To save this limb the main problem is not the fractured bones, but the injury to the surrounding soft tissues.
- Initially: There is a injury to the muscle and blood vessels.
- Danger: The injured muscle tissue swells. Formation of an intramuscular hematoma adds to the swelling.
- Compartment syndrome: Being contained innside the fascia compartment, the intramuscular pressure increases. First he veines collapse making the pressure to rise further. Then also the arteries collapse. Blood perfusion innside the muscle is blocked.
Why is it important?
We need to prevent reperfusion syndromes!
When tissue blood perfusion remains poor form more than 2 hours – and then the blood perfusion is re-established,
trigger chemicals are released from local endothelial cells that creates a chain reaction similar to the post-injury stress response.
This reperfusion syndrome does not only affect the injured limb; it affects the global body physiology with increased risk of organ failure, sepsis, and death.
Prevent fracture infection!
The muscle tissue at the fracture site is impregnated with dirt and bacteria – especially so in blast and fragment fractures. specially when systolic blood pressure is low!
- Poor blood perfusion increases the risk of anaerobic infections.
- Poor blood perfusion restricts white blood cell access to the infected site.
Actual perfusion pressure = (actual systolic blood pressure) – (intramuscular pressure)
In hypotensive patients even slight increase in compartment pressures may cause artery collapse.
Do fasciotomy on ready indications!
Fasciotomy also of foot and hand
The muscle compartments of the sole of the foot and the palm of the hand are narrow and tight. Even moderate swelling of intrinsic muscles plus hematoma formation may cause compartment syndromes and local circulatory collapse.
- Make decision on clinical signs – no need for transducer measurements!
- The first sign of compartment hypoperfusion is increasing pain.
- Feeling of numbness and loss of motor function is a late sign.
High-energy injury + swelling + increasing pain = fasciotomy there and then !
Fasciotomy – also of amputation stumps
“Hidden” compartment syndromes - Some amputation wounds don’t bleed – why is that so?
Probably because the blast wave was transmitted along the bones into proximal muscle compartments – causing “hidden” intramuscular wounds, injuries to the vascular intima, and compartment syndromes.
Fasciotomy is urgent!
Warning: below knee amputations!
We would think that the amputation wound decompressed all muscle compartments, that fasciotomies of the stump would not be necessary. It is not that simple.
Only if the below-knee stump length is less than 1/3 will the stump be decompressed at the end – and fasciotomies not indicated.
In high-energy traumatic transtibial amputations mid-shaft or below there will regularly be too high intramuscular pressures in residual limb – especially inside the anterolateral compartment. Don’t even wait for the surgical operation, but do immediate anterolateral fasciotomy in the emergency room as limb salvage maneuver.