Universidad Central de Venezuela

Instituto Nacional de los Seguros sociales

Hosp. Dr. Miguel Pérez Carreño
Servicio de Traumatología y Ortopedia II

Febrero 2009 Dra. Erika Rojas G.

Residente de 1er año
SINDROME COMPARTIMENTAL
CONTENIDO

• DEFINICION
• ETIOLOGIA
• FISIOPATOLOGIA

• SINTOMAS
• SIGNOS
• EXAMENES PARACLINICOS

• DIAGNOSTICO DIFERENCIAL
• TRATAMIENTO
• COMPLICACIONES

• TRABAJOS PUBLICADOS
• CONCLUSION
• REFERENCIAS
 SINDROME COMPARTIMENTAL
HISTORIA

1881: Richard Von Volkmann, Contractura postraumatica

de la Extremidad lo atribuye a isquemia del musculo
esqueletico.

1926: Jepson, Incremento de presion compartimental

desarrolla isquemia muscular y descompresion temprana
previene contractura.

1940: Segunda Guerra Mundial y Vietnam (Norman

Rich), Fasciotomia en Campo de Batalla.
 SINDROME COMPARTIMENTAL
DEFINICION

Síndrome Compartimental (SC) (Compartment Syndrome): Elevación de la

presión intersticial, por arriba de la presión de perfusión capilar dentro de un
compartimento osteofacial cerrado, con compromiso del flujo sanguíneo en
músculo y nervio, lo que condiciona daño tisular.
 SINDROME COMPARTIMENTAL
ETIOLOGIA

Disminución en el tamaño del compartimento

Compresión o constricción externa

Pantalón Cierre
Escara por Uso
militar Vendaje quirúrgico de
quemadura o prolongado de
antichoque circunferencial defectos
congelacion torniquete
(MAST). fasciales
 SINDROME COMPARTIMENTAL
ETIOLOGIA

Incremento del contenido del

compartimento
Sangre Edema Fluidos (exógenos)
• Trauma (fractura, lesión • Isquemia/reperfusión • Infusión intracompartimental
vascular) • Lesiones eléctricas
• Desórdenes de la • Infusión interósea
coagulación • Trombosis venosa
• Terapia anticoagulante • Ejercicio
• Posterior a cirugía cardiaca
• Choque
• Rabdomiólisis
• Eclampsia
• Síndrome nefrótico
 SINDROME COMPARTIMENTAL
CLASIFICACION

Síndrome Compartimental Agudo (SCA)

Sindrome Compartimental Cronico (SCC)

Sindrome por Aplastamiento (Crush Syndrome)

 SINDROME COMPARTIMENTAL
CLASIFICACION

Síndrome Compartimental Agudo (SCA)

Presion
Intracompartimental

ISQUEMIA Retorno
Venoso

Presion Perfusion
Arterial Capilar
 SINDROME COMPARTIMENTAL
CLASIFICACION

Sindrome Compartimental Cronico (SCC)

Secundaria a Insuficiente Incremento de la

Oxigenación
disminución del perfusión del presión
tisular deficiente
retorno venoso tejido muscular compartimental
 SINDROME COMPARTIMENTAL
CLASIFICACION

Sindrome por Aplastamiento (Crush Syndrome)

• Efectos sistémicos secundarios
• Isquemia grave de múltiples compartimentos por Ruptura de las células musculares

• Libera a la circulación mioglobina y potasio (Hipercalemia)

• Respuesta inflamatoria grave

• Pérdida de líquidos al tercer espacio

• Acidosis metabólica
• Falla renal aguda y choque

• Requiere de apoyo inmediato por UCI

• Manejo agresivo de líquidos y uso de hemodiálisis

• Fasciotomía temprana de las extremidades afectadas

 SINDROME COMPARTIMENTAL
DIAGNOSTICO

HISTORIA CLINICA

SINTOMAS

SIGNOS

EXAMENES PARACLINICOS
 SINDROME COMPARTIMENTAL
SIGNOS Y SINTOMAS

DOLOR

PULSO PRESION

SC
PARALISIS PARESTESIA

PALIDEZ
 SINDROME COMPARTIMENTAL
EXAMENES PARACLINICOS

LABORATORIO IMAGENOLOGIA OTROS

•Hematologia Completa •Rayos X •Medicion de Presion
•PT, PTT •Ecosonograma Doppler Compartimental
•INR •RMN •Espectroscopia
Infrarroja (Oximetro)
•Perfil Hepatico
•Urea, Creatinina
•Mioglobina
•CK, CKMB
•Electrolitos Sericos
•Examen de Orina
 SINDROME COMPARTIMENTAL
DIAGNOSTICO DIFERENCIAL

Distension Muscular

Periostitis

Fractura Tibial por Estres

Fractura Peronea por Estres

Neuropraxia del Nervio Peroneo

Compresion de la Arteria Poplitea

Tendinitis del Tibial Posterior

Sindrome de Estres Tibial Interno

Trombosis Venosa Profunda

Estenosis Raquidea

Hernia de un Nucleo Pulposo Lumbar

Neuropatia Periferica Diabetica

Enfermedad vascular Periferica

 SINDROME COMPARTIMENTAL
TRATAMIENTO

ATENCION DEL PACIENTE

POLITRAUMATIZADO (ABCD)

Fasciotomia del
Muslo

Anterior Interno Posterior

 SINDROME COMPARTIMENTAL
TRATAMIENTO

ATENCION DEL PACIENTE

POLITRAUMATIZADO (ABCD)

Fasciotomia de la
Pierna

Posterior Posterior
Anterior Lateral
Profundo Superficial
 SINDROME COMPARTIMENTAL
TRATAMIENTO

ATENCION DEL PACIENTE

POLITRAUMATIZADO (ABCD)

Fasciotomia del
Antebrazo

Anterior Posterior Lateral

 SINDROME COMPARTIMENTAL
COMPLICACIONES

Contractura Isquemica de Volkmann:

Necrosis de musculos isquemicos.
 Treatment for crush syndrome of extremities with antioxidants

Zhongguo Gu Shang. 2008 Feb;21(2):109-10. PMID: 19105470 [PubMed - in process]

Department of Orthopaedics, Coal General Hospital of Henan Province, Zhengzhou
450002, Henan, China.

OBJECTIVE: To study the clinical therapeutic effect of antioxidants assistant

treatment of extremities crush syndrome (CS)in order to find new therapy.
METHODS: Twenty-one male patients (aged from 24 to 48 years, mean 36 years)
were treated with the next antioxidants in early stage: (1) 20% Mannitol 250 ml
intravenous drip in de
Tratamiento 30 minutes
sindrome (one time per 6 to 8 con
aplastamiento h). (2) Sodium aescinate 20
antioxidantes.
mg, Salvia
21 masc,Miltiorrhiza 20 ml
1. manitol were
20%, 2.dissolved
eoscinato respectively
sodico, 5 in
a7 isotonic saline or 5%
dias OD.
glucose 200 ml and dripped by intravenous drip (50 to 60 drips per minute). The
30mmhg fasciotomia. Resultados: mioglobina disminuye en 2 a 3
drugs were used for 5 to 7 days (one time per day). Basifying urine, keeping the
dias.liquid
negative Conclusion: El electrolyte
balance and uso de antioxidantes en etapas
balance, preventing infection and hold out
treatment were done.
tempranas When the
disminuye lapressure of muscular
contractura osteofascial compartment was
postisquemica.
more than 30 mmHg, deep fasia was cut to decompress timely and the above-
mentioned drugs were continuously applied for patients. RESULTS: Myoglobin urine
of 21 cases died out after 2 to 3 days, of them, 13 cases were performed to
decompress. After open decompression, 2 cases suffered from amputation because
of long time of ischemia, 2 cases took place slight dysfunction of lower limbs, one
hand had ischemia muscular contracture in 1 case and one foot down-vertical in 1
case. After followed-up of 8 months to 1 year, according to the function standard,
the result were excellent in 8 cases, good in 7 cases, fair in 2 cases, poor in 4
cases. The excellent and good rate was about 71.4% (15/21). CONCLUSION: After
extremities crushed for long time, application of antioxidents as early as possible
can decrease significantly the incidence and invalidity rate of CS.
 Compartment syndrome of the leg in the coagulopathic, end-stage liver disease patient:
Fasciotomy is not the best answer.

Int J Surg. 2008 Dec;6(6):e31-3. Epub 2006 Nov 1. PMID: 19059130 [PubMed - in
process]. Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles,
CA, USA.

BACKGROUND: Compartment syndrome of the leg secondary to spontaneous

bleeding has been described in coagulopathic patients. Correction of the
coagulopathy and emergency fasciotomy is the recommended treatment. We
SC enapac
present con patient
cirrhotic coagulopatía porlife
with a short enfemedad
expectancyteminal hepática,
who developed la
compartment
Fasc noofes
syndrome laleg
the mejor respuesta.
secondary Corregir bleeding.
to spontaneous cuagulopatia y fasc underwent
This patient de
fasciotomy
emergencia of the
es leg and recomendado.
el trat subsequently developed persistent
Pac cirrosis postoperative
hepatica terminal bleeding
and required SC
desarrolla repeated transfusions ofespontaneo.
por sangramiento blood and blood
Se products. Theypatient
realiza fasc requiere
eventually expired in the hospital 1 month after surgery. RESULTS: Compartment
post múltiples
syndrome transfusiones.
of the leg Pac fallece
occurring in patients with al mes de cirugia.
coagulopathy secondary to cirrhosis
is Resultados:
very difficult tofasc en estos
manage. pac sobrepesan
Coagulopathy las complic
in these patients decorrect
is hard to no and
constant
realizarbleeding
fasc. from fasciotomy site is a major complication mandating frequent
transfusions of blood and blood products. The complications of fasciotomy in these
patients may outweigh the complications of untreated fasciotomy, particularly in
patients with a short life expectancy. CONCLUSIONS: Fasciotomy is not always the
best treatment for compartment syndrome of the leg. In certain patients,
particularly in the coagulopathic, end-stage cirrhotic patient with a short life
expectancy who is not a candidate for liver transplantation, fasciotomy is not
indicated. Fasciotomy should be used selectively, if at all, in patient population with
end-stage and terminal diseases.
Acute compartment syndrome of the lower limb and the effect of postoperative analgesia
on diagnosis.

Br J Anaesth. 2009 Jan;102(1):3-11. Epub 2008 Nov 19. PMID: 19022795 [PubMed -
indexed for MEDLINE]. Department of Anaesthesia, St Vincent's Hospital, Melbourne,
PO Box 2900, Fitzroy, 3065 VIC, Australia. gjpmar@yahoo.com.au

Acute compartment syndrome can cause significant disability if not treated early,
but the diagnosis is challenging. This systematic review examines whether modern
acute pain management techniques contribute to delayed diagnosis. A total of 28
case reports and case series were identified which referred to the influence of
SCA en
analgesic pierna on
technique y el efecto
the de analgesia
diagnosis of compartmentpostoperatoria
syndrome, ofen el 23
which
discussed epidural Pac
diagnostico. analgesia. In 32 of 35epidural
bajo analgesia patients,seclassic signs and
diagnostica unsymptoms
SC con of
compartment syndrome
examen clinico were present
no siendo in el
el dolor the presence
sintoma of epidural
principal. analgesia,
Realizando
including 18 patients with documented breakthrough pain. There were no
un buen controlled
randomized ex. Clinico y teniendo
trials presente la
or outcome-based sospechatrials
comparative de un SC y to
available
midiendo
include in the la presion
review. Paincompartimental
is often described seasdiagnostica
the cardinalSCA
symptom of
compartment syndrome, but many authors consider it unreliable. Physical
examination is also unreliable for diagnosis. There is no convincing evidence that
patient-controlled analgesia opioids or regional analgesia delay the diagnosis of
compartment syndrome provided patients are adequately monitored. Regardless of
the type of analgesia used, a high index of clinical suspicion, ongoing assessment of
patients, and compartment pressure measurement are essential for early diagnosis.
 Pathology and diagnostic options of lower limb compartment syndrome

Clin Hemorheol Microcirc. 2009;41(1):1-8. PMID: 19136736 [PubMed - in process].

Department of General and Vascular Surgery, Faculty of Medicine, University of Pécs,
Pécs, Hungary.

Background: The indication of surgical treatment in lower limb compartment syndrome

mostly depends on the clinical signs which can be often uncertain, resulting in delayed
insufficient intervention. Aim: The aim of the study was to evaluate the progression of
compartment syndrome by measuring of intracompartmental pressure and monitoring of
decreased tissular oxygenation, indicating an insufficient secondary microcirculation.
Patologia
Materials and y Opcion16diagnostica
methods: patients were de SC eninpiernas.
examined our studyObjetivo:
(12 males,evaluar
4 females,
progresion
mean de SC midiendo
age: 62.7+/-9.5 years), whopresion
underwentintracompartimental y monitoreo de
acute lower limb revascularization surgery
for a critical (lasting
disminucion more than 4 hours)
de oxigenacion tisular,limb ischemia.microcirculacion
indicando The indications were: 5 iliac
deficiente
artery embolizations and 11 femoral artery occlusions. After revascularization, on the
secundaria.
second 16 pac
postoperative revascularizacion
day, (2 dia
we detected significant PO).
lower Resultados:
limb 12 casos
edema and swelling of
ICP >40mmhg
several – StO2the
grade. To monitor – 53% intracompartmental
50elevated se realiza fasciotomia. 4 casos
pressure ICP
(ICP) and to 25
evaluate
the extremital
– 35 mmhg circulation, we used
– StO2 normal. KODIAG pressure
Conclusion: meter
el uso deand
ICPthey tissular
medida oxygen
de
saturation (StO2) was measured by near-infrared-spectroscopy. Results: In 12 cases the
saturacion
ICP exceeded the ayuda a 40
critical la mmHg.
decision quirurgica.
In these patients the average StO2 was 50-53%, in
spite of complete recanalization. In these cases we made urgent, semi-open fasciotomy.
In 4 cases, where the clinical aspect showed compartment syndrome, the measured
parameters did not indicate a surgical intervention (ICP: 25-35 mmHg, StO2: around
normal).Summary: A novel approach in our examination is that, besides empirical
therapeutic guidelines generally applied in clinical practice, we established an objective,
parameter-based ("evidence based medicine") surgical indication strategy for the lower
limb compartment syndrome. Our parameter results produced by the above pressure and
saturation measurements help the clinicians to decide between conservative and
operative treatment of the disease.
 SINDROME COMPARTIMENTAL
REFERENCIAS

Arato, E. y cols. Pathology and diagnostic options of lower limb compartment syndrome. Clin Hemorheol Microcirc.
2009;41(1):1-8. PMID: 19136736 [PubMed - in process]. Department of General and Vascular Surgery, Faculty of
Medicine, University of Pécs, Pécs, Hungary. 2009.

Bucholz, R. y cols. Rockwood y Green, Fracturas en el Adulto. Editorial MARBAN. Philadelphia, USA. 2003.

Caceres, E. y cols. Manual SECOT de cirugia ortopedica y traumatologia. Editorial Panamericana, Espana, 2004.

Fitzgerald, R. y cols. Ortopedia. Editorial Panamericana. St. Louis Missouri, USA. 2004.

Fu, CG. Treatment for crush syndrome of extremities with antioxidants. Zhongguo Gu Shang. 2008 Feb;21(2):109-
10. PMID: 19105470 [PubMed - in process] Department of Orthopaedics, Coal General Hospital of Henan Province,
Zhengzhou 450002, Henan, China.

Mar, GJ. y cols. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on
diagnosis. Br J Anaesth. 2009 Jan;102(1):3-11. Epub 2008 Nov 19. PMID: 19022795 [PubMed - indexed for MEDLINE].
Department of Anaesthesia, St Vincent's Hospital, Melbourne, PO Box 2900, Fitzroy, 3065 VIC, Australia.
gjpmar@yahoo.com.au. 2009.

Mendoza, A. y Manzo, H. Síndrome compartimental en extremidades. Conceptos actuales. Compartment

syndrome in the extremities. Current concepts. Servicio de Cirugía General. Hospital General Balbuena. DDF.
México. Cirujano General Vol. 25 Núm. 4 – 2003.

Milanchi, S. y cols. Compartment syndrome of the leg in the coagulopathic, end-stage liver disease patient:
Fasciotomy is not the best answer. Int J Surg. 2008 Dec;6(6):e31-3. Epub 2006 Nov 1. PMID: 19059130 [PubMed - in
process]. Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA. 2008.