Ext.Sawanya Saowapap
Hadyai hospital
Compartment Syndromes
Definition
Types
Pathophysiology
Etiology
Clinical evaluation
Diagnosis
Management
Complicat...
Definition
An elevation of the interstitial pressure in a closed

osteofascial compartment that results in
micrvascular c...
Types of compartment syndrome
Acute compartment syndrome (ACS)
 medical emergency
 caused by a severe injury
 can lead...
Pathophysiology of ACS
The vicious cycle of
Volkmann's ischemia
 Increased intracompartmental P

 increases local venous...
Pathophysiology of ACS
Whiteside' Theory:
The development of a compartment syndrome also depends
on
MPP = DBP(Diastolic B...
Etiology of ACS


Decrease compartment size

Tight dressings/closure of fascial defect
 External pressures : casts, spli...
Etiology of ACS
 Increase compartment contents
Fractures : the most common are
•In adults --- closed and open tibial sha...
Etiology of ACS
 Increase compartment contents
• Hemorrhage -- vascular injury, coagulopathy
• Muscle edema -- severe exe...
Increase compartment
contents

S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. 10
.Philadelphia,...
Clinical Evaluation of ACS
Clinical presentations :
Swelling/ Tightness of compartment
Inappropiated and uncontrolled p...
Clinical Evaluation of ACS
Physical examination :
 Pain at compartment on passive stretching :

test each compartment se...
Measurement of
Compartment pressures
Indications : High risk injuries in
polytrauma patients
patient not alert/unreliab...
Measurement of
Compartment pressures
Devices

Stryker hand-held system

Stryker slit catheter

, www.wheelessonline.com :...
, Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com
.Duke Orthopaedics : North Calo...
Early management of ACS
Remove cast/bandage
Positioning of the limb at the level of the heart

- Do not elevate the affe...
Early management
reevaluation&

S. Terry Canele. Campeell’s
.Operative Orthopedics Volume 3
, 11th edition. Philadelphia
....
Treatment
Nonoperative
observation
 delta

p > 30 mmHg, no clinical presentation of compartment
syndrome

Operative
e...
Anatomy of Compartments
Arm 2 compartments
Forearm 4 compartments
 Hand 4 compartments
Thigh 3 compartments
Leg 4 com...
2 Compartments of arm
1. Anterior
1. Biceps,Bracialis

2. Musculocutaneous n.
3. Brachial a.

2. Posterior
1. Triceps
2. R...
”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013

21
4 Compartments of forearm
most commonly affect volar

1. Mobile wad
: Brachioradialis,
Radial n
2,3. Dorsal superficial

&...
10 Compartments of hand

”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013

23
3 Compartments of thigh
 Anterior
femoral

n
quadriceps
sartorious

 Posterior
sciatic

n
hamstrings

 Medial
obt...
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003...
4 Compartments of leg
1. Anterior
: Tibialis anterior, EDL,EHL
Peroneus
2. Posterior-Superficial
: Gastrocnemius, soleus,
...
”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013

27
”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013

28
9 Compartments of foot

”Karafsheh.MD, “Compartment Syndrome
.Mark on www.Orthobullets.com, Havard university, 2013
29
Dorsal dual incision

Medial incision

”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard universi...
Fasciotomy - post op care
Skeletal fixation can all be applied at time of initial surgical

decompression

After decompr...
Complications of ACS
Myonecrosis : after an ischemic insult of > 8 hrs.

Treatment
fasciotomy + debridement of the muscl...
Complications of ACS
Volkmann ischemic contracture : myonecrosis replaced

with fibrous tissue  myotendinous adhesion fo...
Complications of ACS
 Reperfusion syndrome : influx of myoglobin, potassium, and

phosphorus into the circulation
 chara...
Complications of ACS
Neurovascular injury
Infection
Amputation
Death

, Clifford R. Wheeles, Wheeless' Textbook of Ort...
36
Chronic Compartment Syndrome
Known as exertional CS, recurrent CS and subacute

CS
 Typical patient is young (20-30s) at...
Pathophysiology of CCS
Not yet fully understood
Probably from increased muscle relaxation pressure

during exercise
 de...
Physical Exam in CCS
Exercise –induced pain
Tenderness over the compartment
Bilateral involvement is common ( up to 82%...
DDx of CCS
Periostitis
Entrapment of the superficial peroneal nerve
Tendinitis of the posterior tibial tendon
Stress f...
Work up of CCS
Plain x-rays : will show 90% of stress fx
Bone scan : diffuse uptake ……..periostitis

localized uptake……s...
Diagnosis of CCS
 Intracompartmental testing is the hallmark of
1)
2)
3)

diagnosis (as reported by Pedwotiz et al ) :
Pr...
Treatment of CCS
 Non-operative :
 NSAIDs
 Electrostimulation
 Muscle relaxants
 Ultrasound
 Cessation or significan...
Treatment of CCS
 Operative treatment



Single incision fasciotomy
Double incision fasciotomy

 After surgery :
Earl...
References
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th

edition. Philadelphia, Pensylvania. Mosby El...
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Compartment syndrome, acute, chronic, anatomy and operation

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  • A wooden feeling on deep palpation is rare but reliable sign.
    Hyperesthesia should be tested by pin prick. It is very early and reliable sign.
  • High risk injuries (Vascular injuries with peripheral ischemia, High-energy trauma, Severe soft-tissue crush, Comminuted fractures of the tibia
    stryker hand-held is used for intermittent pressure reading.widely used.it is used at UofA
    Wick catheter is used for continuous reading.
    There are new investigational methods e.g. MRI with methoxy isobutyle isonitrile, laser doppler
    CT scan can give an idea about muscle necrosis but willn’t be helpful in pressure measurement.
  • Mobile wad of Henry (brachioradials,ECRL & ECRB)
  • Mobile wad : Brachioradialis, extensor carpi radialis longus and extensor carpi radialis brevis, Radial n.
    Dorsal - superficial and deep muscles.
    Superficial - extensor digitorum communis, extensor carpi ulnaris and extensor digiti minimi.
    Deep - abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis and supinator.
    Posterior interosseous n. & a.
    Volar - superficial and deep muscles.
    Superficial - pronator teres, palmaris longus, flexor digitorum superficialis, flexor carpi radialis and flexor carpi ulnaris.
    Deep - flexor digitorum profundus, flexor pollicis longus and pronator quadratus.
    Median and Ulnar n.
    Radial a., Ulnar a., and anterior interosseous a.
  • Myoglobinuric renal failure is treated by maintaining a high urine output and alkalization of urine by bicarbonate 0
  • Compartment syndrome, acute, chronic, anatomy and operation

    1. 1. Ext.Sawanya Saowapap Hadyai hospital
    2. 2. Compartment Syndromes Definition Types Pathophysiology Etiology Clinical evaluation Diagnosis Management Complications 2
    3. 3. Definition An elevation of the interstitial pressure in a closed osteofascial compartment that results in micrvascular compromise. S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 3
    4. 4. Types of compartment syndrome Acute compartment syndrome (ACS)  medical emergency  caused by a severe injury  can lead to permanent muscle damage. Chronic compartment syndrome (CCS)  known as exertional compartment syndrome  not a medical emergency  most often caused by athletic exertion. S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 4
    5. 5. Pathophysiology of ACS The vicious cycle of Volkmann's ischemia  Increased intracompartmental P  increases local venous P  narrowed AV perfusion gradient  compartment tamponade  decrease capillary blood flow  O2 deprivation  local tissue necrosis  nerve injury and muscle ischemia S. Terry Canele. Campeell’s Operative .Orthopedics Volume 3. 11th edition .Philadelphia, Pensylvania. Mosby Elsevier, 2003 5
    6. 6. Pathophysiology of ACS Whiteside' Theory: The development of a compartment syndrome also depends on MPP = DBP(Diastolic BP) – CP(Intracompartment P) Muscle perfusion pressure(MPP) < 30 mmHg  Tissue hypoxia S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 6
    7. 7. Etiology of ACS  Decrease compartment size Tight dressings/closure of fascial defect  External pressures : casts, splints , burn eschar, lying on limb for long period, lithotomy position  S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 7
    8. 8. Etiology of ACS  Increase compartment contents Fractures : the most common are •In adults --- closed and open tibial shaft fx , distal radial fx •In children --- radial head or neck fx , supracondylar fx , forearm fx S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 8
    9. 9. Etiology of ACS  Increase compartment contents • Hemorrhage -- vascular injury, coagulopathy • Muscle edema -- severe exercise , crush injury • Burn -- increase capillary permeability S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 9
    10. 10. Increase compartment contents S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. 10 .Philadelphia, Pensylvania. Mosby Elsevier, 2003
    11. 11. Clinical Evaluation of ACS Clinical presentations : Swelling/ Tightness of compartment Inappropiated and uncontrolled pain Severe pain at rest or passive stretching Pallor/Cyanosis Hyperesthesia/Paresthesia Paralysis : full recovery is rare , www.wheelessonline.com : Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site .Duke Orthopaedics : North Calorina, 2013 11
    12. 12. Clinical Evaluation of ACS Physical examination :  Pain at compartment on passive stretching : test each compartment separately Thigh : - anterior compartment - passive knee flexion - posterior compartment - passive knee extension - medial compartment - passive hip abduction  Hyperesthesia/Paresthesia Peripheral pulses absent - amputation usually inevitable , www.wheelessonline.com : Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site .Duke Orthopaedics : North Calorina, 2013 12
    13. 13. Measurement of Compartment pressures Indications : High risk injuries in polytrauma patients patient not alert/unreliable inconclusive physical exam findings Technique : performed each compartments at close to the fracture site as possible (highest pressure) or maximal swelling area , www.wheelessonline.com : Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site .Duke Orthopaedics : North Calorina, 2013 13
    14. 14. Measurement of Compartment pressures Devices Stryker hand-held system Stryker slit catheter , www.wheelessonline.com : Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site .Duke Orthopaedics : North Calorina, 2013 14
    15. 15. , Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com .Duke Orthopaedics : North Calorina, 2013 15
    16. 16. Early management of ACS Remove cast/bandage Positioning of the limb at the level of the heart - Do not elevate the affected limb  decreases arterial pressure IV hydration Oxygen supplement S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 16
    17. 17. Early management reevaluation& S. Terry Canele. Campeell’s .Operative Orthopedics Volume 3 , 11th edition. Philadelphia .Pensylvania. Mosby Elsevier, 2003
    18. 18. Treatment Nonoperative observation  delta p > 30 mmHg, no clinical presentation of compartment syndrome Operative emergent fasciotomy  Positive clinical presentation  CP = 30-45 mm Hg  delta p < 30 mmHg  Contraindications : Missed compartment syndrome (Various stage of muscle infarction) , Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com .Duke Orthopaedics : North Calorina, 2013 18
    19. 19. Anatomy of Compartments Arm 2 compartments Forearm 4 compartments  Hand 4 compartments Thigh 3 compartments Leg 4 compartments Foot 9 compartments 19
    20. 20. 2 Compartments of arm 1. Anterior 1. Biceps,Bracialis 2. Musculocutaneous n. 3. Brachial a. 2. Posterior 1. Triceps 2. Radial n. ”Mark Karafsheh.MD, “Compartment Syndrome .on www.Orthobullets.com, Havard university, 2013 20
    21. 21. ”Mark Karafsheh.MD, “Compartment Syndrome .on www.Orthobullets.com, Havard university, 2013 21
    22. 22. 4 Compartments of forearm most commonly affect volar 1. Mobile wad : Brachioradialis, Radial n 2,3. Dorsal superficial &deep :Posterior interoseous n & a Dorsal incision ”Mark Karafsheh.MD, “Compartment Syndrome .on www.Orthobullets.com, Havard university, 2013 4. Volar superficial &deep :Median and Ulnar n. Radial a., Ulnar a., ant. interosseous a. 22
    23. 23. 10 Compartments of hand ”Mark Karafsheh.MD, “Compartment Syndrome .on www.Orthobullets.com, Havard university, 2013 23
    24. 24. 3 Compartments of thigh  Anterior femoral n quadriceps sartorious  Posterior sciatic n hamstrings  Medial obturator adductors ”Mark Karafsheh.MD, “Compartment Syndrome .on www.Orthobullets.com, Havard university, 2013 24 n
    25. 25. S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 25
    26. 26. 4 Compartments of leg 1. Anterior : Tibialis anterior, EDL,EHL Peroneus 2. Posterior-Superficial : Gastrocnemius, soleus, plantaris 3. Posterior-Deep : FDL, FHL,Popliteus, Tibialis posterior, Tibial a,v,n. 4. Lateral : Peroneus longus and brevis,peroneal n 26
    27. 27. ”Mark Karafsheh.MD, “Compartment Syndrome .on www.Orthobullets.com, Havard university, 2013 27
    28. 28. ”Mark Karafsheh.MD, “Compartment Syndrome .on www.Orthobullets.com, Havard university, 2013 28
    29. 29. 9 Compartments of foot ”Karafsheh.MD, “Compartment Syndrome .Mark on www.Orthobullets.com, Havard university, 2013 29
    30. 30. Dorsal dual incision Medial incision ”Mark Karafsheh.MD, “Compartment Syndrome .on www.Orthobullets.com, Havard university, 2013 30
    31. 31. Fasciotomy - post op care Skeletal fixation can all be applied at time of initial surgical decompression After decompression care : sterile dressing (saline soaks ), splinting in functional position Return to OR for 2nd look in 2-5 days - If no muscle necrosis  the skin is loosely closed. - If closure is not accomplished  Debridement after another 72- h interval  Skin closure or skin grafting S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 31
    32. 32. Complications of ACS Myonecrosis : after an ischemic insult of > 8 hrs. Treatment fasciotomy + debridement of the muscles + neurolysis may lead to myoglobinuria and eventually renal failure. Diuresis ( by mannitol,diuretics or IV fluids ) should be prompted to increase the tubular flushing and eliminate the proteinaceous material , Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com .Duke Orthopaedics : North Calorina, 2013 32
    33. 33. Complications of ACS Volkmann ischemic contracture : myonecrosis replaced with fibrous tissue  myotendinous adhesion formation. Treatment  Non-surgical (physiotherapy & bracing involve the joints)  Surgical     contracture release, nerve compression release, amputation reconstruction with tissue transfers , Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com .Duke Orthopaedics : North Calorina, 2013 33
    34. 34. Complications of ACS  Reperfusion syndrome : influx of myoglobin, potassium, and phosphorus into the circulation  characterized by hypovolemic shock and hyperkalemia Evaluation :  Fluid loss, Shock  Acidosis  Hyperkalemia  Myoglobinuria, Renal failure : need fluid 12 Lt over 48-hour Management :  Prioperative hydration  Mannitol  Bicarbonate , Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com .Duke Orthopaedics : North Calorina, 2013 34
    35. 35. Complications of ACS Neurovascular injury Infection Amputation Death , Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com .Duke Orthopaedics : North Calorina, 2013 35
    36. 36. 36
    37. 37. Chronic Compartment Syndrome Known as exertional CS, recurrent CS and subacute CS  Typical patient is young (20-30s) athlete (long distance runner)or military recruits Occur mainly in the lower limb S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 37
    38. 38. Pathophysiology of CCS Not yet fully understood Probably from increased muscle relaxation pressure during exercise  decreased muscle blood flow  ischemic pain and impaired muscle function S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 38
    39. 39. Physical Exam in CCS Exercise –induced pain Tenderness over the compartment Bilateral involvement is common ( up to 82% ) Fascial hernias ( 39% in one of the studies ) S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 39
    40. 40. DDx of CCS Periostitis Entrapment of the superficial peroneal nerve Tendinitis of the posterior tibial tendon Stress fracture of tibia Intermittent claudication S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 40
    41. 41. Work up of CCS Plain x-rays : will show 90% of stress fx Bone scan : diffuse uptake ……..periostitis localized uptake……stress fx Tinel test : may be positive in superficial peroneal nerve entrapment NCS : could be helpful MRI : promising results reported Robert J. Duggan. “ How To Diagnose And Treat Chronic Exertional Compartment Syndrome” Podiatry Today Volume 22 ,2009 41
    42. 42. Diagnosis of CCS  Intracompartmental testing is the hallmark of 1) 2) 3) diagnosis (as reported by Pedwotiz et al ) : Pre-exercise resting pressure of 15 mm Hg or more. Pressure of 30 mm Hg 1 minute after the exercise. Pressure of 20 mm Hg or more 5 minutes after the exercise. Robert J. Duggan. “ How To Diagnose And Treat Chronic Exertional Compartment Syndrome” Podiatry Today Volume 22 ,2009 42
    43. 43. Treatment of CCS  Non-operative :  NSAIDs  Electrostimulation  Muscle relaxants  Ultrasound  Cessation or significant reduction of athletic activities S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 43
    44. 44. Treatment of CCS  Operative treatment   Single incision fasciotomy Double incision fasciotomy  After surgery : Early ROM exercises are encouraged. Weight bearing on crutches is allowed on POD1. Light jogging is allowed at 2-3 weeks if no swelling or tenderness S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. .Philadelphia, Pensylvania. Mosby Elsevier, 2003 44
    45. 45. References S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. Philadelphia, Pensylvania. Mosby Elsevier, 2003. Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com, Duke Orthopaedics : North Calorina, 2013. Mark R. Brinker. Fundamental of orthopedics. Bathesta, Maryland : University of Texan Health Sciences Center, 1992. Robert J. Duggan. “ How To Diagnose And Treat Chronic Exertional Compartment Syndrome” Podiatry Today Volume 22 , 2009 Mark Karafsheh.MD, “Compartment Syndrome” on www.Orthobullets.com, Havard university, 2013. 45
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