Early Fasciotomy Research Articles

Massive Soft Tissue Infections: Necrotizing Fasciitis and Purpura Fulminans

Necrotizing fasciitis and purpura fulminans are two destructive infections that involve both skin and soft tissue. Necrotizing fasciitis is characterized by widespread necrosis of subcutaneous tissue and the fascia. Historically, group A beta-hemolytic streptococcus has been identified as a major cause of this infection. However, this monomicrobial infection is usually associated with some underlying cause, such as diabetes mellitus. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is polymicrobial. The diagnosis of necrotizing fasciitis must be made as soon as possible by examining the skin inflammatory changes. Magnetic resonance imaging is strongly recommended to detect the presence of air within the tissues. Percutaneous aspiration of the soft tissue infection followed by prompt Gram staining should be conducted with the "finger-test" and rapid-frozen section biopsy examination. Intravenous antibiotic therapy is one of the cornerstones of managing this life-threatening skin infection. Surgery is the primary treatment for necrotizing fasciitis, with early surgical fasciotomy and debridement. Following debridement, skin coverage by either Integra Dermal Regeneration Template or AlloDerm should be undertaken. Hyperbaric oxygen therapy complemented by intravenous polyspecific immunoglobulin are useful adjunctive therapies. Purpura fulminans is a rare syndrome of intravascular thrombosis and hemorrhagic infarction of the skin; it is rapidly progressive and accompanied by vascular collapse. There are three types of purpura fulminans: neonatal purpura fulminans, idiopathic or chronic purpura fulminans, and acute infectious purpura fulminans. Clinical presentation of purpura fulminans involves a premonitory illness followed by the rapid development of a septic syndrome with fever, shock, and disseminated intravascular coagulation. The diagnosis and treatment of these conditions is best accomplished in a regional burn center in which management of multiple organ failure can be conducted with aggressive debridement and fasciotomy of the necrotic skin. The newest revolutionary advancement in the treatment of neonatal purpura fulminans is the use of activated protein C.

Management Of Peripheral Vascular Trauma: Our Experience

Introduction: The incidence of vascular trauma has increased considerably during the past 40 years. However, although they represent less than 3% of all injuries, they deserve special attention because of their severe complications. The study is to analyses the causes of injury, presentations, surgical approaches, outcome and complication of vascular trauma of the upper and lower limbs. Methods: A retrospective analyses of twelve years. From January 1992 to December 2004, 662 patients were operated for peripheral vascular injuries. Diagnosis was made by physical examination and hand Doppler alone or in combination with Doppler scan/angiography. Primer vascular repair was carried out where possible; if not possible the interposition vein graft was placed. Early liberal fasciotomy was considered as and when required. Patients with isolated venous trauma and patients with obviously unsalvageable lower extremity injury requiring primary amputation were excluded from the study. Result: Five hundred and eighty of the patients were males (88%) and eighty two of them were females (12%), and their ages ranged from 4-65 years (mean 24 years). Mean duration of presentation was ten hours after the injury. The most common etiological reason was road traffic accidents i.e. 70% in penetrating trauma group and 52% amongst all blunt traumas. Incidence of concomitant orthopedic injuries was very high in our study (70.2%). The most common injured artery was brachial artery (32.6%), followed by popliteal artery (29.7%).Surgical procedures performed were primary repair in 55.5%, whereas interposition vein grafts were placed in 35.2% cases. The limb salvage rate was 94.2%. Conclusion: Patients who suffer vascular injuries to the extremities should be transferred to vascular surgery centers as soon as possible. Decisive management of peripheral vascular trauma will maximize patient survival and limb salvage. Priorities must be established in the management of associated injuries, and delay must be avoided when ischemic changes are present. Early fasciotomy is warranted if there is any suspicion of occurrence of compartment syndrome.

Le syndrome de Volkmann néonatal. À propos de deux cas

Neonatal Volkmann's compartment syndrome is a rare entity. This diagnosis may be suspected when a case presents cutaneous damage associated with poor hand and wrist function after delivery. We present two such cases of neonatal Volkmann compartment syndrome with long term clinical and x-ray follow-up. In our patients, a hand surgeon was not consulted in the perinatal period and early fasciotomy was not performed. No particular aetiology or associated cerebrovascular accident was found. A series of operations was necessary in order to improve function of the hand. Neonatal Volkmann compartment syndrome must be recognised early in order to enable further investigation of any underlying condition and to perform early surgical decompression. Long term clinical and x-ray follow-up is necessary to prevent and treat wrist deformation and finger contractures.

THE MEDICAL-LEGAL ASPECTS OF COMPARTMENT SYNDROME

Management of compartment syndrome in the modern era involves not only avoiding the sequelae of a missed diagnosis but also minimizing the risk of a malpractice claim. Little information is available on the legal aspects of compartment syndrome. Twenty-three years of records on closed malpractice claims involving compartment syndrome were reviewed. The data were abstracted from medical records and were analyzed to determine the factors associated with a successful defense. Nineteen closed claims, involving sixteen patients and encompassing a total liability of 3.8 million USD, were found in the data for malpractice claims closed between 1980 and 2003. Ten claims were resolved in favor of the physician. The average time to closure was 5.5 years. All three claims that went to trial resulted in a verdict for the physician. Evidence of poor physician-patient communication was found in six cases, all of which resulted in an indemnity payment (p < 0.01). Increasing time from the onset of symptoms to the fasciotomy was linearly associated with an increased indemnity payment (p < 0.05). A fasciotomy performed within eight hours after the first presentation of symptoms was uniformly associated with a successful defense. While malpractice claims involving compartment syndrome were uncommon, they resulted in a high rate and amount of indemnity payments. Early fasciotomy not only improves patient outcome but is also associated with decreased indemnity risk.

Neglected Compartment Syndrome caused by Folk Remedy: Two Case Reports

Compartment syndrome usually develops as a result of traumatic musculoskeletal injury or vascular injury. Early diagnosis and emergency fasciotomy are mandatory for the decompression of compartment pressure in the acute stage. Minor trauma or a non traumatic event can cause compartment syndrome. No report was available of the folk remedy. We report upon two cases of neglected compartment syndrome caused by a folk remedy.

Compartment syndrome in burn patients: A report of five cases

Compartment syndrome has been observed in five burn patients. In all five patients the diagnosis was delayed and muscle necrosis occurred. Three limbs in two patients required amputation because of complete muscle necrosis, and the function of limbs in the three other patients was affected to different degrees. It is suggested that early limb escharotomies or fasciotomies in patients with full-thickness burns is necessary. Dressing should not be very tightly wound in limbs that have been grafted and the sensory and motor function of fingers or toes must be monitored carefully as well as distal circulation in limbs after operation.

Acute compartment syndromes.

Acute compartment syndrome is both a limb- and life-threatening emergency that requires prompt treatment. To avoid a delay in diagnosis requires vigilance and, if necessary, intracompartmental pressure measurement. This review encompasses both limb and abdominal compartment syndrome, including aetiology, diagnosis, treatment and outcome. A Pubmed and Cochrane database search was performed. Other articles were cross-referenced. Diagnosis of limb compartment syndrome is based on clinical vigilance and repeated examination. Many techniques exist for tissue pressure measurement but they are indicated only in doubtful cases, the unconscious or obtunded patient, and children. However, monitoring of pressure has no harmful effect and may allow early fasciotomy, although the intracompartmental pressure threshold for such an undertaking is still unclear. Abdominal compartment syndrome requires measurement of intra-abdominal pressure because clinical diagnosis is difficult. Treatment is by abdominal decompression and secondary closure. Both types of compartment syndrome require prompt treatment to avoid significant sequelae.

Systemic cytokine response in children bitten by snakes in Costa Rica

To characterize the host response to venom from snakes of the family Viperidae in Costa Rica, we investigated the release of cytokines: IL-1, IL-6, IL-8, TNF-alpha, MIP-1beta, and RANTES in pediatric patients who were bitten by a snake. Patients were included in this study if they were admitted to the hospital within 24 hours of the snakebite. Blood samples were taken immediately on admission to the hospital, and then at intervals of 3, 12, and 24 hours, and on days 3, 5, and 7 after the accident. Patients received gentamicin plus clindamycin or gentamicin plus penicillin intravenously for a minimum of 3 days or longer if necessary. IL-1, IL-8, TNF-alpha, MIP-1beta, and RANTES were determined by monoclonal antibody-based ELISAs, while IL-6 was determined by bioassay. Eighteen patients were included in this study; 15 were bitten by Bothrops asper and three by B. lateralis. Eleven patients were male. Median (range) age was 9 (1-12) years. Nine patients had detectable serum concentrations of IL-6 (200 pg/ mL) and IL-8 (51 pg/mL) on admission, increasing to 500 pg/mL and 115 pg/mL for IL-6 and IL-8, respectively, during the first 12-24 hours. Cytokine concentrations returned to normal or undetectable ranges by 72 hours. TNF-alpha concentrations peaked at 12 hours (mean: 48 pg/mL). Low, but detectable concentrations of MIP-1beta were observed in some patients at various time intervals (48 pg/mL), whereas IL-1 was not detectable at any time point. Regulated on Activation Normal T cell Expressed and Secreted (RANTES) concentrations were evaluated in only five patients, being elevated in all of them. Patients with elevated cytokine concentrations required early fasciotomy (<24 hours after the accident) more often than those who had normal or undetectable cytokine concentrations (P < 0.05). There were no statistically significant associations between severity of envenomation, or outcome, and elevated serum cytokine concentrations (P > 0.05). Bothrops sp snake venoms induce clinical and pathophysiologic alterations similar to acute trauma, with release of proinflammatory cytokines. A better understanding of the role of the inflammatory response could lead to the development of new therapeutic strategies to improve the outcome in snakebitten patients.

Venomous snakebites in children and adolescents: a 12-year retrospective review

Snakebite envenomation is a worldwide problem and in Costa Rica. The following is a retrospective review of 79 patients admitted to the Hospital Nacional de Niños (HNN) from January 1985 to September 1996. Child's age ranged from 9 months to 14 years. The M: F ratio was 1.5:1. Sixty percent of the patients lived in remote rural areas. The most common clinical signs at the time of hospitalization were pain and edema. Fifty patients (63,29%) showed moderate to severe envenomation grades. Fifty-one (64,55%) was caused by Bothrops asper. Complications during hospitalization were compartment syndrome and secondary infection. Three children died, one from disseminated intravascular coagulation, another from renal insufficiency, and the third from a perforated duodenal ulcer. Patients who underwent early fasciotomy had significantly less hospitalization and fewer infectious complications, (p < 0.001). There was no relationship between the envenomation grade and length of hospitalization (p = 0.4). The most common pathogen isolated was S. aureus. Early fasciotomy seemed to reduce the complications seen in these patients. Further studies are necessary to identify the factors that may help clinicians to decide those who should undergo fasciotomy, as well as the best moment to perform it.

Effect of early fasciotomy on intramuscular pressure and electrical excitability of muscles in experimental compartment syndrome

Effect of early fasciotomy on intramuscular pressure and electrical excitability of muscles in experimental compartment syndrome

The orthopaedic management of peripheral ischaemia in meningococcal septicaemia in children

Between March 1993 and February 1999, 14 children aged from eight months to 14.75 years were admitted to the paediatric intensive-care unit with meningococcal septicaemia in association with severe peripheral ischaemia. Of these, 13 were operated upon, eight of whom had early fasciotomies. Five children died. Of the nine survivors, one had no amputations while in the other eight 14 limb segments were amputated. We review the case histories and propose a protocol for the early management of these children.

The orthopaedic management of peripheral ischaemia in meningococcal septicaemia in children.

Between March 1993 and February 1999, 14 children aged from eight months to 14.75 years were admitted to the paediatric intensive-care unit with meningococcal septicaemia in association with severe peripheral ischaemia. Of these, 13 were operated upon, eight of whom had early fasciotomies. Five children died. Of the nine survivors, one had no amputations while in the other eight 14 limb segments were amputated. We review the case histories and propose a protocol for the early management of these children.

Effect of early fasciotomy on intramuscular pressure and electrical excitability of muscles in experimental compartment syndrome.

Experiments on rabbits with compartment syndrome of the leg showed that the main pathogenetic factors of muscle injury are postischemic contracture leading to extravascular microcirculatory disorders and tissue necrosis(early postcompression period) and progressive subfascial edema (18 h-4 days). Therapeutic effect of fasciotomy in the early period consists in restoration of bloodflow due to relaxation of contracted muscles and in the late period in decompression of edematous muscles and prevention of secondary ischemia. Fasciotomy through a small section does not lead to sufficient relaxation of rigid muscles and does not essentially increase the subfascial volume. Fasciotomy decreases subfascial pressure and muscle excitability threshold, however they remain considerably elevated during day 1. An electrodiagnostic test is proposed for early (before subfascial edema) detection of postischemic contracture.

Microvascular response to compartment syndrome-like external pressure elevation: an in vivo fluorescence microscopic study in the hamster striated muscle.

To quantitatively assess the nature and the magnitude of the microvascular response of striated muscle tissue upon elevation of external pressure, as in compartment syndrome. Using the skinfold chamber model in Syrian golden hamsters and intravital fluorescence microscopy, we studied the individual response of the different segments of the microcirculation, i.e., the arterioles, capillaries, and postcapillary venules, in terms of vasomotor control (change of vessel diameter) and cessation of blood flow upon defined changes in external tissue pressure. The unique findings of our study are that (1) arteriolar flow ceased at mean external pressures of 25.6+/-2.4, 28.3+/-2.8, 34.5+/-4.6, and 44.4+/-6.8 mm Hg in vessels with diameters of less than 20, 20 to 40, 40 to 60, and greater than 60 microm, respectively, without signs of spasm or collapse even at a pressure maximum of 70 mm Hg, whereas (2) in venules the increase of external pressure was associated with a diameter reduction ranging from 5 to 25% with cessation of blood flow at mean external pressures between 27 and 33 mm Hg. Blood flow ceased in 50% of the muscle capillaries already at an external pressure of 12 mm Hg. Thus, at distinct external pressure levels venous and capillary blood flow ceased, but arterioles were still capable of carrying flow, which was directed along arteriolo-arteriolar "thoroughfare" channels. To restart blood flow, external pressure had to be decreased by 9, 11, 15, and 17 mm Hg in arterioles with diameters of less than 20, 20 to 40, 40 to 60, and greater than 60 microm, and by approximately 9 mm Hg in venules regardless of vessel diameter. Capillary blood flow was found to be restored at a mean reduction of external tissue pressure of approximately 4 mm Hg. Our study disproves the critical closing theory but complies-in particular because of the supposed constriction-induced increase of venular resistance-with the hypothesis of reduced arteriovenous pressure gradients as the cause of flow cessation in compartment syndrome. The necessity of a substantially increased perfusion pressure gradient to restart blood flow in arterioles, capillaries, and venules confirms the existence of yield stress in these microvessels. The high susceptibility of capillaries to elevated external pressure indicates the necessity of early fasciotomy to restore impaired nutritive circulation in cases of compartment syndrome.

UPPER EXTREMITY PEDIATRIC COMPARTMENT SYNDROMES

Fractures are associated with the majority of compartment syndromes in children. Respect for associated soft-tissue injuries and recognition of specific fractures that can put a limb at risk for compartment syndrome are essential for prevention or successful treatment with early decompressive fasciotomies. In those limbs at risk for compartment syndrome, percutaneous pinning or intramedullary fixation provides fracture stabilization and prevents problems noted with standard cast treatment. Any condition that causes increased tissue pressure within a limited space can lead to compartment syndrome, however. It therefore is important to identify the injured, ill, or hospitalized child with unexplained changes in pain status or soft tissues. In particular, the agitated child with increasing analgesia requirements requires a thorough evaluation. The child's behavior should not be attributed to young age, fear, or fracture pain. This is a trap that must be avoided to prevent the disastrous outcomes of a missed compartment syndrome.

Alternatives in the management of penetrating injuries to the iliac vessels.

The high mortality and morbidity rates after iliac vessel injuries remain a challenging problem for trauma surgeons. Several controversial issues surround the management of iliac vessel injuries, including the value of abbreviated laparotomy, the role of extra-anatomic bypass reconstruction (EABR), the use of vascular prostheses in the presence of contamination, and the need and timing for fasciotomy. Retrospective review of the records of patients who sustained an injury to the iliac vessel between 1987 and 1996. A total of 64 patients were treated, including 23 with isolated iliac vein injuries, 17 with arterial injuries, and 24 with combined arteriovenous injuries. Vascular prostheses were placed in 17 patients with arterial injuries, including 12 with associated intestinal wounds. Graft infection did not occur. Of the 24 patients with combined injuries, 11 underwent abbreviated laparotomy and 1 died. Five deaths, however, occurred in 13 patients in whom no attempts were made for damage control laparotomy. Significant differences between survivors and nonsurvivors included final arterial pH, final prothrombin time, length of hypotension, and number of transfusions. Arterial ligation with EABR was performed in five patients and failed in two. Deep venous thrombosis and pulmonary embolism occurred in four patients, in three of them after venous injuries were ligated. The overall mortality rate was 23%. Our findings show that (1) abbreviated laparotomy reduces mortality in iliac injuries; (2) EABR should be performed early after stabilization to prevent limb ischemia; (3) the use of vascular prostheses with associated intestinal injuries did not appear to increase the incidence of graft infection; and (4) after vein ligation, early fasciotomy and prophylaxis against extremity swelling, deep venous thrombosis, and pulmonary embolism should be considered.

Purpura Fulminans

Victims of purpura fulminans are overcome by a rapidly progressive and sometimes fatal course involving large amounts of tissue loss and multiple organ system failure. From 1986 to 1995, seven children ranging in age from 10 months to 19 years (mean, 6.2 years) were referred to the Shriners Burns Institute in Cincinnati with purpura fulminans. Neisseria meningitidis was identified as the precipitating pathogen in most of the patients. The mean TBSA full-thickness skin loss was 33%. Fourteen extremities were amputated in the seven patients, including three patients with amputations of all four extremities. Transfer to our institution occurred after a mean delay of 20 days, usually after the demarcation of viable tissue. In one patient, however, fasciotomies obviated multiple impending amputations. Monitoring for elevated compartment pressures, early fasciotomies, and expedient transfer to a burn center for a multidiciplinary approach to care should improve the outcome in patients with purpura fulminans.

Upper Extremity Fasciotomy: Sufficiency of Clinical Assessment and Relationship to Persistent Functional Deficit

The authors analyzed 11 upper extremity fasciotomies performed for specific clinical indications following trauma and evaluated the reliability of the clinical diagnosis and causes of postsurgical reduced functional recovery. Tissue-pressure measurements were not used in this study. Types of injury in 11 study patients included: four (36%) gunshot, three (27%) blunt, three (27%) intravascular drug injections, and one (9%) shotgun. Average time from injury to fasciotomy was 9.25 (range: 2 to 18) hours. After follow-up evaluation at 6 weeks to 3 months, four (36%) patients had full functional recovery of the limb; 7 (64%) had diminished function. Two patients required amputation: one after a shotgun injury complicated by sepsis and another in a drug-abuse patient with pressure necrosis secondary to an extended period of prehospital unconsciousness. Diagnosis of upper extremity compartment syndrome was reliably made by using specific and accepted clinical criteria. Despite early fasciotomy, significant morbidity resulted.

The effect of early versus late fasciotomy in the management of extremity trauma

Background . Recent reports have demonstrated an increase in the number of complications associated with delayed timing of fasciotomy for trauma. This study examines the effectiveness of early (less than 12 hours) versus late (more than 12 hours) fasciotomy in the injured extremity. Methods . This is a retrospective review of 88 patients undergoing fasciotomy for extremity trauma admitted to the University of Cincinnati from January 1990 through December 1995. Records were reviewed for demographics, compartment pressures, time and type of fasciotomy, complications, limb salvage, and mortality. Statistical analysis was determined with chi-squared, multivariant regression analysis, and Student's t test with significance at p less than 0.05. Results . Sixty-one (69%) patients had fasciotomy performed before 12 hours and twenty-seven (31%) after 12 hours. Although the rates of infection differed significantly between the two groups (7.3% for early versus 28% for late), the rates of limb salvage and neurologic sequelae were similar. Age, mechanism, shock, associated injuries, and time to fasciotomy were not predictive of complications. Conclusions . Fasciotomy for trauma is most efficacious when performed early. However, when performed late, it results in similar rates of limb salvage as compared with early fasciotomy but at the increased risk of infection. These results support aggressive use of fasciotomy in extremity trauma regardless of time of diagnosis.

Peripheral gangrene associated with fulminating meningococcal septicaemia: Is early escharotomy indicated?

We present a case of a 3-month-old boy presenting with fulminating meningococcal septicaemia associated with extensive peripheral gangrene requiring amputation of three limbs. The surgical management options and the role of early fasciotomy are discussed.