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Thermography by Specialty
Published in James Stewart Campbell, M. Nathaniel Mead, Human Medical Thermography, 2023
James Stewart Campbell, M. Nathaniel Mead
Severe crush injuries or comminuted fractures of the limbs may be complicated by the development of Compartment Syndrome (CS), where hematoma or edema increase the tissue pressure inside a closed fascial space, cutting off the arterial blood supply to the muscles within that space. Even milder injuries or a cast that is applied too tightly may cause CS. Arterial pulses distal to the injury usually remain full. Severe pain occurs and muscle necrosis may result unless emergency fasciotomy is performed to relieve the compartment pressure. Forearm fractures involving both radius and ulna, as well as tibial fractures of the leg, are most prone to CS complications.25 A study using thermography to aid in the detection of CS showed a highly significant “thigh-foot index” (TFI), or difference between thigh and ankle temperatures, of over 8°C (150F) in the involved leg as compared to about 2°C (3.6°F) in the uninvolved normal leg (Figure 11.8).26
Managing Crush Injuries on Arrival
Published in Kajal Jain, Nidhi Bhatia, Acute Trauma Care in Developing Countries, 2023
Sarvdeep Singh Dhatt, Deepak Neradi
Open wounds should be managed with extensive debridement and fasciotomy if needed. Early debridement is incomplete and repeat debridement might be required in the future. For closed wounds, fasciotomy should be performed in case of absent pulses or compartment syndrome. If pulses are intact and have no compartment syndrome, fasciotomy is contraindicated in closed crush injury due to high morbidity and mortality (due to sepsis) associated with fasciotomy. Crushed muscle without restoration of blood supply for the significant duration is already dead and non-salvageable. Fasciotomy in crush injuries is associated with a high risk of life-threatening infections, morbidity and sequelae, requiring surgical intervention due to which there is a lot of controversy regarding whether fasciotomy improves outcome. Despite this, in presence of clinical signs (pain on passive muscle stretch, motor weakness, hypoaesthesia) or objective signs (raised compartmental pressure) of compartment syndrome, fasciotomy should be performed within 6 hrs. After 24 hrs, muscles become necrosed dead and fasciotomy is contraindicated in such cases due to high risk of life-threatening sepsis.
Inferior heel pain
Published in Maneesh Bhatia, Essentials of Foot and Ankle Surgery, 2021
Dishan Singh, Shelain Patel, Karan Malhotra
Surgical strategies include plantar fasciotomy, lengthening the gastrocnemius-soleus complex or both these techniques. Release of the medial head of the gastrocnemius has been shown in some studies to have a beneficial effect on symptoms, but no randomised studies have been carried out. Fasciotomy can be accomplished through percutaneous, open and endoscopic techniques. Releasing a maximum of 50% of the plantar fascia is suggested, since the risk of medial arch collapse and lateral column overload increases beyond this value (23, 24). Broadly speaking all three techniques are associated with significant improvements in the modern literature. Lengthening the gastrocnemius-soleus complex can be accomplished at various levels along the myotendinous unit. A recent randomised trial identified comparable outcome scores between open plantar fasciotomy and posteromedial gastrocnemius recession, although the latter technique was associated with a faster recovery (25).
Comparison and convergence of compartment syndrome techniques: a narrative review
Published in Expert Review of Medical Devices, 2023
Naveen Sharma, Nitin Mohan Sharma, Apurva Sharma, Sarfaraj Mirza
As stated above, ACS is generally considered a medical emergency. The aim is to decrease the pressure inside the compartment, so that tissue damage can be minimized. Any external splint, cast, or dressing may also be removed to lower the ICP [54]. One sided release of the plaster cast can result in a reduction of pressure by 30%, whereas bivalving the cast may help in reducing another 35% pressure, and cutting the dressing may reduce the ICP by 10 to 20% [55]. However, the widely accepted treatment for CS is surgical, as clinical treatments are doubted and need much time and history. For ACS, fasciotomy (surgery) is the only treatment available. In fasciotomy, the muscle compartment is opened up to let the muscle tissue swell, lower the pressure, and allow blood flow to return. Fasciotomy is the procedure of exposing the skin and muscular fascia covering the affected compartment or compartments at abnormal regions. It allows more blood flow to reach the tissue by releasing compartment pressure from enclosed muscle. But before treatment, it should be 100% certain whether the pain is due to the presence of CS or not. That means, the symptoms and indications for performing a fasciotomy must be taken into account.
Moderate-to-severe Vipera berus envenoming requiring ViperaTAb antivenom therapy in the UK
Published in Clinical Toxicology, 2021
Thomas Lamb, David Stewart, David A. Warrell, David G. Lalloo, Pardeep Jagpal, Dacia Jones, Ruben Thanacoody, Laurence A. Gray, Michael Eddleston
Four patients underwent surgery during their hospital admission resulting in an increased length of hospital stay (median of 6 days). One case underwent a fasciotomy without prior assessment of compartmental pressure (Table 3). The resulting surgery revealed healthy muscle. A further case was due to undergo imminent fasciotomy before advice to reconsider altered the plan and a conservative approach was taken. The patient with severe local envenoming with marked oedema of the thorax, after a bite on the hand, was effectively treated with antivenom only, after measurement of compartmental pressures showed normal pressures (Table 3). Local cytotoxicity from V. berus envenoming can result in marked soft tissue oedema but seldom if ever results in compartment syndrome. Both ultrasound and compartmental pressure assessment have been strongly advocated to distinguish extra fascial from subfascial oedema, thus limiting surgical intervention where possible [32–34].
Cottonmouth snake bites reported to the ToxIC North American snakebite registry 2013–2017
Published in Clinical Toxicology, 2020
K. Domanski, K. C. Kleinschmidt, S. Greene, A. M. Ruha, V. S. Bebarta, N. Onisko, S. Campleman, J. Brent, P. Wax
One patient in our series underwent a fasciotomy for a suspected but unconfirmed compartment syndrome. Animal studies reflect that morbidity and mortality are increased following prophylactic fasciotomy when compared to antivenom [16,17]. In a review of 99 publications evaluating the efficacy of fasciotomy in animals and humans, the author could not identify any situation in which surgery was beneficial [18]. An expert panel consisting of trauma surgeons and medical toxicologists also concluded that prophylactic fasciotomy was not beneficial and was possibly harmful [19]. The same authors concluded that, even in the case of confirmed compartment syndrome, the initial treatment should be additional doses of antivenom, not fasciotomy. The rationale, supported by animal studies, is that elevated compartment pressure represents a severe envenomation but is not the cause of the morbidity. Rather, it is the venom causing the damage, and neutralizing the venom is the definitive treatment [20].