Laporan Kasus Seorang Laki-laki Usia 70 Tahun dengan Stroke Ischemic. Bagian Ilmu Penyakit Saraf FK UMS 2013Deskripsi lengkap
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January 2014Full description
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Makalah Prosedur Pemeriksaan Pada Pasien Akut Lim IskemikFull description
Laporan Kasus Seorang Laki-laki Usia 70 Tahun dengan Stroke Ischemic. Bagian Ilmu Penyakit Saraf FK UMS 2013
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Objective To address, in a practical way, the acute treatment of ischemic cerebrovascular accident CVA based on the scientific recommendations latest. Methods A bibliographic search was performed in the PubMed, Scopus, Scielo and Uptodate database fr
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Guideline Acute Ischemic Stroke AHA 2018 (Translated to Bahasa). 6 subtopik: 1. prehospital stroke management and system of care, 2. emergency evaluation, 3. Emergencu Supportive care and tr…Full description
VOLKMANN¶S ISCHEMIC CONTRACTURE Definition : A condition which is characterized by ischemic necrosis of the structures contained within the volar compartment of the forearm associated with crippling contractures and varying degrees of neurologic deficit.
HISTORY 1881, Volkmann stated that paralytic contractures that develop within a few hours after injury are caused by arterial insufficiency or ischemia of muscles.
HISTORY 1906, Hildebrand first used the term "Volkmann ischemic contracture" to describe the final result of any untreated compartment syndrome. 1909, Thomas found that paralytic contractures followed severe contusions of the forearm without fractures. 1914, Murphy reported that increased internal pressures in the deep compartments of the forearm due to hemorrhage and effusion in the muscles resulted in ischemia.
HISTORY 1928, Jones concluded that Volkmann¶s contracture could be caused by pressure from within, from without or both.
Volkmann¶s ischemic contracture is a late sequela of untreated or inadequately treated compartment syndrome in which necrotic muscle and nerve tissue are replaced with fibrous tissue
ANATOMY At the entrance to the flexor compartment of the forearm, the lacertus fibrosus fans medially from the biceps tendon. Beneath the lacertus fibrosus the brachial artery and median nerve pass to enter the flexor compartment.
ANATOMY The brachial artery divides into radial and ulnar arteries.
The radial artery courses superficially and is not crossed by any structure in the forearm.
The ulnar artery passes beneath the pronator teres where it gives a major branch, the common interosseus artery.
The common interosseus artery further divides into volar and dosal interosseus arteries.
ANATOMY The median nerve accompanies the brachial artery beneath the lacertus fibrosus and enters the substance of the pronator teres passing between its humeral and ulnar heads.
ANATOMY Compartments of the forearm. 1.
Superficial volar compartment.
2.
Deep volar compartment.
3.
Dorsal compartment.
4.
Mobile wad of Henry.
ETIOLOGY Supracondylar fractures of the humerus in children is the most common precipitating injury. The brachial artery may get impinged on the sharp proximal fragment against which it is held by lacertus fibrosus.
ETIOLOGY
Hemorrhage and edema may further compress the brachial artery and the median nerve in this region.
ETIOLOGY
Ischemia ± Edema cycle as depicted by Eaton and Green
ETIOLOGY Other Causes : 1.
Crush injuries.
2.
Prolonged external compression.
3.
Internal bleeding (Hemophilia).
4.
Burns.
5.
Snake bites.
6.
Intravenous regional anesthesia.
ETIOLOGY Tolerance of tissue. 1.
Muscle : - functional impairment after 22-4 -4 hours of ischemia. - Irreversible functional loss after 4-12 4-12 hours.
2.
Nerves : - functional impairment after 30 mins of ischemia. - Irreversible function loss after 12--24 12 -24 hrs.
CLINICAL PICTURE Acute compartment syndrome (Impending Volkmann¶s Volkmann¶ s ischemic contracture) 2. If arterial If arterial injury is the cause : Stretch pain Parasthesia Pulselessness Pallor ( or Cyanosis) Paresis
CLINICAL PICTURE Two point discrimination is more than 1 cm in the sensory zone of the median nerve.
Diminished perception of vibratory sense of 256 cycles/sec stimulus.
CLINICAL PICTURE Measurement of intracompatmental pressure : 1.
Whitesides handheld pressure monitoring system.
2.
Wick catheter.
3.
Slit catheter.
CLINICAL PICTURE Evaluating the intracompartmen intracompartmental tal pressure. - Range between 10 ± 20 mmHg below the diastolic
pressure ± cessation of blood flow is eminent. - 40 ± 50 mmHg ± muscle threatening compression and
ischemia are present. - Pressure of 30 of 30 mmHg or greater ± greater ± criterion for
fasciotomy.
Deformities in Volkmann¶s ischemic contracture. Mild type :
Deep flexors are partially involved particularly, Flexor digitorum profundus.
Flexion contractures of one or more fingers which can be extended on hyperflexing the wrist.
Resistant pronation contracture involving either the pronator teres or pronator quadratus.
Deformities in Volkmann¶s ischemic contracture Moderate type :
Involves most of the flexor digitorum profundus, flexor pollicis longus and part of flexor digitorum superficialis.
Neurological deficit involving median nerve more than ulnar nerve is present.
Deformity is intrinsic minus hand.
Diminished sensations in median and ulnar nerve zones.
Deformities in Volkmann¶s ischemic contracture Severe type :
All the flexor muscles are involved.
Neurological deficit is severe.
Joint contractures are marked.
Wasting of forearm muscles .
MANAGEMENT ± ACUTE COMPARTM COMPARTMENT ENT SYNDROME (IMPENDING VIC)
Incision : A volar curvilinear liberal incision medial to the biceps tendon, crossing the elbow flexion crease at an angle carring it distally to the palm to release the carpal tunnel.
MANAGEMENT ± ACUTE COMPARTM COMPARTMENT ENT SYNDROME (IMPENDING VIC) Exploration must extend deeply to the FDP and FPL. Necrotic muscle tissue is excised. Median nerve freed beneath the lacertus fibrosus. Ulnar nerve is freed and transplanted anteriorly. Brachial artery must be inspected and decompressed. Surgical wound is left open for secondary closure later when swelling subsibes. Extremity suppoted with splint in funtional position.
CONSERVATIVE MANAGEMENT ESTABLISED ESTABLISE D DEFORMITIES Robert Jones method (1930s). Wooden tongue depressors were used to correct established deformities gradually from distal to proximal over a prolonged period of time .
CONSERVATIVE MANAGEMENT ESTABLISED ESTABLISE D DEFORMITIES Banjo splint : Banjo B anjo splint used with rubber bands fastened to adhesive tape on the fingers permits the fingers to be exercised at all times and is most efficient.
ESTABLISHED VOLKMANN¶S ISCHEMIC CONTRACTURE - MANAGEMENT
Muscle sliding operation of flexors of forearm.
Inglis & Cooper
Williams
& Haddad
INGLIS & COOPER
Incision on the medial aspect of volar side of the arm 5 cm proximal to medial epicondyle epicondyle and distally to midpoint of forearm over the ulna.
INGLIS & COOPER
Ulnar nerve is identified, released from the cubital tunnel and protected. Tendinous origins of muscles on the medial epicondyle are cut. Flexor carpi ulnaris and Flexor digitorum profundus are completely released from the medial epicondyle and ulna.
INGLIS & COOPER
Lacertus fibrosus is divided along with any remaining portions of the flexor muscle origin. Ulnar nerve is trasposed anteriorly.
WILLIAMS AND HADDAD
Medial aspect of arm and forearm anterior to the medial epicondyle of the humerus, beginning 5 cm proximal to the elbow extending distally to 5 cm proximal to the wrist.
WILLIAMS AND HADDAD
Structures anterior and medial to the elbow are exposed.
WILLIAMS AND HADDAD
Lacertus fibrosus is divided. Origins of the superficial flexors are released from the medial epicondyle. Origin of flexor digitorum superficialis is released from radius
WILLIAMS AND HADDAD
Origin of Flexor carpi ulnaris is released from olecronon. Common origin of flexor carpi ulnaris and flexor digitorum profundus are released from ulna.
WILLIAMS AND HADDAD
Origin of flexor digitorum profundus is released from volar aspect of ulna and interosseous membrane.
WILLIAMS AND HADDAD
Origin of flexor digitorum profundus to the index finger is released from radius.
WILLIAMS AND HADDAD
Ulnar nerve is transplanted anteriorly into brachialis muscle.
AFTER SURGERY Sutures are removed after 3 weeks. Extension hand splint should be worn for 3 months. Occupation and physiotherapy should be continued until desirable function is attained.
