lecture note about compartment syndrome

1. Compartment Syndrome
Mosheer Ziadi
R1

2. Objectives
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What is it
Definition
Pathophysiology
Eitology
Diagnosis
Sign and symptoms
Treatment

3. What is it ?
• Increase in hydrostatic pressure in closed
osteofascial space resulting in decreased
perfusion of muscle and nerves within
compartment.

4. What is it?
• RAISED PRESSURE WITHIN A CLOSED SPACE with a
potential to cause irreversible damage to the
contents of the closed space.

5. Definition
• Symptoms resulting from
increased pressure within a
limited space
– compromising
• circulation
• function

6. Pathophysiology
• A continuous increase in pressure within a
compartment occurs until the low
intramuscular arteriolar pressure is exceeded
and blood cannot enter the capillaries

7. Pathophysiology
• Increased compartment pressure
Increased venous pressure
Decreased blood flow
Decreases perfusion

8. Pathophysiology
• Autoregulatory mechanisms may
compensate:
– Decrease in peripheral vascular resistance
– Increased extraction of oxygen
• As system becomes overwhelmed:
– Critical closing pressure is reached
– Oxygen perfusion of muscles and nerves decreases

9. Muscle Ischemia
• 4 hours - reversible damage
• 8 hours - irreversible
changes
• 4-8 hours - variable
Hargens JBJS 1981

10. Muscle Ischemia
• Myoglobinuria after 4 hours
– Renal failure
– Maintain a high urinary output
– Alkalinize the urine
• Cell death initiates a “vicious cycle”
– increase capillary permeability
– increased muscle swelling

11. Increased muscle swelling
Increased
permeability
Increased compartment
pressure

12. • Increased pressure
Increased venous pressure
Decreased blood flow
Decreases perfusion

13. Nerve Ischemia
• 1 hour - normal conduction
• 1- 4 hours - neuropraxic damage
reversible
• 8 hours - axonotmesis and
irreversible change
Hargens et al. JBJS 1979

14. Pathophysiology:
• CAUSES:
• Increased Volume - internal :
hemmorhage, fractures, swelling from traumatized
tissue, increased fluid secondary to burns, post-ischemic
swelling
• Decreased volume - external: tight casts, dressings
• Most common cause of hemmorhage into a compartment:
fractures of the tibia, elbow, forearm or femur

15. Etiology
• Fractures
• Soft Tissue Injury (Crush)
• Arterial Injury
– Post-ischemic swelling
– Reperfusion injury
• Drug Overdose (limb compression)
• Burns

16. Fractures
• Most common cause
• Incidence accompanying compartment syndrome 9.1 %
• The Incidence is directly proportional to the degree of
injury to soft tissue and bone .
• Tibial diphesyal #
• Forearm #
• Distal radius #
Bick et al JBJS 1986

17. Arterial Injuries
• Secondary to
revascularization:
• Ischemia causes
damage to cellular
basement membrane
that results in edema
• With reestablishment
of flow, fluid leaks
into the compartment
increasing the
pressure.

18. Diagnosis
• Clinical diagnosis
– High index of suspicion
• Syndrome
– History
– Physical Exam

19. Difficult Diagnosis
• Classic signs of the 5 P’s - ARE NOT RELIABLE:
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pain
pallor
paralysis
pulselessness
paresthesias
• These are signs of an ESTABLISHED compartment
syndrome where ischemic injury has already
taken place
• These signs may be present in the absence of
compartment syndrome.

20. Signs & Symptoms
• Pain
–Passive muscle stretching
–Out of proportion
–Progressive
–Not relieved by immobilization

21. Diagnosis
• Pain
• Compartment pressure
– Confirmatory test
– Don’t just measure

22. Diagnosis
• Palpable pulses are usually present in
acute compartment syndromes unless an
arterial injury occurs.
• Sensory changes and paralysis do not
occur until ischemia has been present for
about 1 hour or more

23. Diagnosis
• The most important
symptom of an
impending
compartment
syndrome is PAIN
DISPROPORTIONATE
TO THAT EXPECTED
FOR THE INJURY

24. Signs & Symptoms
• Pain
–May be worse with elevation
–Patient will not initiate
motion on own
• Be careful with coexisting
nerve injury

25. Signs & Symptoms
• Parasthesia
–Secondary to nerve ischemia
• Must be differentiated from
nerve injury

26. Signs & Symptoms
• Paralysis (Weakness)
– Ischemic muscles lose function

27. Signs & Symptoms
• Tense compartment on palpation
• Elevated compartment pressure

28. Tissue Pressure
• Normal tissue pressure
– 0-4 mm Hg
– 8-10 with exertion
• Absolute pressure theory
– 30 mm Hg - Mubarak
– 45 mm Hg - Matsen
• Pressure gradient theory
– < 20 mm Hg of diastolic pressure – Whitesides
– < 30 mm Hg of diastolic pressure McQueen, et
al

29. Who is at high risk?

30. High energy fractures
• Severe
comminution
• Joint
extension
• Segmental
injuries
• Widely
displaced
• Bilateral
• Floating knee
• Open fractures

31. Impaired Sensorium
• Alcohol
• Drug
• Decreased
GCS
• Unconscious
• Chemically
unconscious
• Neurologic
deficit
• Cognitively
challenged

32. Diagnosis
• The presence of an open fracture does NOT rule out the
presence of a compartment syndrome
• 6-9% of open tibial fractures are associated with compartment
syndromes
• McQueen et al found no significant differences in
compartment pressures between open and closed tibial
fractures
• No significant difference in pressures between tibial fractures
treated with IM Nails and those treated with Ex-Fix

33. Most Common Locations
• Leg: deep posterior and the
anterior compartments
• Forearm: volar compartment,
especially in the deep flexor
area

34. Lower leg
• 4 compartmens:
Lateral:
• Proneus longus and previs
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• Anterior :
• EHL,EDC,tibialis anterior
,peroneus tertius
• Superficial post. :
• Gastrocnemius and soleus
.
• Deep posterior :
• Tibial posterior , FHL,FDL

35. Treatment
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Remove restricting cast:
*comaprtment pressure falls by 30% is split on one side.
*Falls by 65% when the cast spread after splitting
*Splitting the padding reduces it by further 10 % and
complete removalof cast by another 15%
• Serial exams
• When diagnosis made
– Immediate surgery
• 4 compartment fasciotomy
*Garfin, Mubarak JBJS 1981

36. Treatment
• Don’t wait so long..!

37. Treatment

38. Indication of fasciotomy

39. Fasciotomy Princeples

40. Treatment
• Fasciotomy
– One incision
• With or without
Fibulectomy
– Two (double) incisions
• All 4 compartments must
be released
– Not selective

41. Lower Leg

42. • Lateral compartment

43. • Anterior compartment

44. Lower Leg

45. Lower Leg

46. Two incisions
• Lateral
• Medial

48. Double Incision
• Anterolateral Incision

49. Double Incision
• Posteromedial Incision
• Soleus must be detached from tibia in
order to adequately decompress proximal
portion of deep posterior compartment

50. Thigh
• Rare
• Crush injury with femur fracture
• Over distraction
– relative under distraction

51. Thigh
• Quadriceps
–Lateral
• Hamstrings
–Posterior
• Abductor
–Medial

52. Treatment
• Based upon involvement
• Usually Quadriceps and
Hamstrings
• Usually, a single lateral incision
will suffice

53. Forearm

54. Treatment
• Volar- Henry approach:
• Include a carple tunnel releas
• Begins lateral to biceps tendon =>crosses elbow crease and
extends radially => extended distally along medial aspect of
brachioradialis =>extends across the palm along the thenar
crease.

55. Henry Approach
• Fascia over superficial muscles
is incised
• Care of NV structures

56. Volar-Henry Approach
• Brachioradialis and superficial
radial n. are retracted radially
and FCR and radial artery are
retracted ulnar to expose the
deep volar muscles
• Fascia of each of the deep
muscles is then incised
• Consider dorsal approach

57. Foot

58. Foot

59. Hand

60. Post Fasciotomy…
• Must get bone stability
– IMN
– exfix
• ~48hrs after procedure patient should
be brought back to OR for further
debridement
• Delayed skin closure or skin-grafting 37 days after the fasciotomies

61. Aftercare
• VAC dressings
• Elevation of limb
• Delayed wound closure
– Split thickness skin graft

62. Remember…
• Fasciotomies are not benign
• Complications are real >25%
– Chronic swelling
– Chronic pain
– Muscle weakness
– Iatrogenic NV injury
– Cosmetic concerns
*** BUT if they are needed do not come up with
excuses to not do them !!!

63. Take home message
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Very important to make diagnosis
Missed compartment is devastating
Physical exam
Re-examine patient!