1. Presented by : Dr. Mohamed Adel Al-Weshali
Resident of G.surgury, orthopedic arabic board
48 modern hospital
Under supervision of :
Dr. Ali Mohamed Saled
Dr. Abdo shamsan
Dr. Mohamed Essa
Dr. Raidan Al-Eryani
3. Acute compartment syndrome
Occurs when the tissue pressure within a closed
muscle compartment exceeds the perfusion pressure,
and results in muscle and nerve ischemia.
8. Arterial injury
Post ischemic swelling
Reperfusion injury :
Ischemia causes damage to cellular basement membrane
that results in edema.
With re-establishment of flow, fluid leaks into the
compartment, increasing the pressure.
11. Diagnosis
Based on clinical assessment ( 5 P’s )
Parasthesia
Paresis
Pain
Pink color
Present pulse
12. Difficult diagnosis? Why?
classic ( 5 p’s ) signs are not reliable because these are
signs of an established compartment syndrome where
ischemic injury has already taken place
These signs may be present in the absence of
compartment syndrome
Palpable pulses are usually present in acute
compartment syndromes unless an artrial injury
oocurs
Sensory changes (paresthesia and paralysis) do not
oocur until ischemia has been present for about 1 hour
and more
13. Pain
The most important symptom of CS is pain
disproportionate to that expected for injury, and pain
with passive stretching of the affected limb
pain worsen with elevation
Patient will not initiate motion on own
Always be carful of co-existing nerve injury
14. Always remember that :
Pain out of proportion to the injury and
pain with passive stretching of the muscles in the
affected compartment, are the earliest (sensitive) and
most reliable indicators of acute compartment syndrome
15. Clinical findings vs. timing
Early ACS Late ACS
Pain out of proportion to injury Pulselss
Pain with passive stretch of muscles in
the affected compartment
Paralysis
paresthesia Paresthesia / sensation loss
17. Physical signs of ACS
Pain with passive stretch of limb.
A firm and tense compartment with a firm “wood-like”
feeling.
Diminished sensation.
Muscle weakness (onset within two to four hours of
ACS)
Paralysis (late finding)
18. Who is at high risk?
inability to obtain history and physical exam such as:
Head trauma
Drug/Alcohol intake
pediatric
Multiple trauma patients with hypoxia and hypotension
Compartment syndrome can occur at lower absolute pressure
high energy fractures
Severe comminution
Segmental injuries
widely displaced
Bilateral
Floating knee
Open fractures
Presence of an open fracture does not role out the presence of a C.S.
Impaired sensorium
Alcohol
Drug
Decreased GCS
Unconscious
Neurologic deficit
Post operative patients on analgesia that mask the development of pain
19. Intramuscular pressure (IMP)
measurment
Adjunct to clinical examination
By using Stryker device
Needed for comatose or otherwise non-evaluable
patient:
Anasthesia
Head injury
Sedated
Intoxicated
Pediatric Pts.
20.
21. Sequences of ACS
Muscle ischemia
4hours - reversible damage
8hours – irreversible damage
4-8hours – variable
Myoglobinuria after 4 hours causing renal failure is
monitored by checking CK levels, and maintaining a
high urinary output is mandatory.
Nerve ischemia
1hour – normal conduction
1-4hours - neuropraxic damage reversible
8hours – irriversible changes.
22. Management
Immediately assess the patient
Identification and removal of external compressive
forces, and releasing casts or dressings down to skin
The limb should not be elevated above heart level, and
instead kept at the level of the heart to avoid
decreasing arterial blood flow any further
Maintain normal BP as hypotension may decrease
perfusion further and compound any existing tissue
injury.
Early assessment of metabolic acidosis and
myoglobinaemia is mandatory to avoid RF.
25. Technique of fasciotomy
longitudinal skin incision that extends the entire
length of the compartment
Release the fascia and involved muscle
Skin left open
Closure achieved after swelling subsides
Skin grafting may be required.
2nd and 3rd look may also be required
