i bc27f85be50b71b1 (122 page)

• Biophosphanate administration

VASCULAR SYSTEM AND HEMATOLOGY

399

Compartment Syndrome

Compartment syndrome is the swelling in the muscle compartments

(myotendon, neural, and vascular structures contained withjn a fascial

compartmenr of an extremiry) that can occur after traumatic injury to

the arteries. These injuries include fractures, crush injuries, hematomas,

penetrating injuries, circumferential burn injury, electrical injuries, and

status post revascularization procedures. External factors, such as casts

and circular dressings that are too constrictive, may also lead to compartment syndrome.6.'8.J6 Compartment syndrome can also occur as a chronic condition that develops from overuse associated with Strenous

exercise. Diagnosis of comparrment syndrome is established by measuring compartment pressures. Comparrment pressures of 25-30 mm Hg can cause compression of capillaries.J6

A common symptOm of compartment syndrome is pain associated

with tense, tender muscle groups that worsens with palpation or passive movement of the affected area. Numbness or paralysis may also be accompanied by a gradual diminution of peripheral pulses. Pallor,

which indicates tissue ischemia, can progress to tissue necrosis if

appropriate management is nOt performed.6,'8.J6

Management of compartment syndrome consists of preventing

prolonged external compression of the involved limb, limb elevation,

and, ultimately, fasciotomy (incisional release of the fascia) if compartment pressures exceed 30-45 mm Hg. Mannitol can also be used to help reduce swelling.6.18.36

Clinical Tip

• Patient, staff, and family eduction on proper positioning techniques can reduce the risk of swelling and subsequent compartment syndrome .

• The physical therapist should delineate any range-ofmotion precautions that may be present after fasciotomies

that cross a joint line.

Venous Disorders

Varicose Veins

Varicose veins arc chronic dilations of the veins that first result from a

weakening in the venous walls, which then leads to improper closure

of the valve cusps. Incompetence of the valves further exacerbates the

400 AClJfE CARE HANDBOOK FOR PHYSICAL THERAPISTS

venous dilatation. Risk factors for developing varicose veins include

increasing age, occupations that require prolonged standing, and obesity (in women).37 The occurrence of venous thrombosis can also promote varicose vein formation. Patients generally complain of itchy, tired, heavy-feeling legs after prolonged standing.6•J7

Management of varicose veins may consist of any of the following:

behavioral modifications (e.g., avoiding prolonged sitting or standing

and constrictive clothing), weight loss (if there is associated obesity),

elevating the feet for 10-15 minutes 3 or 4 times a day, gradual exercise, applying well-fitting support stockings in the morning, showering or bathing in the evening, sclerotherapy (to close dilated veins), and surgical ligation and stripping of incompetent veins.6•37

Venous Thrombosis

Venous thrombosis can occur in the superficial or deep veins (deep venous

thrombosis [DVT1) and can result from a combination of venous stasis,

injury to the endothelial layer of the vein, and hypercoagulability. The primary complication of venous thrombosis is pulmonary embolism (PE).6

The following arc risk factors associated with venous thrombosis

formation 18,38:

• Surgery and nonsurgical trauma, such as lower-extremity fracture

• Immobilization

• Limb paresis or paralysis

• Heart failure or myocardial infarction

• Previous DVT

• Increasing age

• Malignancy

• Obesity

• Pregnancy

• Use of oral contraceptives

Signs and symptoms of venous thrombosis can include the

following18,,,:

• Pain and swelling distal to the site of thrombus

• Redness and warmth in the area around the thrombus

VASCULAR SYSTEM AND HEMATOLOGY

401

• Dilated veins

• Low-grade fever

• A dull ache or tightness in the region of DVT

Clinical Tip

• Homans' sign (pain in upper calf with forced ankle dorsiflexion) has been lIsed as a screening tool for venous

thrombosis, but it is an insensitive and nonspecific test that

has a very high false-positive rate.1.3 .... o

• A positive Homans' sign accompanied by swelling, redness, and warmth may be more clinically indicative of a

DVT than is a positive Homans' sign alone.

• Ultimately, examination by vascular diagnostic tests,

such as venous duplex scanning,l8 and laboratOry testing of

clotting times (PT and PTT), is a better method to evaluate

the presence of DVT.

• Physical therapy intervention for patients with suspected DVT should be withheld until cleared by the medical-surgical team.

Prevention of venous thrombosis includes avoidance of immobilization; lower-extremity elevation or application of compression stOckings (elastic or pneumatic), or both, if bed rest is required; and

anticoagulation medications (intravenous heparin or oral warfarin

[CoumadinJ).

Management of venous thrombosis may also consist of anticoagulation therapy, thrombolytic therapy (streptOkinase and urokinase), or both, and surgical thrombectomy (limited uses).6 Current research has

demonstrated that ambulation while wearing compression stockings as

early as 24-72 hours after adequate anticoagulation therapy has been

attained will prevent extension of the thrombus and formation of PE."

Pulmonary Embolism

PE is the primary complication of venous thrombosis, with emboli

commonly originating in the lower extremities. Other sources are the

upper extremities and pelvic venous plexus. Mechanical blockage of a

pulmonary artery or capillary, depending on clot size, results in an

acute ventilation-perfusion mismatch that leads to a decrease in partial pressure of oxygen and oxyhemoglobin saturation, which ultimately manifests as tissue hypoxia. Chronic physiologic sequelae