a IMPORTANT EMERGENCY CONDITION OF oRTHOPEDICS

1. COMPARTMENTCOMPARTMENT
SYNDROMESYNDROME
JAYANT SHARMAJAYANT SHARMA
M.S.,D.N.B.,M.N.A.M.S.M.S.,D.N.B.,M.N.A.M.S.

2. Compartment SyndromeCompartment Syndrome
DEFINITIONDEFINITION
 Elevated tissue pressure within aElevated tissue pressure within a
closed fascial spaceclosed fascial space
 Reduces tissue perfusion - ischemiaReduces tissue perfusion - ischemia
 Results in cell death - necrosisResults in cell death - necrosis
 True Orthopaedic EmergencyTrue Orthopaedic Emergency

3. HistoryHistory
 Volkmann 1881Volkmann 1881
 Richard von VolkmannRichard von Volkmann
published an article in whichpublished an article in which
he attempted to describe thehe attempted to describe the
condition of irreversiblecondition of irreversible
contractures of the flexorcontractures of the flexor
muscles of the hand tomuscles of the hand to
ischemic processes occurringischemic processes occurring
in the forearmin the forearm
 Application of restrictiveApplication of restrictive
dressing to an injured limbdressing to an injured limb

4.  Hildebrand 1906Hildebrand 1906
 First used the term Volkmann ischemicFirst used the term Volkmann ischemic
contracture to describe the final resultcontracture to describe the final result
of any untreated compartmentof any untreated compartment
syndrome, and was the first tosyndrome, and was the first to
suggest that elevated tissue pressuresuggest that elevated tissue pressure
may be related to ischemicmay be related to ischemic
contracture.contracture.

5.  Thomas 1909Thomas 1909
 Reviewed the 112 published cases ofReviewed the 112 published cases of
Volkmann ischemic contracture andVolkmann ischemic contracture and
found fractures to be the predominantfound fractures to be the predominant
cause.cause.
 Also, noted that tight bandages, anAlso, noted that tight bandages, an
arterial embolus, or arterialarterial embolus, or arterial
insufficiency could also lead to theinsufficiency could also lead to the
problemproblem

6.  Murphy 1914Murphy 1914
 First to suggest that Fasciotomy mightFirst to suggest that Fasciotomy might
prevent the contracture.prevent the contracture.
 Also, suggested that tissue pressureAlso, suggested that tissue pressure
and Fasciotomy were related to theand Fasciotomy were related to the
development of contracturedevelopment of contracture

7.  Ellis 1958Ellis 1958
 Reported a 2% incidence ofReported a 2% incidence of
compartment syndrome with tibiacompartment syndrome with tibia
fractures, and increased attention wasfractures, and increased attention was
paid to contractures involving thepaid to contractures involving the
lower extremitieslower extremities

8.  Seddon, Kelly, and Whitesides 1967Seddon, Kelly, and Whitesides 1967
 Demonstrated the existence of 4Demonstrated the existence of 4
compartments in the leg and to the need tocompartments in the leg and to the need to
decompress more than just the anteriordecompress more than just the anterior
compartment.compartment.
 Since then, compartment syndrome hasSince then, compartment syndrome has
been shown to affect many areas of thebeen shown to affect many areas of the
body, including the hand, foot, thigh, andbody, including the hand, foot, thigh, and
buttocks.buttocks.

9. Compartment SyndromeCompartment Syndrome
EtiologyEtiology
Compartment SizeCompartment Size
 tight dressing;tight dressing; Bandage/CastBandage/Cast
 localised external pressure;localised external pressure; lying on limblying on limb
 Closure of fascial defectsClosure of fascial defects
Compartment ContentCompartment Content
 Bleeding; Fractures, vascular inj, bleedingBleeding; Fractures, vascular inj, bleeding
disordersdisorders
 Capillary Permeability;Capillary Permeability;
 Ischemia / Trauma / Burns / Exercise / Snake Bite /Ischemia / Trauma / Burns / Exercise / Snake Bite /
Drug Injection / IVFDrug Injection / IVF

10. Fracture
 The most common causeThe most common cause
 incidence of accompanyingincidence of accompanying
compartment syndrome ofcompartment syndrome of
9.1%9.1%
 The incidence is directlyThe incidence is directly
proportional to the degree ofproportional to the degree of
injury to soft tissue and boneinjury to soft tissue and bone
 occurred most often inoccurred most often in
association with aassociation with a
comminuted, grade-III opencomminuted, grade-III open
injury to a pedestrianinjury to a pedestrian
 Blick et al JBJS 1986Blick et al JBJS 1986
Blunt Trauma
2nd most common cause2nd most common cause
About 23% of CSAbout 23% of CS
25% due to direct blow25% due to direct blow

11. IncidenceIncidence
 164 pts with CS, 149 male, 15 female164 pts with CS, 149 male, 15 female
 Most pts were usually under 35Most pts were usually under 35
 69% with associated fx, about half69% with associated fx, about half
were tibial shaftwere tibial shaft
 23% soft tissue injury without fx23% soft tissue injury without fx
 Ranges of 2-12% have beenRanges of 2-12% have been
publishedpublished
McQueen et al; JBJS Br 2000McQueen et al; JBJS Br 2000

12. IncidenceIncidence
Type ofType of
FxFx
% of% of
ACSACS
IncidencIncidenc
e alle all
agesages
IncidenceIncidence
<35<35
TibialTibial
diaphysidiaphysi
ss
36%36% 4.3%4.3% 5.9%(3 fold)5.9%(3 fold)
DistalDistal
radiusradius
9.8%9.8% 0.25%0.25% 1.4%(301.4%(30
fold)fold)
ForearmForearm
diaphysidiaphysi
7.9%7.9% 3.1%3.1% 3.2%3.2%

13. Patient PositioningPatient Positioning
 Leaving the calf free when the leg is placedLeaving the calf free when the leg is placed
in the hemilithotomy position.in the hemilithotomy position.
 Instead of using a standard well-leg holderInstead of using a standard well-leg holder
 Increases the difference between theIncreases the difference between the
diastolic blood pressure and thediastolic blood pressure and the
intramuscular pressure.intramuscular pressure.
 May decrease the risk of compartmentMay decrease the risk of compartment
syndrome.syndrome.
-Meyer, Mubarak JBJS 2002

14. Patient positioningPatient positioning
Meyer, Mubarak JBJS 2002

15. PathophysiologyPathophysiology
 Normal tissue pressureNormal tissue pressure
– 0-4 mm Hg0-4 mm Hg
– 8-10 with exertion8-10 with exertion
 Absolute pressure theoryAbsolute pressure theory
– 30 mm Hg - Mubarak30 mm Hg - Mubarak
– 45 mm Hg - Matsen45 mm Hg - Matsen
 Pressure gradient theoryPressure gradient theory
– < 20 mm Hg of diastolic pressure –< 20 mm Hg of diastolic pressure –
Whitesides & McQueen, et alWhitesides & McQueen, et al

16. Tissue SurvivalTissue Survival
 MuscleMuscle
– 3-4 hours - reversible changes3-4 hours - reversible changes
– 6 hours - variable damage6 hours - variable damage
– 8 hours - irreversible changes8 hours - irreversible changes
 NerveNerve
– 2 hours - looses nerve conduction2 hours - looses nerve conduction
– 4 hours - neuropraxia4 hours - neuropraxia
– 8 hours - irreversible changes8 hours - irreversible changes

17. PathophysiologyPathophysiology
 Pressure increases exceeding lowPressure increases exceeding low
intramuscular arterioles decreasingintramuscular arterioles decreasing
capillary blood flow -Cap pressure 20-capillary blood flow -Cap pressure 20-
30mmHg30mmHg
 If prolonged pressure causes necrosisIf prolonged pressure causes necrosis
of the tissuesof the tissues

18.  Pressure >30mmHgPressure >30mmHg results in nerveresults in nerve
conduction velocity blockage after 6-8conduction velocity blockage after 6-8
hrs and irreversibility after 8 hrshrs and irreversibility after 8 hrs
(normal pressure 4mmHg)(normal pressure 4mmHg)
--Hargens--Hargens

19. PathophysiologyPathophysiology
 Necrosis causes cell death andNecrosis causes cell death and
inflammatory processinflammatory process – increasing– increasing
intracellular calcium concentrationintracellular calcium concentration
causing fluid shift into muscle fiberscausing fluid shift into muscle fibers
 After 8 hoursAfter 8 hours irreversible muscleirreversible muscle
changeschanges

20. DiagnosisDiagnosis
 The 6 P’s:The 6 P’s:
 PulselessnessPulselessness
 PallorPallor
 ParalysisParalysis
 Pain with passive stretchPain with passive stretch
 Paresthesia/hypoesthesiaParesthesia/hypoesthesia
 Palpably tense compartmentPalpably tense compartment

21. ““Pain and the aggravation of pain byPain and the aggravation of pain by
passive stretching of the muscles inpassive stretching of the muscles in
the compartment in question are thethe compartment in question are the
most sensitive (and generally the only)most sensitive (and generally the only)
clinical finding before the onset ofclinical finding before the onset of
ischemic dysfunction in the nerves andischemic dysfunction in the nerves and
muscles.”muscles.”
Whitesides AAOS 1996Whitesides AAOS 1996

22.  PainPain – most important. Especially pain out of– most important. Especially pain out of
proportion to the injury (child becomingproportion to the injury (child becoming
more and more restless /needing moremore and more restless /needing more
analgesia)analgesia)
 Most reliable signsMost reliable signs are pain on passiveare pain on passive
stretching and pain on palpation of thestretching and pain on palpation of the
involved compartmentinvolved compartment
 Other features like pallor, pulselessness,Other features like pallor, pulselessness,
paralysis, paraesthesia etcparalysis, paraesthesia etc. appear very late. appear very late
and we should not wait for these things.and we should not wait for these things.
Willis &Rorabeck OCNA 1990Willis &Rorabeck OCNA 1990

23. Important signsImportant signs
 PainPain on palpation of compartmenton palpation of compartment
 Tense compartmentTense compartment compared to other sidecompared to other side
 Pain on passive stretch across compartmentPain on passive stretch across compartment
 Sensory deficitSensory deficit of nerve traversing theof nerve traversing the
compartmentcompartment
 Muscle weaknessMuscle weakness
 Normal capillary refillNormal capillary refill
 Compartment syndrome seen in open tibias 6-Compartment syndrome seen in open tibias 6-
9%9%
--Blick--Blick

24.  Beware of epidural analgesiaBeware of epidural analgesia
Strecker JBJS 1986Strecker JBJS 1986
Morrow J. Trauma 1994Morrow J. Trauma 1994
 Beware long acting nerve blocksBeware long acting nerve blocks
Hyder JBJS Br 1995Hyder JBJS Br 1995
 Beware of controlled intravenousBeware of controlled intravenous
opiate analgesiaopiate analgesia

25. Differential DiagnosisDifferential Diagnosis
 Arterial occlusionArterial occlusion
 Peripheral nerve injuryPeripheral nerve injury
 Muscle ruptureMuscle rupture

26. Pressure MeasurementsPressure Measurements
 Suspected compartment syndromeSuspected compartment syndrome
 Equivocal or unreliable examEquivocal or unreliable exam
 Clinical adjunctClinical adjunct
 ContraindicationContraindication
– Clinically evident compartment syndromeClinically evident compartment syndrome

27. Pressure measurementsPressure measurements
 MubarakMubarak -- Fasciotomy when >30--- Fasciotomy when >30-
40mmHg40mmHg
 MatsenMatsen -- >45 mmHg developed ACS-- >45 mmHg developed ACS
 WhitesidesWhitesides -- Fasciotomy when within-- Fasciotomy when within
20mmHg of DBP20mmHg of DBP
 McQueenMcQueen -- Fasciotomy when within-- Fasciotomy when within
30mmHg of DBP30mmHg of DBP
 HeppenstallHeppenstall – within 40mmHg (MAP-– within 40mmHg (MAP-
compartment pressurescompartment pressures

28. Pressure MeasurementsPressure Measurements
 InfusionInfusion
– manometermanometer
– salinesaline
– 3-way stopcock3-way stopcock
 CatheterCatheter
– wickwick
– slit wickslit wick
----Whitesides, CORRWhitesides, CORR
19751975
Arterial line
16 - 18 ga. Needle
(5-19 mm Hg higher)
transducer
monitor
Stryker device
Side port needle

29. Pressure MeasurementsPressure Measurements
 Arterial lineArterial line
– Zero at the level of the affected limbZero at the level of the affected limb

30. Pressure MeasurementsPressure Measurements
Simple Needle
18 gauge
Least accurate
Usually gives falsely higher
reading
Slit Catheter and Side ported
needle
No significant difference
More accurate
Moed et al JBJS 1993Moed et al JBJS 1993

31.  MeasurementsMeasurements must be made in allmust be made in all
compartmentscompartments
 Anterior and deep posteriorAnterior and deep posterior are usuallyare usually
highesthighest
 MeasurementMeasurement made within 5 cm of fracturesmade within 5 cm of fractures
 Marginal readingsMarginal readings must be followed withmust be followed with
repeat physical exam and repeatrepeat physical exam and repeat
compartment pressure measurementcompartment pressure measurement
Heckman, WhitesidesHeckman, Whitesides JBJS 1994JBJS 1994

33. SUSPECTED COMPARTMENTSUSPECTED COMPARTMENT
SYNDROMESYNDROME
Unequivocal + FindingsUnequivocal + Findings
FASCIOTOMYFASCIOTOMY
Pt. notPt. not
alert/polytrauma/unconciousalert/polytrauma/unconcious
Comp. pressure measurementComp. pressure measurement
within 30 mm Hg >30 mm Hgwithin 30 mm Hg >30 mm Hg
of DBPof DBP
Serial examsSerial exams
FASCIOTOMYFASCIOTOMY
McQueen JBJSB 1996

35. Compartment SyndromeCompartment Syndrome
Emergent TreatmentEmergent Treatment
 Remove castRemove cast or dressingor dressing
 Place at level of heartPlace at level of heart
(DO NOT ELEVATE(DO NOT ELEVATE as elevation reducesas elevation reduces
the arterial inflow and the arterio-venousthe arterial inflow and the arterio-venous
pressure gradientpressure gradient
Alert ORAlert OR and Anesthesiaand Anesthesia
 Medical treatment-Medical treatment- Supplemental oxygenSupplemental oxygen
administrationadministration
 Ensure patient is normotensiveEnsure patient is normotensive

36. Medical ManagementMedical Management
 Compartmental pressure falls by 30% whenCompartmental pressure falls by 30% when
cast is split on one sidecast is split on one side
 Falls by 65% when the cast is spread afterFalls by 65% when the cast is spread after
splitting.splitting.
 Splitting the padding reduces it by a furtherSplitting the padding reduces it by a further
10% and complete removal of cast by10% and complete removal of cast by
another 15%another 15%
 Total of 85-90% reduction by just taking offTotal of 85-90% reduction by just taking off
the plaster!the plaster!
Garfin, Mubarak JBJS 1981

37. Threshold forThreshold for
FasciotomyFasciotomy
 116 pts with tibial diaphyseal fx had116 pts with tibial diaphyseal fx had
continuous monitoring of anteriorcontinuous monitoring of anterior
compartment pressure for 24 hourscompartment pressure for 24 hours
– 53 pts had ICP over 30 mmHg53 pts had ICP over 30 mmHg
– 30 pts had ICP over 40 mmHg30 pts had ICP over 40 mmHg
– 4 pts had ICP over 50 mmHg4 pts had ICP over 50 mmHg
McQueen, Court-Brown JBJS Br 1996McQueen, Court-Brown JBJS Br 1996

38.  Only 3 hadOnly 3 had Delta pr(DBP-ICP)Delta pr(DBP-ICP) of < 30,of < 30,
they hadthey had FasciotomyFasciotomy
 None of the patients had any sequalaeNone of the patients had any sequalae
of the compartment syndromeof the compartment syndrome
 DecompressionDecompression should be performed ifshould be performed if
the differential pressure level drops tothe differential pressure level drops to
under 30 mmHgunder 30 mmHg

39. Surgical TreatmentSurgical Treatment
 Fasciotomy,Fasciotomy,
Fasciotomy,Fasciotomy,
Fasciotomy,Fasciotomy,
– All compartments !!!All compartments !!!

40. Compartment SyndromeCompartment Syndrome
Surgical TreatmentSurgical Treatment
 Fasciotomy - prophylactic release ofFasciotomy - prophylactic release of
pressure before permanent damagepressure before permanent damage
occurs. Will not reverse injury fromoccurs. Will not reverse injury from
trauma.trauma.
 Fracture care – stabilizationFracture care – stabilization
– Ex-fixEx-fix
– IM NailIM Nail

41. Compartment SyndromeCompartment Syndrome
Indications for FasciotomyIndications for Fasciotomy
 Unequivocal clinical findingsUnequivocal clinical findings
 Pressure within 15-20 mm hg of DBPPressure within 15-20 mm hg of DBP
 Rising tissue pressureRising tissue pressure
 Significant tissue injury or high risk ptSignificant tissue injury or high risk pt
 > 6 hours of total limb ischemia> 6 hours of total limb ischemia
 Injury at high risk of compartment syndromeInjury at high risk of compartment syndrome
 CONTRAINDICATION -CONTRAINDICATION -
Missed compartment syndrome (>24-Missed compartment syndrome (>24-
48 hrs)48 hrs)

42. Fasciotomy PrinciplesFasciotomy Principles
 Make early diagnosisMake early diagnosis
 LongLong extensile incisionsextensile incisions
 Release all fascial compartmentsRelease all fascial compartments
 Preserve neurovascular structuresPreserve neurovascular structures
 Debride necrotic tissuesDebride necrotic tissues
 Coverage within 7-10 daysCoverage within 7-10 days

43. Compartment SyndromeCompartment Syndrome
Lower LegLower Leg
 4 compartments4 compartments
– Lateral: Peroneus longusLateral: Peroneus longus
and brevisand brevis
– Anterior: EHL, EDC, TibialisAnterior: EHL, EDC, Tibialis
anterior, Peroneus tertiusanterior, Peroneus tertius
– Supeficial posterior-Supeficial posterior-
Gastrocnemius, SoleusGastrocnemius, Soleus
– Deep posterior-TibialisDeep posterior-Tibialis
posterior, FHL, FDLposterior, FHL, FDL

45. Single IncisionSingle Incision
 Perifibular FasciotomyPerifibular Fasciotomy
– Matsen et al (1980)Matsen et al (1980)
– Single incision justSingle incision just
posterior to fibulaposterior to fibula
– Common peroneal nerveCommon peroneal nerve

46. Double IncisionDouble Incision
 In most instances itIn most instances it
affords better exposure ofaffords better exposure of
the four compartmentsthe four compartments
 2 vertical incisions separated2 vertical incisions separated
by minimum 8 cmby minimum 8 cm
 One incision over anterior andOne incision over anterior and
lateral compartmentslateral compartments
 Superficial peroneal nerveSuperficial peroneal nerve
 One incision locatedOne incision located
1-2 cm behind postero1-2 cm behind postero
-medial aspect of tibia-medial aspect of tibia
 Saphenous nerve and veinSaphenous nerve and vein
Mubarak et al JBJS 1977

47. Fasciotomy: Medial LegFasciotomy: Medial Leg
Flexor digitorum
longus
Gastroc-soleus

48. Fasciotomy: Lateral LegFasciotomy: Lateral Leg
Superficial peroneal
nerve
Intermuscular septum

49. Look for SuperficialLook for Superficial
Peroneal NervePeroneal Nerve
 Superficial peroneal nerveSuperficial peroneal nerve
exits from lateral compartmentexits from lateral compartment
about 10 cm above lateralabout 10 cm above lateral
malleolus and courses into themalleolus and courses into the
anterior compartmentanterior compartment
 Risk of injuryRisk of injury

50. PerifibularPerifibular
 Posterior to fibular headPosterior to fibular head to just aboveto just above
Lat malleolusLat malleolus
 Expose and protect CommonExpose and protect Common
Peroneal Nerve proximallyPeroneal Nerve proximally
 More difficult to decompress deepMore difficult to decompress deep
compartmentcompartment
 Anterior insicion mobilized aroundAnterior insicion mobilized around
fibula decompress ant/latfibula decompress ant/lat
compartmentscompartments

52. Two - IncisionTwo - Incision
 11stst
incisionincision placed half – way betweenplaced half – way between
tibia crest and fibulatibia crest and fibula
 Transverse facsia incision to identifyTransverse facsia incision to identify
the intermuscular septumthe intermuscular septum
 Watch out for superficial peronealWatch out for superficial peroneal
nerve close to the septumnerve close to the septum
 22ndnd
incisionincision posteromedial approachposteromedial approach
-2cm posterior to posteromedial-2cm posterior to posteromedial
margin of tibiamargin of tibia
 Avoids saphenous nerve/veinAvoids saphenous nerve/vein

53. Use a Generous IncisionUse a Generous Incision
 Lengthening the skin incisions to an averageLengthening the skin incisions to an average
ofof 16 cm16 cm decreases intra compartmentaldecreases intra compartmental
pressures significantly.pressures significantly.
 The skin envelope is a contributing factor inThe skin envelope is a contributing factor in
acute compartment syndromes of the legacute compartment syndromes of the leg
and The use of generous skin incisions isand The use of generous skin incisions is
supportedsupported
Cohen, Mubarak JBJS Br 1991

54. Compartment SyndromeCompartment Syndrome
ForearmForearm
 Anatomy-3 compartmentsAnatomy-3 compartments
– Mobile wad-Mobile wad-
BR,ECRL,ECRBBR,ECRL,ECRB
– Volar-Superficial and deepVolar-Superficial and deep
flexorsflexors
– Dorsal-ExtensorsDorsal-Extensors
– Pronator quadratusPronator quadratus
described as a separatedescribed as a separate
compartmentcompartment

55. Forearm FasciotomyForearm Fasciotomy
 Volar-HenryVolar-Henry
approachapproach
– Include a carpalInclude a carpal
tunnel releasetunnel release
 Release lacertusRelease lacertus
fibrosus and fasciafibrosus and fascia
 Protect medianProtect median
nerve, brachialnerve, brachial
artery and tendonsartery and tendons
after releaseafter release

57. Forearm FasciotomyForearm Fasciotomy
 Protect medianProtect median
nerve, brachialnerve, brachial
artery and tendonsartery and tendons
after releaseafter release
 Consider dorsalConsider dorsal
releaserelease

58. Hand FasciotomyHand Fasciotomy
 Interosseous muscles surrounded byInterosseous muscles surrounded by
investing fascia - not a true compartmentinvesting fascia - not a true compartment
 Dorsal incisionsDorsal incisions along 2along 2ndnd
and 4and 4thth
MCMC
releasing on both sides and deep bluntlyreleasing on both sides and deep bluntly
 Can reach the adductor compartment viaCan reach the adductor compartment via
22ndnd
MC incisionMC incision
 Thenar radial side of thumbThenar radial side of thumb
 Hypothenar ulnar side of 5Hypothenar ulnar side of 5thth
MCMC

59. Compartment SyndromeCompartment Syndrome
HandHand
 non specific achingnon specific aching
of the handof the hand
 disproportionatedisproportionate
painpain
 loss of digitalloss of digital
motion & continuedmotion & continued
swellingswelling
– MP extensionMP extension
and PIP flexionand PIP flexion
 difficult to measuredifficult to measure

60.  10 separate osteofascial10 separate osteofascial
compartmentscompartments
– dorsal interossei (4)dorsal interossei (4)
– palmar interossei (3)palmar interossei (3)
– thenar and hypothenarthenar and hypothenar
(2)(2)
– adductor pollicis (1)adductor pollicis (1)
Fasciotomy of HandFasciotomy of Hand

61. Finger fasciotomyFinger fasciotomy
 Investing fascia supported by toughInvesting fascia supported by tough
volar skinvolar skin
 Compartmentalize at flexion creasesCompartmentalize at flexion creases
 Ulnar side index, long, and ring fingerUlnar side index, long, and ring finger
 Radial side thumb and smallRadial side thumb and small

62.  Spares dorsal digital nerve branchesSpares dorsal digital nerve branches
 Make incision at neutral axis of motion -Make incision at neutral axis of motion -
where flexor creases endwhere flexor creases end
 Over distal phalanx close to nailOver distal phalanx close to nail

65. Compartment SyndromeCompartment Syndrome
FootFoot
 9 compartments9 compartments
– Medial, Superficial, Lateral,Medial, Superficial, Lateral,
CalcanealCalcaneal
– Interossei(4), AdductorInterossei(4), Adductor
 Careful exam with any swellingCareful exam with any swelling
 Clinical suspicion with certainClinical suspicion with certain
mechanisms of injurymechanisms of injury
– Lisfranc fracture dislocationLisfranc fracture dislocation
– Calcaneus fractureCalcaneus fracture

66. Foot FasciotomyFoot Fasciotomy
 Traditionally five compartments (Traditionally five compartments (lateral,lateral,
medial, central, interosseous, andmedial, central, interosseous, and
calcaneal)calcaneal)
 Two dorsal incisionsTwo dorsal incisions over 2over 2ndnd
and 4and 4thth
MTMT
– Releases interossei and adductorReleases interossei and adductor
 Medial incisionMedial incision – 3cm from plantar– 3cm from plantar
surface, 4cm from posterior heelsurface, 4cm from posterior heel
– Subsequent released sup. and inf.Subsequent released sup. and inf.
Exposing plantar aponeurosis and getsExposing plantar aponeurosis and gets
abductor hallucis, calcaneal comartment,abductor hallucis, calcaneal comartment,
digiti quintidigiti quinti

68.  Dorsal incisionDorsal incision -to release the-to release the
interosseous and adductorinterosseous and adductor
 Medial incisionMedial incision -to release the-to release the
medial, superficial lateral andmedial, superficial lateral and
calcaneal compartmentscalcaneal compartments
Compartment SyndromeCompartment Syndrome
FootFoot

69. Compartment SyndromeCompartment Syndrome
ThighThigh
 Lateral to releaseLateral to release
anterior andanterior and
posteriorposterior
compartmentscompartments
 May require medialMay require medial
incision for adductorincision for adductor
compartmentcompartment
Lateral septum
Vastus lateralis

70. Delayed FasciotomyDelayed Fasciotomy
Is it Safe?Is it Safe?
– infection rate of 46% and amputation rate of 21%infection rate of 46% and amputation rate of 21%
after a delay of 12 hoursafter a delay of 12 hours
– 4.5 % complications for early fasciotomies and4.5 % complications for early fasciotomies and
54% for delayed ones54% for delayed ones
 RecommendationsRecommendations
– If the CS has existed for more than 8-10 hrs,If the CS has existed for more than 8-10 hrs,
supportive treatment of acute renal failure shouldsupportive treatment of acute renal failure should
be considered.be considered.
– Skin is left intact and late reconstructions maybeSkin is left intact and late reconstructions maybe
planned.planned.
Sheridan, Matsen.JBJSSheridan, Matsen.JBJS
19761976

71. Delayed FasciotomyDelayed Fasciotomy
Is it Safe?Is it Safe?
– 5 pts, nine fasciotomies in lower limbs5 pts, nine fasciotomies in lower limbs
– Avg delay 56 h. (35-96 hrs).Avg delay 56 h. (35-96 hrs).
– 1 pt died of septicaemia and multi organ1 pt died of septicaemia and multi organ
failure, the others required amputationsfailure, the others required amputations
 RecommendationsRecommendations::
– In delayed cases, routine fasciotomy mayIn delayed cases, routine fasciotomy may
not be successfulnot be successful
Finkelstein et al. J Trauma 1996Finkelstein et al. J Trauma 1996

72. Wound ManagementWound Management
 After the Fasciotomy, a bulky compression dressingAfter the Fasciotomy, a bulky compression dressing
and a splint are applied.and a splint are applied.
 ““VAC” (Vacuum Assisted Closure) can be usedVAC” (Vacuum Assisted Closure) can be used
 Foot should be placed in neutral to prevent equinusFoot should be placed in neutral to prevent equinus
contracture.contracture.
 Incision for the Fasciotomy usually can be closed afterIncision for the Fasciotomy usually can be closed after
three to five daysthree to five days

73. Interim CoverageInterim Coverage
TechniquesTechniques
 Simple absorbentSimple absorbent
dressingdressing
 SemipermeableSemipermeable
skin-like membraneskin-like membrane
 Vessel loopVessel loop
“bootlace”“bootlace”
 ““VAC” (VacuumVAC” (Vacuum
Assisted Closure)Assisted Closure)

74. Wound ManagementWound Management
 Wound is not closed at initial surgeryWound is not closed at initial surgery
 Second look debridement with considerationSecond look debridement with consideration
for coverage after 48-72 hrsfor coverage after 48-72 hrs
– Limb should not be at risk for further swellingLimb should not be at risk for further swelling
– Pt should be adequately stabilizedPt should be adequately stabilized
– Usually requires skin graftUsually requires skin graft
– DPC possible if residual swelling is minimalDPC possible if residual swelling is minimal
– Flap coverage needed if nerves, vessels, or boneFlap coverage needed if nerves, vessels, or bone
exposedexposed
 Goal is to obtain definitive coverage within 7-10Goal is to obtain definitive coverage within 7-10
daysdays

75. Wound ClosureWound Closure
 STSGSTSG
 Delayed primaryDelayed primary
closure with relaxingclosure with relaxing
incisionsincisions

76. Complications Related toComplications Related to
FasciotomiesFasciotomies
 Altered sensation within the margins of the wound (77%)Altered sensation within the margins of the wound (77%)
 Dry, scaly skin (40%)Dry, scaly skin (40%)
 Pruritus (33%)Pruritus (33%)
 Discolored wounds (30%)Discolored wounds (30%)
 Swollen limbs (25%)Swollen limbs (25%)
 Tethered scars (26%)Tethered scars (26%)
 Recurrent ulceration (13%)Recurrent ulceration (13%)
 Muscle herniation (13%)Muscle herniation (13%)
 Pain related to the wound (10%)Pain related to the wound (10%)
 Tethered tendons (7%)Tethered tendons (7%)
Fitzgerald, McQueen Br J Plast SurgFitzgerald, McQueen Br J Plast Surg
20002000

77. Complications related toComplications related to
CSCS
 Late SequelaeLate Sequelae
 Volkmann’s contractureVolkmann’s contracture
 Weak dorsiflexorsWeak dorsiflexors
 Claw toesClaw toes
 Sensory lossSensory loss
 Chronic painChronic pain
 AmputationAmputation

78. SummarySummary
 Keep a high index of suspicionKeep a high index of suspicion
 Treat as soon as you suspect CSTreat as soon as you suspect CS
 If clinically evident, do not measureIf clinically evident, do not measure
 FasciotomyFasciotomy
– Reliable, safe, and effectiveReliable, safe, and effective
– The only treatment for compartmentThe only treatment for compartment
syndrome,syndrome,
when performed in timewhen performed in time

79. VOLKMANN’S ISCHAEMICVOLKMANN’S ISCHAEMIC
CONTRACTURESCONTRACTURES
 Contracture results from insufficient arterial perfusion &Contracture results from insufficient arterial perfusion &
venous stasis followed by ischemic degeneration ofvenous stasis followed by ischemic degeneration of
muscle;muscle;
- irreversible muscle necrosis begins after 4-6 hrs;- irreversible muscle necrosis begins after 4-6 hrs;
- Resulting edema impairs circulation, leads to- Resulting edema impairs circulation, leads to
forearmforearm comapartmentcomapartment syndromesyndrome, which propagates, which propagates
progressive muscle necrosis;progressive muscle necrosis;
- Muscle degeneration is most affected at the- Muscle degeneration is most affected at the
middle third of muscle belly, being most severe closermiddle third of muscle belly, being most severe closer
to bone;to bone;

80. -- There is less involvement toward theThere is less involvement toward the
proximal & distal surfaces;proximal & distal surfaces;
- Necrosis of the muscle with- Necrosis of the muscle with
secondary fibrosis that may developsecondary fibrosis that may develop
followed by calcification in its finalfollowed by calcification in its final
phasephase

81. AnatomyAnatomy
 - distal to Lacertus fibrosus --Brachial- distal to Lacertus fibrosus --Brachial
artery branches into Radial & Ulnar artery.artery branches into Radial & Ulnar artery.

- Radial artery is superficially located,- Radial artery is superficially located,
whereas ulnar artery is deeply situated,whereas ulnar artery is deeply situated,
traversing deep to pronator teres muscles.traversing deep to pronator teres muscles.

- Ulnar artery gives rise to the common- Ulnar artery gives rise to the common
interosseous artery, which divides immediatelyinterosseous artery, which divides immediately
into anterior & PIN branches.into anterior & PIN branches.

- Flexor digitorum longus and the Flexor- Flexor digitorum longus and the Flexor
pollicis longus muscles derive their bloodpollicis longus muscles derive their blood
supply thru anterior interosseous artery.supply thru anterior interosseous artery.

82. PathoanatomyPathoanatomy

- Infarct has ellipsoid shape with its axis along- Infarct has ellipsoid shape with its axis along
anterior interosseous artery & its central point slightlyanterior interosseous artery & its central point slightly
above middle of the forearmabove middle of the forearm
 - Therefore, the muscles most dependent on- Therefore, the muscles most dependent on
the Anterior Interosseous artery (FDP, FPL, FDS, andthe Anterior Interosseous artery (FDP, FPL, FDS, and
the pronator teresthe pronator teres
 - FDP and FDS muscles become contracted- FDP and FDS muscles become contracted
and are replaced by scar, which leads to wrist flexionand are replaced by scar, which leads to wrist flexion
contracture and clawing of the fingerscontracture and clawing of the fingers
 - In addition to muscle necrosis, there will also- In addition to muscle necrosis, there will also
be injury to the Median and Ulnar nerves leading tobe injury to the Median and Ulnar nerves leading to
High Ulnar nerve and Median nerve palsyHigh Ulnar nerve and Median nerve palsy

83. FingersFingers
- may lie in intrinsic minus- may lie in intrinsic minus
position (due to high nerve palsy)position (due to high nerve palsy)
- alternatively, the fingers - alternatively, the fingers
may lie in an intrinsic plus positionmay lie in an intrinsic plus position
(MP's flexed, PIP extended), if there(MP's flexed, PIP extended), if there
has been a concomitant compartmenthas been a concomitant compartment
syndrome of the hand resulting insyndrome of the hand resulting in
intrinsic contractureintrinsic contracture