Compartment syndrome occurs when increased pressure within a closed osteofascial space compromises blood flow to muscles and nerves. It is most commonly caused by fractures that increase swelling. The diagnosis is based on pain disproportionate to the injury that worsens with passive stretching. While signs like pallor, paralysis and pulselessness occur late, an early fasciotomy is the definitive treatment to prevent permanent damage. Locations prone to compartment syndrome include the lower leg, forearm, thigh and foot.

1. Compartment Syndrome
Mosheer Ziadi
R1

2. Objectives
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What is it
Definition
Pathophysiology
Eitology
Diagnosis
Sign and symptoms
Treatment

3. What is it ?
• Increase in hydrostatic pressure in closed
osteofascial space resulting in decreased
perfusion of muscle and nerves within
compartment.

4. What is it?
• RAISED PRESSURE WITHIN A CLOSED SPACE with a
potential to cause irreversible damage to the
contents of the closed space.

5. Definition
• Symptoms resulting from
increased pressure within a
limited space
– compromising
• circulation
• function

6. Pathophysiology
• A continuous increase in pressure within a
compartment occurs until the low
intramuscular arteriolar pressure is exceeded
and blood cannot enter the capillaries

7. Pathophysiology
• Increased compartment pressure
Increased venous pressure
Decreased blood flow
Decreases perfusion

8. Pathophysiology
• Autoregulatory mechanisms may
compensate:
– Decrease in peripheral vascular resistance
– Increased extraction of oxygen
• As system becomes overwhelmed:
– Critical closing pressure is reached
– Oxygen perfusion of muscles and nerves decreases

9. Muscle Ischemia
• 4 hours - reversible damage
• 8 hours - irreversible
changes
• 4-8 hours - variable
Hargens JBJS 1981

10. Muscle Ischemia
• Myoglobinuria after 4 hours
– Renal failure
– Maintain a high urinary output
– Alkalinize the urine
• Cell death initiates a “vicious cycle”
– increase capillary permeability
– increased muscle swelling

11. Increased muscle swelling
Increased
permeability
Increased compartment
pressure

12. • Increased pressure
Increased venous pressure
Decreased blood flow
Decreases perfusion

13. Nerve Ischemia
• 1 hour - normal conduction
• 1- 4 hours - neuropraxic damage
reversible
• 8 hours - axonotmesis and
irreversible change
Hargens et al. JBJS 1979

14. Pathophysiology:
• CAUSES:
• Increased Volume - internal :
hemmorhage, fractures, swelling from traumatized
tissue, increased fluid secondary to burns, post-ischemic
swelling
• Decreased volume - external: tight casts, dressings
• Most common cause of hemmorhage into a compartment:
fractures of the tibia, elbow, forearm or femur

15. Etiology
• Fractures
• Soft Tissue Injury (Crush)
• Arterial Injury
– Post-ischemic swelling
– Reperfusion injury
• Drug Overdose (limb compression)
• Burns

16. Fractures
• Most common cause
• Incidence accompanying compartment syndrome 9.1 %
• The Incidence is directly proportional to the degree of
injury to soft tissue and bone .
• Tibial diphesyal #
• Forearm #
• Distal radius #
Bick et al JBJS 1986

17. Arterial Injuries
• Secondary to
revascularization:
• Ischemia causes
damage to cellular
basement membrane
that results in edema
• With reestablishment
of flow, fluid leaks
into the compartment
increasing the
pressure.

18. Diagnosis
• Clinical diagnosis
– High index of suspicion
• Syndrome
– History
– Physical Exam

19. Difficult Diagnosis
• Classic signs of the 5 P’s - ARE NOT RELIABLE:
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pain
pallor
paralysis
pulselessness
paresthesias
• 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.

20. Signs & Symptoms
• Pain
–Passive muscle stretching
–Out of proportion
–Progressive
–Not relieved by immobilization

21. Diagnosis
• Pain
• Compartment pressure
– Confirmatory test
– Don’t just measure

22. Diagnosis
• Palpable pulses are usually present in
acute compartment syndromes unless an
arterial injury occurs.
• Sensory changes and paralysis do not
occur until ischemia has been present for
about 1 hour or more

23. Diagnosis
• The most important
symptom of an
impending
compartment
syndrome is PAIN
DISPROPORTIONATE
TO THAT EXPECTED
FOR THE INJURY

24. Signs & Symptoms
• Pain
–May be worse with elevation
–Patient will not initiate
motion on own
• Be careful with coexisting
nerve injury

25. Signs & Symptoms
• Parasthesia
–Secondary to nerve ischemia
• Must be differentiated from
nerve injury

26. Signs & Symptoms
• Paralysis (Weakness)
– Ischemic muscles lose function

27. Signs & Symptoms
• Tense compartment on palpation
• Elevated compartment pressure

28. Tissue Pressure
• Normal tissue pressure
– 0-4 mm Hg
– 8-10 with exertion
• Absolute pressure theory
– 30 mm Hg - Mubarak
– 45 mm Hg - Matsen
• Pressure gradient theory
– < 20 mm Hg of diastolic pressure – Whitesides
– < 30 mm Hg of diastolic pressure McQueen, et
al

29. Who is at high risk?

30. High energy fractures
• Severe
comminution
• Joint
extension
• Segmental
injuries
• Widely
displaced
• Bilateral
• Floating knee
• Open fractures

31. Impaired Sensorium
• Alcohol
• Drug
• Decreased
GCS
• Unconscious
• Chemically
unconscious
• Neurologic
deficit
• Cognitively
challenged

32. Diagnosis
• The presence of an open fracture does NOT rule out the
presence of a compartment syndrome
• 6-9% of open tibial fractures are associated with compartment
syndromes
• McQueen et al found no significant differences in
compartment pressures between open and closed tibial
fractures
• No significant difference in pressures between tibial fractures
treated with IM Nails and those treated with Ex-Fix

33. Most Common Locations
• Leg: deep posterior and the
anterior compartments
• Forearm: volar compartment,
especially in the deep flexor
area

34. Lower leg
• 4 compartmens:
Lateral:
• Proneus longus and previs
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• Anterior :
• EHL,EDC,tibialis anterior
,peroneus tertius
• Superficial post. :
• Gastrocnemius and soleus
.
• Deep posterior :
• Tibial posterior , FHL,FDL

35. Treatment
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Remove restricting cast:
*comaprtment pressure falls by 30% is split on one side.
*Falls by 65% when the cast spread after splitting
*Splitting the padding reduces it by further 10 % and
complete removalof cast by another 15%
• Serial exams
• When diagnosis made
– Immediate surgery
• 4 compartment fasciotomy
*Garfin, Mubarak JBJS 1981

36. Treatment
• Don’t wait so long..!

37. Treatment

38. Indication of fasciotomy

39. Fasciotomy Princeples

40. Treatment
• Fasciotomy
– One incision
• With or without
Fibulectomy
– Two (double) incisions
• All 4 compartments must
be released
– Not selective

41. Lower Leg

42. • Lateral compartment

43. • Anterior compartment

44. Lower Leg

45. Lower Leg

46. Two incisions
• Lateral
• Medial

48. Double Incision
• Anterolateral Incision

49. Double Incision
• Posteromedial Incision
• Soleus must be detached from tibia in
order to adequately decompress proximal
portion of deep posterior compartment

50. Thigh
• Rare
• Crush injury with femur fracture
• Over distraction
– relative under distraction

51. Thigh
• Quadriceps
–Lateral
• Hamstrings
–Posterior
• Abductor
–Medial

52. Treatment
• Based upon involvement
• Usually Quadriceps and
Hamstrings
• Usually, a single lateral incision
will suffice

53. Forearm

54. Treatment
• Volar- Henry approach:
• Include a carple tunnel releas
• Begins lateral to biceps tendon =>crosses elbow crease and
extends radially => extended distally along medial aspect of
brachioradialis =>extends across the palm along the thenar
crease.

55. Henry Approach
• Fascia over superficial muscles
is incised
• Care of NV structures

56. Volar-Henry Approach
• Brachioradialis and superficial
radial n. are retracted radially
and FCR and radial artery are
retracted ulnar to expose the
deep volar muscles
• Fascia of each of the deep
muscles is then incised
• Consider dorsal approach

57. Foot

58. Foot

59. Hand

60. Post Fasciotomy…
• Must get bone stability
– IMN
– exfix
• ~48hrs after procedure patient should
be brought back to OR for further
debridement
• Delayed skin closure or skin-grafting 37 days after the fasciotomies

61. Aftercare
• VAC dressings
• Elevation of limb
• Delayed wound closure
– Split thickness skin graft

62. Remember…
• Fasciotomies are not benign
• Complications are real >25%
– Chronic swelling
– Chronic pain
– Muscle weakness
– Iatrogenic NV injury
– Cosmetic concerns
*** BUT if they are needed do not come up with
excuses to not do them !!!

63. Take home message
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Very important to make diagnosis
Missed compartment is devastating
Physical exam
Re-examine patient!