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
Vendaje Escara por Uso
militar quirúrgico de
circunferencial quemadura o prolongado de
antichoque 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
•Espectroscopia
•INR •RMN
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
intravTernaotaumsdierinptiond30emsinnudtreosm(oeneaptilmasetpaemri6etnoto8ch)o.n(2a)nStoiodxiuimdaanetsecsin.ate20
mg, S2a1lvmiaaMscilti,1or.rmhizaani2to0lm20lw%e,re2.deisossoclvinedatroesspoedcitcivoe,ly5ian7isodtioansicOsDal.ineor 5%
gluco3s0em2m00hmglfaasncdiodtroipmpeiad.bRyeisnutrlatavednoosu:smdiroipgl(o5b0intao6d0isdmriipnsuypeeremnin2uate3).The
drugs were used for 5 to 7 days (one time per day). Basifying urine, keeping the
negadtiivaes.liqCuoidnbcalulasnicoena:nEdleulescotrodleyteanbtailoaxncide,anprteevsenetninegtianpfeacstionand hold out
treattmeemnptrwaenreasdodnies.mWinheunyethleapcreosnsturraecotfumrauspcousa l trisoqstueeomfasicciaa.lcompartment was
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
co a gu lo pa th y a n d e m e rg e nc y f asc io to my is th e re c o mm e nd e dt re a tm e nt .W e
S C e n p a c c onc oa gu lopatíap o r enfe m e da d t em i na lh ep átic a, la
present a cirrhotic patient with a short life expectancy who developed compartment
syFnadsrocmneooefsthelalemgesjeocronredasrpyuteosstpao.nCtaonrereougsirbclueeadgiunglo.pTahtisapyatfaiesnctudnederwent
faescmioetorgmeyncoifatheesleegltarandtrseucbosmeqeunednatldyod.ePveac l opceridropseirssihsteepnattpicoastotepremraintiavelbleeding
andderseaqruroirleladSreCpepaoterdsatrnagnsrafumsiioennstoofebslpooodntaanndebol.oSodepreroadliuzcatsf.aTshceypraetiqeunitere
ev e n tua ly ex p ir ed in t he ho s p it al 1 m on th a f te rs ur g er y .R ES U LT S: Compartment
p o s t m úl ti p les tra ns f us i on es .P a c f al le ce alm e s d e c ri u gi a .
syndrome of the leg occurring in patients with coagulopathy secondary to cirrhosis
isRveersyudltifafidcuolst:tofamsacneangee.sCtooasguploapcasthoybrinetpheesseanpaltaiesntcsom i shpalricdtdoecnororectand
cornesatalinztabrlfeaesdcin.gfrom 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
anaSlgCeAsicetnecphineiqrnueaoynetlheefdeicagtonodseisaonfacolgmepsairatmpeonsttsoypnedrroamtoer,iaofewnheiclh23
discduisasgendoesptidicuora.lPaancalgbeasjioa.aInna3lg2eosfia35eppiadtuiernatlss,ecladsiasigcnsoigsntsicaanudnsySmCpctoomnsof
comepxaarmtmeenntclsinynicdoronmoeswieenrdeopreelsdenotloinrethlesipnrteosmenaceproinfceippiadlu.rRaleaanliazlgaensdiao,
including 18 patients with documented breakthrough pain. There were no
ranudonmbiuzeednceoxn.trCollinedicotriyalsteonrieonudtcoompree-sbeasnetedlcaomsopsapraetcivheatrdiaelsuanvSaiClabyleto
inclmudideieinntdhoelraevpierews.ioPanincoismopftaerntimdeescnrtiablesdeadsitahgencoasrtdicinaalSsCymAptomof
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
d ec re as ed t iss ul ar o xy g en ati o n, i nd ica t ing an in su f ici en t s ec o nd ar y mic r oci rc u la ti on.
P at o lo gia y O p c i o n d ia g no sti ca de S C enp iern a s . O b je tivo :e v a lua r
Materials and methods: 16 patients were examined in our study (12 males, 4 females,
mperaongaregse:io6n2.d7e+/S-9C.5myeidairesn),dwohporuensdioernwienntraaccuotmep l oawretrimlimenbtraelvyasmcuolanritzoarteioondsuergery
fodrisamcrinitiucaclio(lnasdtiengomxiogreentahcanio4nhtiosuursla) rl,iminbdiisccahnemdoia.mTihceroincdiriccautliaoncsiownedree:fi5ciieliancte
a rt e ry em bol iza ti on s a nd 1 1 f e m or al ar t er y occ lu sio n s. Afte r re v asc u la r iza ti on , o n t he
se c unpostoperative
second da r ia. 16 paday, c rewev asdetected
c u la riz asignificant
c io n (2 dilowera P Olimb ). R edema
e s u ltaand d osswelling
: 12 ca sofos
sIeCvePra>l4gr0amdem.Thogm–oSnittOor2th5e0elev–5a3te%ds i netrarceoamlipzaartfmasecnitoaltopmreisas.ur4ec(IaCsPo)sanICdPto2e5valuate th–
e3e5xtmremmihtaglc–ircSutlOat2ionn,owrmeuasl.edCKoOnDcIlAuGsipornes:seurleumseotedreanICdPtheytmisseudlairdoaxydgeen
s at ur ati on ( S tO 2 ) w as m ea su re d b y ne ar - inf ra re d- sp ectroscopy.Results: In 12 cases the
s a tu ra cio n a yu d a a l a d e ci s io n qu ir ur g ic a .
ICP exceeded the critical 40 mmHg. 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.