骨科英文书籍精读（32）｜骨折早期并发症之骨筋膜室综合征
COMPARTMENT SYNDROME
Fractures of the arm or leg can give rise to severe ischaemia, even if there is no damage to a major vessel. Bleeding, oedema or inflammation (infection) may increase the pressure within one of the osseofascial compartments; there is reduced capillary flow, which results in muscle ischaemia, further oedema, still greater pressure and yet more profound ischaemia – a vicious circle that ends, after 12 hours or less, in necrosis of nerve and muscle within the compartment.
Nerve is capable of regeneration but muscle, once infarcted, can never recover and is replaced by inelastic fibrous tissue (Volkmann’s ischaemic contracture). A similar cascade of events may be caused by swelling of a limb inside a tight plaster cast.
Clinical features
High-risk injuries are fractures of the elbow, forearm bones, proximal third of the tibia, and also multiple fractures of the hand or foot, crush injuries and circumferential burns. Other precipitating factors are peration (usually for internal fixation) or infection.
The classic features of ischaemia are the five Ps:
· Pain
· Paraesthesia
· Pallor
· Paralysis
· Pulselessness.
However in compartment syndrome the ischaemia occurs at the capillary level, so pulses may still be felt and the skin may not be pale! The earliest of the ‘classic’ features are pain (or a ‘bursting’ sensation),
altered sensibility and paresis (or, more usually, weakness in active muscle contraction). Skin sensation should be carefully and repeatedly checked.
Ischaemic muscle is highly sensitive to stretch. If the limb is unduly painful, swollen or tense, the muscles (which may be tender) should be tested by stretching them. When the toes or fingers are passively hyperextended, there is increased pain in the calf or forearm.
Confirmation of the diagnosis can be made by measuring the intracompartmental pressures. So important is the need for early diagnosis that some surgeons advocate the use of continuous compartment pressure monitoring for high-risk injuries (e.g. fractures of the tibia and fibula) and especially for forearm or leg fractures in patients who are unconscious. A split catheter is introduced into the compartment and the pressure is measured close to the level of the fracture. A differential pressure (ΔP) – the difference between diastolic
pressure and compartment pressure – of less than 30 mmHg (4.00 kilopascals) is an indication for immediate compartment decompression.
Treatment
The threatened compartment (or compartments) must be promptly decompressed. Casts, bandages and dressings must be completely removed – merely splitting the plaster is utterly useless – and the limb should be nursed flat (elevating the limb causes a further decrease in end capillary pressure and aggravates the muscle ischaemia). The ΔP should be carefully monitored; if it falls below 30 mmHg, immediate open fasciotomy is performed. In the case of the leg, ‘fasciotomy’ means opening all four compartments through medial and lateral incisions. The wounds should be left open and inspected 2 days later: if there is muscle necrosis, debridement can be carried out; if the tissues are healthy, the wounds can be sutured (without tension) or skin-grafted.
NOTE: If facilities for measuring compartmental pressures are not available, the decision to operate will have to be made on clinical grounds. If three or more signs are present, the diagnosis is almost certain (Ulmer, 2002). If the clinical signs are ‘soft’, the limb should be examined at 30-minute intervals and if there is no improvement within 2 hours of splitting the dressings, fasciotomy should be performed. Muscle will be dead after 4–6 hours of total ischaemia – there is no time to lose!
---from 《Apley’s System of Orthopaedics and Fractures》P687-688
重点词汇整理：
COMPARTMENT SYNDROME筋膜室综合征
ischaemia/is'ki:miə/n. 局部贫血
oedema /ɪˈdiːmə/n. [病理] 水肿；[植] 瘤腺体
osseofascial compartments 骨筋膜室
fascial筋膜的
capillary flow 毛细血管血流
capillary /ˈkæpəleri/n. 毛细血管；毛细管；微血管adj. 毛细管的；毛状的；表面张力的
a vicious circle恶性循环
vicious /ˈvɪʃəs/adj. 恶毒的；恶意的；堕落的；有错误的；品性不端的；剧烈的
infarcted /in'fa:ktid/adj. （血管）梗塞的
inelastic fibrous tissue非弹性纤维组织
inelastic /ɪnɪ'læstɪk/adj. 无弹性的；无适应性的；不能适应的
elastic/ɪˈlæstɪk/n. 松紧带；橡皮圈adj. 有弹性的；灵活的；易伸缩的
Volkmann’s ischaemic contracture缺血性肌挛缩
cascade /kæˈskeɪd/n. 小瀑布，瀑布状物；串联vi. 像瀑布般大量倾泻下来vi. 像瀑布般悬挂着
proximal third of the tibia,胫骨近三分之一处，
crush injuries挤压伤
circumferential burns圆周烧伤
circumferential /sɚ,kʌmfə'rɛnʃəl/adj. 圆周的
precipitating factors诱因
/prɪˈsɪpɪteɪtɪŋ/adj. 起沉淀作用的；急落的；猛冲的
peration穿刺
· Pain 疼痛
· Paraesthesia 感觉异常
· Pallor 苍白
· Paralysis 麻痹；无力
· Pulselessness. 无脉
altered sensibility and paresis感觉异常和麻痹
Ischaemic muscle is highly sensitive to stretch.缺血肌肉对伸展高度敏感。
unduly /ˌʌnˈduːli/adv. 过度地；不适当地；不正当地
swollen or tense, 肿胀或紧张,
swollen/ˈswoʊlən/adj. 肿胀的，浮肿的；浮夸的；激动兴奋的v. 膨胀；隆起（swell的过去分词）
passively hyperextended, 被动的过度伸展
calf /kæf/n. [解剖] 腓肠，小腿；小牛；小牛皮；(鲸等大哺乳动物的)幼崽
intracompartmental pressures. 间室内压力
differential pressure压力差；压差
diastolic pressure 舒张压/ˌdaɪəˈstɑːlɪk/adj. 心脏舒张的
immediate compartment decompression. 立即筋膜室切开减压
utterly useless完全没用；一点儿用处也没有
the limb should be nursed flat 四肢应平放
fasciotomy /fæʃi'ɔtəmi/n. [外科] 筋膜切开术
百度翻译：
室间隔综合征
手臂或腿的骨折会导致严重的缺血，即使主血管没有损伤。出血、水肿或炎症（感染）可能会增加一个骨筋膜室内的压力；毛细血管流量减少，导致肌肉缺血，进一步水肿，更大的压力和更严重的缺血-一个恶性循环，在12小时或更短的时间内结束，神经和肌肉坏死隔间。
神经可以再生，但肌肉一旦梗死，就永远无法恢复，取而代之的是非弹性纤维组织（沃尔克曼缺血性挛缩）。类似的连锁反应也可能是由于石膏石膏内的肢体肿胀引起的。
临床特征
高风险损伤包括肘部、前臂骨、胫骨近端三分之一的骨折，以及手或脚的多处骨折、挤压伤和周围烧伤。其他诱发因素是手术（通常用于内固定）或感染。
缺血的典型特征是5个P：
·疼痛
·感觉异常
·苍白
·瘫痪
·无脉动。
然而，在室间隔综合征中，缺血发生在毛细血管水平，因此仍能感觉到脉搏，皮肤可能不会变白！最早的“经典”特征是疼痛（或“爆发”的感觉），
敏感性改变和轻瘫（或者，更常见的是，肌肉活动性收缩无力）。皮肤感觉应仔细反复检查。
缺血肌肉对拉伸高度敏感。如果肢体过度疼痛、肿胀或紧张，则应通过拉伸肌肉（可能是柔软的）进行测试。当脚趾或手指被动过度伸展时，小腿或前臂疼痛加剧。
可通过测量心内压来确诊。早期诊断的必要性非常重要，因此一些外科医生提倡对高危损伤（如胫腓骨骨折）尤其是昏迷患者的前臂或腿部骨折使用持续室压监测。一个分裂的导管被引入隔间，压力的测量接近骨折的水平。压差（ΔP）——舒张压和室压之间的压差——小于30 mmHg（4.00千帕）是立即室压减压术的指征。
治疗
受到威胁的隔间必须立即减压。石膏、绷带和敷料必须完全去除——仅仅是拆开石膏是完全无用的——肢体应该护理平整（抬高肢体会导致末端毛细血管压力进一步降低，并加重肌肉缺血）。应仔细监测ΔP；如果低于30mmhg，应立即行开放性筋膜切开术。对于腿部，“筋膜切开术”是指通过内侧和外侧切口打开所有四个腔室。伤口应保持开放，2天后检查：如有肌肉坏死，可清创；如组织健康，可缝合（无张力）或植皮。
注：如果没有测量室压的设施，则必须根据临床情况决定手术。如果出现三个或更多的症状，诊断几乎是肯定的（Ulmer，2002）。如果临床症状是“软”的，应每隔30分钟检查一次肢体，如果在拆开敷料的2小时内没有改善，则应进行筋膜切开术。肌肉将在4-6小时的完全缺血后死亡-没有时间失去！