notes on compartment syndrome

1. DR REMYA R KRISHNAN
RESIDENT INTERN
AZEEZIA MEDICAL COLLEGE

2. Definition
An elevation of the intercompartment pressure to a
level & duration without decompression will results
in tissue ischemia and necrosis.
Occurs in closed osteofascial compartment
Causes microvascular compromise

3. 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.

4. Pathophysiology

5. Pathophysiology
The vicious cycle of Volkmann's ischemia
Increased intracompartmental Pressure
 increases local venous Pressure
 narrowed AV perfusion gradient
 compartment tamponade
decrease capillary blood flow
 O2 deprivation
 local tissue necrosis
 nerve injury and muscle ischemia

6. Theories
Critical closing pressure theory
Arteriovenous gradient theory
Macrovascular occlusion thoery

7. Etiology of ACS
DECREASED COMPARTMENT SIZE
INCREASED COMPARTMENT PRESSURE
7

8. 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

9. Etiology
 Increased compartment contents
SNAKE BITE
IATROGENIC CAUSES
Fractures : the most common are
Tibial diaphyseal
Distal radial and forearm diaphyseal

10. Etiology
 Increased compartment contents
• Hemorrhage -- vascular injury, coagulopathy
• Muscle edema -- severe exercise , crush injury
• Increase capillary permeability–
burn,orthopaedic surgeries
• Soft tissue injury
• Metabolic diseases– diabetes, hypertension

11. Increased compartment
contents

12. Clinical features
Swelling/ Tightness of compartment
Inappropiate and uncontrolled pain
Stretch pain & rest pain
Pallor
Pulselessness
Paresthesia
Paralysis (full recovery is rare)

13. In children :3 A
ANXIETY
AGITATION
INCREASED REQUIREMENT OF ANALGESICS
13

14. 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
Measurement of
Compartment pressures

16. Devices
Stryker hand-held system Stryker slit catheter
Newer devices

17. Management
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

19. Treatment
Operative
Emergency fasciotomy
Positive clinical presentation pressure = 30-45 mm Hg
Contraindications : Missed compartment syndrome
(Various stage of muscle infarction)

20. Types
Forearm Syndromes
Deep forearm Syndrome
Compresion ischemia
Anterior tibial Syndrome
Deep posterior tibial Syndrome
Peroneal Compartment Syndrome
Superficial posttibial compartment Syndrome

21. Types by location
2 compartments of arm
4compatments of forearm
10 compartments of hand
3 compartments of thigh
4 compartments of leg
9compartments of foot

22. 2 Compartments of arm
1. Anterior
1. Biceps,Bracialis
2. Musculocutaneous n.
3. Brachial a.
2.Posterior
1. Triceps
2. Radial n.

23. 4 Compartments of forearm
1. Mobile wad
: Brachioradialis,
Radial n
2,3. Dorsal superficial
&deep
:Posterior intero-
seous n & a
4. Volar superficial
&deep
:Median and Ulnar n.
Radial a., Ulnar a.,
ant. interosseous a.
-most commonly
affect volar
Dorsal incision

24. 10 Compartments of hand

25. 3 Compartments of thigh
Anterior
femoral n
quadriceps
sartorious
Posterior
sciatic n
hamstrings
Medial
obturator n
adductors

27. 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

30. 9 Compartments of foot

31. Dorsal dual incision
Medial incision

32. Complications
Myonecrosis : after an ischemic insult of > 8 hrs.
Treatment
fasciotomy + debridement of the muscles + neurolysis
 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,

33. Reperfusion syndrome : group of complications following reestablished
blood flow to ischemic tissues
Occur after fasciotomy & restoration of blood flow
Evaluation :
 Fluid loss, Shock
 Acidosis
 Hyperkalemia
 Myoglobinuria, Renal failure
Management :
 Preoperative hydration
 Mannitol
 Bicarbonate
Complications

34. Complications
Neurovascular injury
Infection

35. Chronic Compartment Syndrome
Known as exertional CS, recurrent CS or subacute CS
 Typical patient is young (20-30s) athlete (long
distance runner)or military recruits
Occur mainly in the lower limb

36. Pathophysiology
Not yet fully understood
Probably from increased muscle relaxation pressure
during exercise
 decreased muscle blood flow
 ischemic pain and impaired muscle function

37. Recurrent pain
Temporary paraesthesia & numbness
Limitation of movements
Tenderness over the compartment
Muscle hernias seen
Bilateral involvement is common
Clinical features

38. Periostitis
Entrapment of the superficial peroneal nerve
Tendinitis of the posterior tibial tendon
Stress fracture of tibia
Intermittent claudication
Differential diagnosis

39. Plain x-rays : show stress fracture
Tinel test : may be positive in superficial peroneal
nerve entrapment
Nerve Conduction Study
MRI
Investigations

40. Treatment
Non-operative :
 NSAIDs
 Muscle relaxants
 Cessation or significant reduction of athletic activities

41. Treatment
Operative treatment
 Single incision fasciotomy
 Double incision fasciotomy
After surgery :
Physiotherapy is a must

42. Compartment syndrome is a serious syndrome, Which needs
to be diagnosed early.
Palpable pulse doesn’t exclude compartment syndrome
If diagnosis and fasciotomy were done within 24 hrs, the
prognosis is good.
If delayed, complications will develop.
The earlier you diagnose, the safer you are

43. THANK YOU