Compartment syndrome occurs when increased pressure within a closed muscle compartment reduces blood flow, potentially causing tissue damage. It is caused by factors that increase compartment volume or decrease space such as fractures, contusions, surgery, or prolonged limb compression. Symptoms include pain disproportionate to the injury that is not relieved by pain medications. Diagnosis involves clinical assessment and compartment pressure measurement. Early fasciotomy is the treatment of choice to release pressure and prevent permanent nerve and muscle damage. Complications of untreated compartment syndrome include contractures, weakness, sensory loss, and limb loss.

1. DR HARDEV SINGH
P.G IN ORTHOPAEDICS
BHMRC
NEW DELHI

2. What is a compartment?
Closed area of muscles
group, nerves & blood
vessels surrounded by
fascia
Pressure: 5-15 mmhg

3. Definition:
An increased pressure within enclosed
osteofascial space that reduces capillary
perfusion below level necessary for
tissue viability;
the underlying mechanism is:
- increased volume within space
- decreased space for contents
- combination of both

4. What is a compartment
syndrome?
 intra comp. pressure
(35-40 mmhg)
 capillaries collapse
 Blood flow to muscles
and nerves
 Bl.Vs collapse

5. Pathophysiology:
Increased compartment pressure
leads to increased venous pressure
which decreases A-V gradient
resulting in muscle and nerve
ischemia.

6. Pathophysiology:
Normal tissue pressure
0-4 mm Hg
8-10 with exertion
Absolute pressure theory
30 mm Hg - Mubarak
45 mm Hg - Matsen

8. Consequences –vicious cycle

9. Why is it dangerous?
Nerves:
neuropraxia: will
regenerate
Ischemia: cell death
Muscles: contracture
(Volkmann's ischemic
contracture)
Gangrene

10. Compartment Syndrome- CAUSES
Causes
 Fractures
 Contusions
 Surgery
 Post Ischemic swelling after arterial occlusion
 Major vascular trauma
 Crush injuries
 Burns
 Prolonged limb compression

11. Causes
Fracture of a long bone
(Supracondylar humerus,
forearm, hand,tibia and
foot)

13. CAUSES

14. Drilling &
reaming
Dissection
Tourniquet

15. CAUSES
Tight cast
swelling
Bluish
discolorationnumbness

16. CAUSES
Severe bruised muscle
(even if there is no fracture)
Don’t take contusion lightly

17. COMPARTMENT SYNDROME

18. Signs and Symptoms
Increased Pressure and Tightness
Progressive pain out of proportion to initial
injury
Markedly swollen area
Progressive neurologic deficit
Seven P’s
Pain
Pressure
Pain with passive stretch
Parethesia
Paresis/ Paralysis
Pulselessness
Pallor

19. SYMPTOMS
Severe pain
inappropriate to the
injury(not relieved even
with morphia)

20. SYMPTOMS
Burning of the affected limb
Tight muscle(rigid)tightness feeling
Numbness: bad sign

21. SIGNS & DIAGNOSIS
Passive stretching of fingers or toes (muscle
stretch)will lead to severe pain (diagnostic sign)
Never wait for signs of ischemia (5 Ps):irreversible
damage

22. STRECH TEST
It is possible to strech
the affected muscles by
passively moving the
joints in direction
opposite to that of the
damaged muscles,s
action (( e.g. ::: passive
extension of fingers
produces pain in flexor
compartment of forearm

23. Technique
STRYKER TECHNIQUE
MERCURY
MANOMETER
Wick hand held
instrument

24. Whiteside maneuver Wick hand held instrument
syringe
3 way stopcock
mmhg
mano.
electrode
Direct
reading

25. Stryker Stic System
Easy to use
Can check multiple compartments
Different areas in one compartment

26. Complications related to CS
Late Sequelae
 Volckmann’s contracture
 Weak dorsiflexors
 Claw toes
 Sensory loss
 Chronic pain
 Amputation

27. Compartment Syndrome
Tissue Survival
• Muscle
– 3-4 hours - reversible changes
– 6 hours - variable damage
– 8 hours - irreversible changes
• Nerve
– 2 hours - looses nerve conduction
– 4 hours - neuropraxia
– 8 hours - irreversible changes

28. COMPARTMENT SYNDROME

29. Management
Non surgical management:
 Remove any tight bandage, soaked dressing
 Cast should be removed completely
 Elevation

30. •management
Surgical management:
(FASCIOTOMY)
Open skin and fascia
down to a compartment
It is a surgical procedure
where the fascia is cut to
relieve tension or
pressure commonly to
treat the resulting loss of
circulation to the tissue

31. Fasciotomy Principles
Make early diagnosis
Long extensile incisions
Release all fascial compartments
Preserve neurovascular structures
Debride necrotic tissues
Coverage within 7-10 days

32. Compartment Syndrome
Indications for Fasciotomy
Unequivocal clinical findings
Pressure within 15-20 mm hg of DBP
Rising tissue pressure
Significant tissue injury or high risk pt
> 6 hours of total limb ischemia
Injury at high risk of compartment syndrome

33. Single Incision
• Perifibular Fasciotomy
– Matsen et al (1980)
– Single incision just
posterior to fibula
– Common peroneal nerve

34. Double Incision
Mubarak et al JBJS 1977

35. Forearm Fasciotomy
Volar-Henry
approach
Include a carpal
tunnel release
Release lacertus
fibrosus and fascia
Protect median
nerve, brachial artery
and tendons after
release

36. Compartment syndrome foot
9 compartments
-medial superficial
lateral calcaneal
interossei(4)
adductor.
Suspicion with
-lisfranc fracture
-calcaneal fracture

37. Compartment syndrome foot
 Dorsal incision to
release the interossei and
adductor
Median incision to
release the medial
superficial lateral and
calcaneal compartment

38. Flexor digitorum
longus
Gastroc-soleus

39. Superficial peroneal
Intermuscular septu

40. Fasciotomy of Hand
10 separate osteofascial
compartments
dorsal interossei (4)
palmar interossei (3)
thenar and hypothenar
(2)
adductor pollicis (1)

41. Close skin by 2ry
sutures after oedema
subsides

42. It may need skin graft

43. Wound Management
Wound is not closed at initial surgery
Second look debridement with consideration for
coverage after 48-72 hrs
Limb should not be at risk for further swelling
Pt should be adequately stabilized
Usually requires skin graft
DPC possible if residual swelling is minimal
Flap coverage needed if nerves, vessels, or bone
exposed
Goal is to obtain definitive coverage within 7-10
days

44. Wound Management
After the fasciotomy, a bulky compression dressing and
a splint are applied.
“VAC” (Vacuum Assisted Closure) can be used
 Foot should be placed in neutral to prevent equinus
contracture.
Incision for the fasciotomy usually can be closed after
three to five days

45. Complications Related to
Fasciotomies
Altered sensation within the margins of the wound (77%)
Dry, scaly skin (40%)
Pruritus (33%)
Discolored wounds (30%)
Swollen limbs (25%)
Tethered scars (26%)
Recurrent ulceration (13%)
Muscle herniation (13%)
Pain related to the wound (10%)
Tethered tendons (7%)
Fitzgerald, McQueen Br J Plast Surg 2000Fitzgerald, McQueen Br J Plast Surg 2000

46. Compartment syndrome is a serious syndrome, Which needs
to be diagnosed early.
Palpable pulse doesn’t exclude compartment syndrome
If diagnosis and fasciotomy were done within 24 hrs, the
prognosis is good.
If delayed, complications will develop.
The earlier you diagnose, the safer you are