compartment syndrome

1. COMPARTMENT
SYNDROME
DR ABHISHEK GAUTAM
MODERATOR-DR MAHENDRA MEENA

2. INTRODUCTION
WHAT IS COMPARTMENT?
A compartment is a group of muscles, nerves and
blood vessels. A thin but firm membrane (covering) called a
fascia lies over each compartment. It keeps the muscles in
place. But the fascia isn't meant to stretch or expand
NORMAL PRESSURE RANGE - 5 to 15 mmhg
UNDERLYING MECHANISM-
1) INCREASED VOLUME WITHIN SPACE
2) DECREASED SPACE FOR CONTENTS
3) COMBINATION OF BOTH

3. What is compartment syndrome?
A condition in which increased
compartment pressure within a
confined space, compromises the
circulation and viability of the
tissues within that space

4. First Documentation
• The first medical reference was in
1881, when German doctor Richard von
Volkmann described a permanent
contracture of the forearm related to
ischemia within muscle compartments
of the arm

5. 4 Compartment at the leg level

6. Cross section at the leg level

7. Compartment at the level of forearm

8. INC. COMPARTMENT PRESSURE(35-40 mm hg)
CAPILLARIES COLLAPSE
DEC. BLOOD FLOWTO MUSCLES& NERVE
BLOOD VESSELS COLLAPSE

9. PATHOPHYSIOLOGY OF
COMPARTMENT SYNDROME

10. PATHOPHYSIOLOGY
• INCREASED COMPARTMENT PRESSURE LEADS TO INCREASED
VENOUS PRESSURE WHICH DECREASES A-V GRADIENT
RESULTING IN MUSCLE AND NERVE ISCHAEMIA
• VICIOUS CYCLE OF -INCREASED PRESSURE IN ONE OF THE
OSSEOFASCIAL COMPARTMENTS,THERE IS REDUCED
CAPILLARY FLOW,RESULTING IN MUSCLE ISCHAEMIA,FURTHER
OEDEMA,GREATER PRESSURE AND YET MORE PROFOUND
ISCHAEMIA(A VICIOUS CIRCLE THAT ENDS,AFTER 6 hrs or less, IN
NECROSIS OF NERVE AND MUSCLE WITHIN COMPARTMENT)
• NERVE IS CAPABLE OF REGENERATION BUT MUSCLE ,ONCE
INFARCTED ,CAN NEVER RECOVER AND IS REPLACED BY
INELASTIC FIBROUS TISUE(VOLKMANN’S ISCHAEMIC
CONTRACTURE).
• ABOVE SIMILAR CASCADE OF EVENTS MAY BE CAUSED BY
SWELLING OF A LIMB INSIDE A TIGHT PLASTER CAST)

11. Causes of compartment syndrome

13. EATON AND GREEN CYCLE

15. WHY IT IS DANGEROUS?
1 NERVES:
NEUROPRAXIA: WILL REGENERATE
ISCHAEMIA: CELL DEATH
2 MUSCLES:
CONTACTURE (VOLKMANN’S ISCHAEMIC
CONTRACTURE)
3 GANGRENE

16. CLINICAL PRESENTATION

17. SIGNS AND SYMPTOMS
• INCREASED PRESSURE ANDTIGHTNESS
• PROGRESSIVE PAIN OUT OF PROPORTION TO INITIAL INJURY
• MARKEDLY SWOLLEN AREA
• PROGRESSIVE NEUROLOGIC DEFICIT
7 P’S
• PAIN
• PRESSURE
• PAIN WITH PASSIVE STRETCH
• PARAESTHESIA
• PALLOR
• PARESIS/PARALYSIS
• PULSELESSNESS

18. SIGNS AND SYMPTOMS
• HOWEVER ,IN COMPARTMENT SYNDROME ISCHAEMIA OCCURS
AT CAPILLARY LEVEL,SO PULSES MAY STILL BE FELT AND SKIN
MAY NOT BE PALE.
• EARLIEST CLASSICAL FEATURE IS SEVERE PAIN (BURSTING
SENSATION)/PAIN OUT OF PROPORTION INCREASED PAIN WITH
PASSIVE STRETCH OF INVOLVED MUSCLE IS A CONSISTENT
DIAGNOSTIC INDICATOR OF COMPARTMENT SYNDROME.
• INCASE OF LOWER LIMB INVOLVEMENT LEADING TO
COMPARTMENT SYNDROME-THE TIME OF FOOT DROPVARIES
WITHTHE COMPARTMENT INVOLVED PASSIVE HYPER
EXTENSION OFTOES AND FINGERS LEADS TO INCREASED PAIN
IN CALF OR FOREARM.

19. • Leg compartment syndrome is found in 2% to 9%
of tibial fractures. It is strongly related to fractures involving the
tibial diaphysis as well as other sections of the tibia.[2
• Any external compression (tourniquet, orthopedic casts or
dressings applied on the affected limb) should be removed.
Cutting of the cast will reduce the intracompartmental pressure
by 65%, followed by 10 to 20% pressure reduction once
padding is cut. After removal of the external compression the
limb should be placed at the level of the heart. The vital signs
of the patient should be closely monitored. If the clinical
condition does not improve, then fasciotomy is indicated to
decompress the compartments. An incision large enough to
decompress all the compartments is necessary. This surgical
procedure is performed inside an operating theater under
general or local anesthesia

20. CONFIRMATORY SIGN

21. DIAGNOSIS CONFIRMATION
• BY MEASURING INTRACOMPARTMANTAL PRESSURE-
ESPECIALLY IN HIGH RISK PATIENTS EG. FRACTURES OF
TIBIA AND FIBULA
• SPLIT CATHETER IS INTRODUCED INTO COMPARTMENT
AND PRESSURE IS MEASURED CLOSE TO LEVEL OF
FRACTURE
• DIFFERENTIAL PRESSURE DELTA-P IS DIFFERENCE
BETWEEN DIASTOLIC AND COMPARTMENT PRESSURE
OF LESSTHAN 30 mm hg (4 kilo pascals) IS AN
INDICATION FOR IMMEDIATE COMPARTMENT
DECOMPRESSION)

22. Quickly diagnosing tips

23. STRYKER PRESSURE MANOMETER

24. ACUTE ANTERIOR COMPARTMENT
SYNDROME
• PAIN WITH PASSIVE TOE FLEXION,WEAKNESS OFTOE
EXTENSION AND DIMINISHED SENSATION IN FIRST WEB
SPACE(DUETO DEEP PERONEAL NERVE COMPRESSION)
• FIRST MUSCLETO SHOW WEAKNESS-EXTENSOR HALLUCES
LONGUS
CAUSES - TRAUMA TO EXTREMITY
MARCH GANGRENE
CLINICAL FEATURES- LOCAL ERYTHEMA,HEAT AND BRAWNY
EDEMA OVER ANTERIOR COMPARTMENT
TREATMENT- WIDE FASCIOTOMY OF ANTERIOR COMPARTMENT
MUST BE PERFORMED TO SALVAGE ISCHAEMIC MUSCLES

26. ACUTE DEEP POSTERIOR
COMPARTMENT SYNDROME
• PRESENTS AS PAIN AND SOME WEAKNESS OFTOE FLEXION
AND ANKLE INVERSION
• PAIN ON PASSIVETOE EXTENSION REFERRED TO CALF
• DIMINISHED SENSATION OVER SOLE OF FOOT,ESPECIALLY ON
MEDIAL SIDE(DUETO POSTERIOR TIBIAL NERVE
COMPRESSION)
• FOOT DROP DUETO ISCHAEMIC CONTRACTURE OF
POSTERIOR COMPARTMENT,SEEN IF ACUTE SYNDROME IS
NOTTREATED
• TREATMENT- WIDE FASCIOTOMY OF INVOLVED
COMPARTMENT IS MANDATORY ATTIME OF ACUTE
PRESENTATION

28. CHRONIC COMPARTMENT SYNDROME
• OCCURS IN ATHLETES IN 3rd or 4th decade,WHO HAVE EXERCISE –
INDUCED PAIN IN LOWER LEG OR FOOTWITHIN 20TO 30 MINUTESOF
BEGINNINGW=EXERCISE.
• RECENT INCREASE IN INTENSITYOR DURATIONOFTRAININGOR AFTER A
CHANGE INTRAINING ROUTINE PREDISPOSESTO SYMPTOMS
• SYMPTOMS RESOLVEAFTER 15TO 30 MINSOF REST.
• ANTERIORCOMPARTMENT IS MOST COMMONLY INVOLVED,MAY HAVE
DIMINISHED SENSATION IN FIRST DORSALWEB SPACE
• RECORDINGSOF INTRACOMPARTMENTAL PRESURES BEFORE,DURING
ANDAFTER EXERCISE CAN PROVIDE USEFUL DIAGNOSTIC
INFORMATION,ASTO WHICH COMPARTMENTS MAY BE INVOLVED
• NON SURGICALTREATMENTOF CHRONIC COMPARTMENT SYNDROME IS
SUCCESSFUL
• BUT IF ATHLETEWILLINGTO DISCONTINUE INCITINGACTIVITY-SURGICAL
TREATMENTOF CHOICE IS FASCIOTOMY OF INVOLVEDCOMPARTMENT.

31. CLINICAL CRITERIA
Patients are considered positive with one or more
of the following findings:
• (1) Pre-exercise pressure greater than or equal
to 15 mmHg,
•(2) 1-minute post-exercise pressure greater than
or equal to 30 mmHg, or
• (3) 5-minute post-exercise pressure greater than
or equal to 25 mmHg.

33. EXERCISETO PREVENT

34. MANAGEMENT OF COMPARTMENT SYNDROME
• THREATENED COMPARTMENT/S MUST BE PROMPTLY DECOMPRESSED
• CASTS,BANDAGES AND DRESSINGS MUST BE COMPLETELY REMOVED
• LIMB SHOULD BE NURSED FLAT(AS ELEVATING LIMB CAUSES FURTHER
DECREASE IN END CAPILLARY PRESSURE AND AGGARVATES MUSCLE
ISCHAEMIA)
• DELTA-PTO BE MONITORED CAREFULLY-IF IT FALLS BELOW 30mm hg-
IMMEDIATE OPEN FASCIOTOMY
• IF CLINICAL SIGNS ARE SOFT ,LIMB SHOULD BE EXAMINED AT 30 MINS
INTERVAL AND,IFTHERE IS NO IMPROVEMENT WITHIN 2 HRS OF SPLINTING
THE DRESSINGS-FASCIOTOMY SHOULD BE PERFORMED
• (MUSCLES WILL BE DEAD AFTER 4-6 HRS OFTOTAL ISCHAEMIA HENCETHERE IS
NOTIMETO LOOSE)
• INCASE OF LEG-FASCIOTOMY MEANS OPENING ALL 4 COMPARTMENT
THROUGH POSTERIOR -MEDIAL ANDANTERO- LATERAL INCISONS.WOUNDS
SHOULD BE LEFT OPEN AND INSPECTED 2 DAYS LATER,IFTHERE IS MUSCLE
NECROSIS,DEBRIDEMENT CAN BE CARRIED OUT.
• IFTISSUES ARE HEALTHY ,WOUND CAN BE SUTURED (WITHOUTTENSION) OR
SKIN-GRAFTED

35. FASCIOTOMY

37. OUTCOME
•WITHIN 6 HRS OF ONSET OF SYMPTOMS-
RESULTS IN FULL RECOVERY
• DELAYED COMPRESSION-RISK OF PERMANENT
DYSFUNCTION
• FROM MILD SENSORY AND MOTOR LOSS
•TO SEVERE MUSCLE AND NERVE DAMAGE,JOINT
CONTRACTURES

38. Compartment syndrome vs crush syndrome

39. Volkmann’s Ischemic
Contracture

40. Seddon modified by tsurge
• The following three grades of Volkmann
contracture have been described:
• Mild (involving the flexor digitorum profundus)
• Moderate (involving injury to the flexor
digitorum profundus, flexor digitorum
superficialis, flexor pollicis longus, flexor
carpi radialis, and flexor carpi ulnaris)
• Severe (involving both the flexors and the
extensors

41. MILD

42. mild
• Mild (localized)
 Limited to extrinsic finger flexors
 Usually 2 or 3 fingers
 Hand sensibility & strength are normal
 Intrinsic muscles not involved
 Fixed joint contracture not present
 Usually occur in young adults
 Most are caused by fractures or crush injury

43. MODERATE

44.  Classic type
 Primarily affects FDP & FPL
 Occasionally FDS, FCR & FCU
 Wrist & thumb are flexed
 Claw hand deformity
•Moderate
 20 nerve compression
 Commonly median
 Rarely radial
moderate

45. SEVERE

46. •Severe
 Affect forearm extensors & flexors
 Commonly due to brachial artery damage
 Often encountered:
 Loss of nerve function
 Malunion or nonunion
 Cutaneous scarring
 Contractures

47. Principle of management
• Mild (early)
 Normal hand sensibility & strength: conservative
 Passive & dynamic extension splinting
 Alternate passive & dynamic splints at 2-hour
 At night: extension splints
 Satisfactory outcome with early treatment
• Mild (late)
 Excision of infarcted muscle
•  Lengthening the tendon

48. •Moderate to severe (4 phases)
 Release of 20 nerve compression
 Treatment of contractures
 Tendon transfers for substitution /
reinforcement
 Salvage procedure (bone

49. THANKYOU