orthopedics, compartment syndrome

1. COMPARTMENT SYNDROME

2. The limbs contain muscles along with vessels and
nerves that are enclosed by Fascia, bones and
interosseous membrane. This osteo-fascial
compartment is very resistant to expansion. And
whenever there
is swelling of
muscles due to
any reason, the
compartment
doesn’t expand,
and there is
increase in
pressure, leading
to hampering of
Micro-Circulation.

3. Compartment syndrome is an elevation of the
interstitial pressure in a closed osteo-fascial
compartment that results in microcirculation
compromise.
The end result is ischemic muscle necrosis and
nerve damage. This leads to PERMANENT
fibrosis and contractures and varying degrees of
nerve injury.

4. Compartment syndrome can develop anywhere
where skeletal muscle is
surrounded by fascia, such
as in buttock, thigh,
shoulder, hand, foot, arm,
and lumbar paraspinal
muscles.
But the most commonly involved areas are the
anterior and deep posterior compartments of the
leg and the volar compartment of the forearm.

5. Compartment syndrome can be classified as
• Acute or
• Chronic,

6. ACUTE compartment syndrome is caused by an acute
injury and can cause devastating complications. It is
an ORTHOPEDIC EMERGENCY. It is usually is caused
by
• fractures, especially
 Tibial fractures
 Forearm fractures
 Supracondylar humeral fractures
• Crush injuries
• Severe soft tissue trauma,
• arterial injury,
• limb compression during altered consciousness,
• and burns.

7. PATHOLOGY
Injury causes edema that results in increased tissue
pressure, decreased capillary blood flow, (pulses and
oxygen saturation is usually normal). This causes
local oxygen deprivation leading to tissue necrosis.
This leads to permanent nerve damage and muscle
contractures.
Experimental evidence suggests that
“even 30 mm Hg increase in intracompartmental
pressure can lead to significant muscle necrosis in 8
hours even with normal blood flow.”
Higher pressures have been shown to cause greater
compromise of neuromuscular viability in shorter
periods of time.

8. Diagnosis:
Diagnosis is CLINICAL and is based on a high degree of suspicion
especially in the under risk groups (forearm fractures, tibia fractures,
supracondylar fractures, crush injuries etc.)
Signs and symptoms of acute compartment syndrome include :
• PAIN, out of proportion to the injury and not relieved by usual doses
of analgesics,
• Muscle weakness, hyperasthesia, paraesthesias.
• Remember, CS is problem of MICROCIRCULATION, pulses and sO2 are
usually normal
• SWELLING (increase in limb girth).
• TIGHTNESS of the involved compartment,
• STRETCH TEST: pain with passive motion of the muscles passing
through the compartment,
The diagnosis of acute compartment syndrome may be delayed in
patients with multiple injuries or altered consciousness and in children.

9. Compartment pressure measurements are used ONLY IF an
adequate examination cannot be performed. Monitoring of
compartment pressures is helpful in patients with altered
neurological function, continuous epidural anesthesia,
peripheral nerve injury, or tourniquet palsy. ETC
.

10. Studies have shown, however, that pressure
measurements are erroneous in as many as 30%
of patients and should not be used as the
primary determinant for or against fasciotomy.

11. If compartmental syndrome is diagnosed, immediate fasciotomy is indicated.
Compartment syndrome associated with a fracture should be treated at the
time of fracture stabilization.
Nonreamed intramedullary nailing is preferred for lower limbs.
In impending compartment syndrome we can try to lower the compartment
pressure by
• Splitting any cast and underlying padding if done.
• Splitting any circular constrictive bandages
• RICE therapy (Rest, immobilisation, cold compresses, elevation)
If symptoms do not resolve within 30 to 60 minutes after appropriate
treatment, or IF IN DOUBT, DO A FASCIOTOMY.
Even with timely fasciotomy, many patients have long-term sequelae,
including altered sensation, swelling, pain, functional deficits, and cosmetic
concerns.

12. CHRONIC COMPARTMENT SYNDROME

13. Chronic exertional compartment syndrome is defined as
reversible ischemia secondary to a noncompliant
osteofascial compartment that is unresponsive to the
expansion of muscle volume that occurs with exercise. It
most often in the anterior or deep posterior
compartment of the leg.
Exertional compartment syndrome of the lower extremity
is most common in long-distance runners and military
recruits pushed past normal limits of functional
tolerance.
It also has been reported to occur elsewhere, including
the forearms in weightlifters, rowers, welders, and others
who place large demands on their upper extremities.
Anabolic steroid and creatine use also increases muscle
volume.

14. Exercise can increase muscle volume by 20%,
causing an increase in pressure in a noncompliant
compartment.
CECS is most common in young adult recreational
runners, elite athletes, and military recruits.

15. The importance of an accurate history cannot be
overemphasized in the evaluation of patients with lower
extremity pain.
A typical patient with CECS is a competitive runner, 20 to
30 years old, who describes exercise-induced pain and a
feeling of tightness that begins after 20 to 30 minutes of
running or exercise. The pain usually resolves within 15 to
30 minutes of cessation of exercise.
Paresthesias of the nerves running through the involved
compartment often are reported.
Physical examination may reveal tenderness over the
musculature of the involved compartment,
Symptoms are bilateral in about 75% of patients. Studies
have indicated that a 2-year delay in diagnosis is typical.

16. Treatment includes:
• Conservative measures include relative rest
(limiting activity to a level that avoids all but
minimal symptoms)
• Antiinflammatory medications,
• manual stretching and strengthening of the
involved muscles,
• and orthotics.
If symptoms persist, if pressures are extremely
elevated, or if the athlete desires to continue activity
at the same level, fasciotomy of the involved
compartments is indicated
Subcutaneous and endoscopic techniques have been
described for fasciotomy.

17. Thank you