Lecture on Compartment Syndrome GMC Bhopal

1. Compartment Syndrome
Dr Abhishek Pathak
Associate Professor
Orthopaedics
GMC Bhopal

2. Definition
• Compartment syndrome
is a condition in which the
circulation within a
compartment is
compromised by an
increase in pressure
within the osteofascial
compartment, causing
necrosis of muscles,
nerves, and eventually
the skin because of
excessive swelling.

3. • The first report of the condition was attributed to
Hamilton in 1850.
• 1881-Volkman described contracted state believed due
to ischemic muscle
• 1884-Lesser developed clinical model
• 1906-Hildebrand coined “Volkman’s ischemic
contracture”
• 1914-Murphy recommended fasciotomy to prevent
contracture
• 1940-Griffiths ‘4 Ps’
• 1967-Whiteside stressed 4 compartment fasciotomy

4. Types
• Can be divided into two types
1. Acute compartment Syndrome
2. Chronic Exertional Compartment Syndrome
3. Volkman’s Ischaemic Contracture

5. Acute Compartment Syndrome
• Acute compartment syndrome is defined as
the elevation of intracompartmental pressure
(ICP) to a level and for a duration that without
decompression will cause tissue ischemia and
necrosis.

6. Chronic Exertional compartment
syndrome
• Exertional compartment syndrome is the
elevation of intracompartmental pressure
during exercise, causing ischemia, pain, and
rarely neurologic symptoms and signs. It is
characterized by resolution of symptoms with
rest

7. Volkman’s Iscaemic Contracture
• Volkmann ischemic contracture is the end
stage of neglected acute compartment
syndrome with irreversible muscle necrosis
leading to ischemic contractures.

8. ACUTE COMPARTMENT SYNDROME

9. Causes
• Most common cause is a fracture with tibia
fracture being the commonest, followed by
both bone forearm and supracondylar
humerus (esp in children)
• Soft Tissue Injury ( impact increases if
associated with fracture)
• Crush Syndrome
• Burns

10. Causes
• Snake Bite
• Arterial Injury
• Nephrotic Syndrome
• Exercise

11. Etiopathogenesis

12. Arteriovenous (AV) gradient theory
• According to this theory the increases in local
tissue pressure reduce the local AV pressure
gradient and thus reduce the blood flow.
• When flow diminishes to less than the
metabolic demands of the tissues (not
necessarily to zero), then functional
abnormalities result.

13. SITES
Common:
1. Leg Compartment syndrome
2.Hand compartment syndrome
3. Forearm compartment syndromes
4.Foot compartment syndrome
Rare:
5.Thigh compartment syndrome
6.Arm compartment syndrome

14. Tissue Threshold to
Ischaemia
• Muscle 4 hrs
• Nerve 8 hrs
• Fat 12 hrs
• Skin 24 hrs
• Bone 72-96 hrs
Therefore for a viable functional limb the upper
threshold is about 6 hrs

15. DIAGNOSIS

16. Symptoms
• Deep aching Pain out of proportion to the injury
Signs:
• Incredible pain on passive movement of leg – due to
stretched ischaemic muscles
• As arterial supply cut off – Pulselessness ?
• Parasthesia - distally
• Pallor
• Perishing Cold
• Paralysis
• Tight tense swollen limb
• Redness, mottling, blisters
• 6P’s may or may not be present; cannot exclude condition
based on their absence
Clinical Diagnoses

17. Classically out of proportion to injury
Exaggerated with passive stretch of the
involved muscles in compartment
Earliest symptom but inconsistent
Not available in obtunded patient
Pain

18. Pallor
• The extremity may appear cyanotic or mottled early in
the course of events.
• Cyanosis is present early, whereas marked pallor in the
distal extremity occurs late, after major arterial occlusion
has occurred.
• Neither pallor nor cyanosis should be considered a sign
that is necessary for the diagnosis of Compartment
Syndrome

19. Also early sign
Peripheral nerve tissue is more sensitive
than muscle to ischemia
Permanent damage may occur in 75 minutes
Difficult to interpret
Will progress to anesthesia if pressure not
relieved
Paresthesia

20. Paralysis :
• Development of motor dysfunction
suggests that ischaemia has been
established and permanent damage has
Occurred.
• Irreversible muscle fibre changes occurs
early as six hours after the onset on tissue
ischaemia

21. Pulselessness
• The loss of palpable pulse has been shown to
occur late, or sometimes not at all, in the
course of Compartment Syndrome.
• • Clinical experience and experimental
evidence verify that irreversible tissue
damages can occur in a patient with palpable
pulse.

22. Measuring Intracompartment Pressure
• When compartment syndrome is suspected
and the necessary equipment is available,
compartment pressures should be obtained to
confirm the diagnosis.
• Compartment pressures over 30 mm Hg or
within 20 mm Hg of the diastolic pressure are
indicative of compartment syndrome.

23. Whiteside Technique

24. Stryker stic hand held monitor

25. • In most of practicle scenario the diagnosis of
compartmental syndrome is essentially clinical
with all the investigations aiding in
substantiating the diagnosis

26. TREATMENT

27. Fasciotomy
• Impending tissue ischemia may be considered
when the tissue pressure reaches between 30
and 20 mm Hg below the diastolic blood
pressure.
• As a general rule, when in doubt, the
compartment should be released. If it proves
later to have been unnecessary, only a scar will
result. However, if a fasciotomy should have been
done but was not, loss of muscle tissue and
worse may result.

28. Fasciotomy
• Fasciotomy should be performed in
(1) normotensive patients with positive clinical findings
and compartment pressures of greater than 30 mm Hg,
and when the duration of the increased pressure is
unknown or thought to be longer than 8 hours;
(2) uncooperative or unconscious patients with
compartment pressures of greater than 30 mm Hg; and
(3) patients with low blood pressure and compartment
pressures of greater than 20 mm Hg.

30. A DELAY IN DIAGNOSIS WAS THE
MOST IMPORTANT DETERMINING
FACTOR FOR POOR OUTCOME.

31. Fasciotomy of leg
Three approaches have been described for
release of the compartment of the lower leg
• Double-incision fasciotomy
• Single-incision fasciotomy
• Fibulectomy

32. Single incision Faciotomy

34. Double-incision Fasciotomy

35. Fasciotomy Closure
Shoe lace technique

36. Forearm Fasciotomy

37. Forearm Fasciotomy

39. Thigh Fasciotomy

40. Thigh Fasciotomy

41. shoe-lace technique

42. Disadvantage of Fasciotomy
1. Close Fracture converted into
compound fracture.
2.Loss of stability.

43. Management of associated
fractures:
Fracture stabilization should be
performed after fasciotomy.
Stabilization of fracture allows
easy excess to the soft tissue and
protect the soft tissues, permitting
it to heal.

44. Wound Care
• Soft tissue coverage by 5-7 days
• Delayed closure
–Vascular loop ‘lace technique’
• Split thickness skin graft
• Flaps or free tissue transfer

45. Prognosis
• Fair if diagnosed in time and timely fasciotomy
is done
• Delay in diagnosis is most common cause of
poor results with significant sequelae,
including muscle contractures, muscle
weakness, sensory loss, infection, and
nonunion of fractures and in severe cases
even amputation due to lack of function

46. Chronic exertional compartment
syndrome (CECS)
• Chronic exertional compartment syndrome
(CECS) is defined as reversible ischemia
secondary to a noncompliant osteofascial
compartment that is unresponsive to the
expansion of muscle volume that occurs with
exercise

47. Epidemeology
• Common in
– young recreational athelete
– New military recruits
– Elite atheletes
• The anterior and lateral compartments are
most often affected
• Symptoms are bilateral in about 75% of
patients.
• A 2-year delay in diagnosis is typical for CECS.

48. Diagnosis
(1) preexercise, resting pressure of 15 mm Hg or
more;
(2) pressure of 30 mm Hg or more 1 minute
after exercise; and
(3) pressure of 20 mm Hg or more 5 minutes
after exercise.

49. Conservative
• Anti inflamatory
• Rest
• Muscle Stretching
• Structured strengthening exercises

50. Fasciotomy
double mini-incision fasciotomy for chronic anterior compartment syndrome. A, Two
vertical 2-cm skin incisions. B, Development of subcutaneous flap with blunt dissection.
C, Skin retraction to allow fasciotomy under direct vision. D, After wound closure

51. VOLKMAN’S ISCHAEMIC
CONTRACTURE

52. Complication
Volkmann's Ischemic Contracture
• Volkmann ischemic contracture is a sequel of untreated or
inadequately treated compartment syndrome in which
necrotic muscle and nerve tissue has been replaced with
fibrous tissue.
• The typical posture includes elbow flexion forearm
pronation, wrist flexion, and thumb adduction with
the metacarpophalangeal joints extended and the
interphalangeal joints flexed

54. Tsuge's Classification of VIC
Mild Moderate Severe
 Flexor
Digitorum
Profundus
 Flexor Pollicis
longus
 Involvement of FDP + FPL
 Supperficial finger flexor
 Wrist Flexors
 Thumb flexors
 all flexors
 Few extensors
 Neurologic deficit
 Contracutre of Joint
 Skin scarred
 Bones deformed.

55. TREATMENT :-
Mild type
1. Dynamic splinting
2. Physioherapy
3. Total excision if single muscle is
involved. .

56. TREATMENT :-
Moderate type
l. Max page's muscle sliding operation
2. Excision of cicatrix.
3. Neurolysis consists of freeing the
peripheral nerves from the surrounding
fibrous tissue.
4. Tendon transfer

57. TREATMENT :-
Severe type
1. Excision of the scar.
2. Seddon's carpectomy
3. Arthrodesis of the wrist in functional
position.
4. Amputation for very server cases of
VIC with gangrene.

58. THANKS