REFERENCE -Campbell's operative orthopaedics -Mercer's textbook of orthopaedics - google etc

1. COMPARTMENT SYNDROME
BY DR MANMATHA NAYAK
JUNIOR RESIDENT ,DEPT OF ORTHOPAEDIC
GOVT MEDICAL COLLEGE, KOTTAYAM,KERALA

2. COMPARTMENT SYNDROME
• DEFINiTION
• TYPES
• PATHOPHYSIOLOGY
• ETIOLOGY
• CLINICAL EVALUATION
• DIAGNOSIS
• MANAGEMENT
• COMPLICATION

3. DEFINITION
‘’Elevation of the interstitial pressure in a closed osteofascial
compartment that result in microvascular compromise’’

5. TYPES
• Depending on the cause of the increased pressure and the duration of
symptoms
• A)ACUTE COMPARTMENT SYNDROME
• B)CHRONIC EXERTIONAL COMPARTMENT SYNDROME

6. PATHOPHYSIOLOGY
• Insult to normal local tissue haemostsis results in
-Increased tissue pressure
-decreased capillary blood flow
-local tissue necrosis caused by oxygen deprivation

7. EATON AND GREEN VICIOUS CYCLE

8. ETIOLOGY OF ACS

9. • A)Increase in compartmental content
- edema –prolonged limb compression,post trauma
-hemorrhage-vessel laceration
-combination of both –fractures
B)decrease in compartment size
- constrictive casts
-circular dressings
-extensive burns

10. • Most common causes of ACS are
- fractures
- soft tissue trauma
-arterial injury
-limb compression during altered
conscious and burn
-iv fluid etravasation
-anticoagulants
• Acute exertional cs-seen in the foot in runners,basket ball player,and other
athelets

11. CLINICAL EVALUATION
• MUBARAK AND HARGENS SIX P’’ characteristics of ACS
1. high pressure-evident from swollen and tense compartment
2. pain –especially with passive stretch and out of proportion to the
clinical picture
3. paresthesia
4. pallor
5. Pulse –distal pulses are almost always present
6. Paralysis

12. MEASUREMENT OF COMPARTMENT
PRESSURE
• INDICATIONS-high risk injuries in
- polytrauma patients
- pt not alert or not reliable
- inconclusive physical examination finding
TECHNIQUE-performed each compartment at close to the fracture site
as possible ( highest pressure )or maximal swelling area

13. STRYKER HAND HELD SYSTEM

14. STYKER SLIT CATHETER

15. WHITESIDES MANEUVER

16. MANAGEMENT
• EARLY MANAGEMENT-
> remove cast or bandage
> positioning of the limb at the level heart
-do not elevate the affected limb ->decrease arterial pressure
> hydration
> oxygen suppliment

18. TREATMENT
• NONOPERATIVE
-if the stage is of impending compartment syndrome
• OPERATIVE –(emergency fasciotomy)
- positive clinical finding + cp > 30mmhg
=> contra indication –missed compartment syndrome
(various stage of muscle infarction)

19. ANATOMY OF COMPARTMENTS
• ARM – 2 compartment
• FOREARM- 4 compartment
• HAND - 10 compartment
• THIGH-3 compartment
• LEG -4 compartment
• FOOT- 9 compartment

32. FASCIOTOMY POST OP CARE
• Skeletal fixation can be done at time of initial surgical decompression
• After decompression sterile dressings( saline soaks),splinting in
functional position
• Return to OT for 2nd look in 2-5days
-if no muscle necrosis-the skin is loosely closed
- if closure is not accomplished
- debridement after another 72hr interval
- skin closure or SSG

33. COMPLICATIONS

34. oMYONECROSIS-
functional impairement –after 2-4hr of ischemia
Irreversible functional loss-after 4-12hr of ischemia
may lead to myoglobunuria and renal failure

35. • NERVE DAMAGE –
abnormal function after 30 minute of ischemia
irreversible functional loss after 12 to 24 hr

36. • VIC –
necrotic muscle and nerve tissue has been replaced with fibrous tissue

37. • REPERFUSION SYNDROME-
> Influx of myoglobulin ,phosphorus,potassium into the circulation
> resulting in myoglobunuria,hyperkalemia,hypovolemic shock
acidosis, renal failure

38. • INFECTION
• AMPUTATION

39. CHRONIC COMPARTMENT SYNDROME
• Known as exertional cs
recurrent cs
subacute cs
typical patients are young athelet (long distance runner) and military
recruits
occur mainly in lower limb

40. PATHOPHYSIOLOGY
• Not yet fully understood
• Probably increased muscle relaxation pressure during exercise
- decreased muscle blood flow
- ischemic pain and impaired muscle function

41. PHYSICAL EXAM IN CCS
• Exercise induced pain
• Tenderness over the compartment
• Bilateral involvement is common upto 82%
• Fascial hernia

42. DD
• Periostitis
• Entrapment of superficial peroneal nerve
• Tendinitis posterior tibial tendon
• Stress fracture of tibia
• Intermittent claudication

43. WORK UP OF CCS
• Plain x ray- show 90% of stress fracture
• Bone scan – diffuse uptake – periostitis
localized uptake – stress fracture
• Tinel test – +ve in nerve entrapment
• NCS – could be helpful
• MRI - promising results reported

44. DIAGNOSIS OF CCS
• Intracompartmental testing is the hallmark of diagnosis (as reported
by PEDWOTIZ ET.AL)
1) Preexercise resting pressure of 15mmhg or more
2) After 1 minute of exercise pressure of 30mmhg
3) After 5minute of exercise pressure of 20mmhg or more

45. TREATMENT OF CCS
• NONOPERATIVE-
-- NSAID
- Electrostimulation
- muscle relaxant
- cessation or significant reduction of atheletic activities

46. • OPERATIVE TREATMENT-
> single incision fasciotomy
>double incision fasciotomy

50. • AFTER SURGERY -
> early ROM are encouraged
>wt bearing on crutches is allowed on POD1
>light jogging is allowed at 2-3weeks if no swelling or tenderness