular surgeons, angiologists, dermatologists and phlebologists. 2., update Edition. Schattauer, 2007, ISBN 978-3-7945-2570-6 .
- ↑ LC Maki, SE Kim, MD Winter, KY Kow, JA Conway, DD Lewis: Compartment syndrome associated with expansile antebrachial tumors in two dogs. In: Journal of the American Veterinary Medical Association. Volume 244, Number 3, February 2014, pp. 346-351, doi : 10.2460 / javma.244.3.346 , PMID 24432967 .
