intracompartment syndrome, 5P

1. COMPARTMENT SYNDROME
CME
ORTHOPAEDIC DEPARTMENT
HEBHK

2. OUTLINES
• DEFINITION
• TYPES
• PATHOPHYSIOLOGY
• ETIOLOGY
• CLINICAL EVALUATION
• DIAGNOSIS
• MANAGEMENT
• COMPLICATION

3. DEFINITION
• An elevation of the interstitial pressure in a
closed osteofascia compartment that results
in microvascular compromise

4. TYPES
• Acute compartment syndrome
– Medical emergency
– Caused by a severe injury
– Can lead to permanent muscle damage
• Chronic compartment syndrome
– Known as exertion compartment syndrome
– Not a medical emergency
– Most often caused by athletic exertion

5. PATHOPHYSIOLOGY

6. Vicious cycle of volkmann’s ischaemic
• Bleeding, oedema or inflammation (infection) may
increase the pressure within one of the osteofascial
compartments
• Reduced capillary flow which results in muscle
ischaemia
• A vicious circle that ends, after 12 hours or less, in
necrosis of nerve and muscle within the compartment.
• Nerve is capable of regeneration but muscle, once
infarcted, can never recover and is replaced by inelastic
fibrous tissue (Volkmann’s ischaemic contracture).

7. Whiteside’s theory
• The development of compartment syndrome
also depends on
• MPP= DBP-CP(Intracompartment P)
• Muscle perfusion pressure(MPP) < 30 mmHg
 Tissue hypoxia

8. ETIOLOGY
CONSTRICTION
OF
COMPARTMENT
Closure of
fascia defect
Scarring or contraction of
skin/fascia due to burn
EXTERNAL
COMPRESSION
Excessive or prolonged
inflation of air splint
Tight cast or dressing
Prolonged compression of limb
(as in alcohol/drug
induced/metabolic/traumatic
coma)

9. INCREASED
FLUID CONTENT
IN
COMPARTMENT

10. CLINICAL FEATURES
• High-risk injuries are fractures of the
Elbow
Forearm bones
Proximal one-third of the tibia
Multiple fractures of the hand or foot
Crush injuries
Circumferential burns
• Other precipitating factors are
operation (usually for internal fixation) or infection.

11. • Classic features of ischaemia:
 Pain
 Paraesthesia
 Paralysis
 Pulselessness
 Pallor
Ischaemia occurs at the capillary
level, so pulses may still be felt and
the skin may not be pale
The earliest of the classic features are
PAIN (or bursting sensation)
Altered sensibility and paresis (weakness in active muscle contraction)
Ischaemic muscle is highly sensitive to
stretch, so when the toes or fingers are
passively hyperextended, there is
increased pain in the calf or forearm.

12. DIAGNOSIS
1. Physical examination
o Tenderness on passive stretching
o Pain out of proportion
o Looks congested
o Woody hard
o Numbness or tingling sensation
o Unable to move limbs
o CRT >2sec and absent distal pulses
o Pale and cold limb
-Pulse oxymetry: identifying limb hypoperfusion

13. 2. Laboratory studies
o Often normal and not helpful to rule out CS
3. Imaging studies
o Radiography of the affected extremity
o ultrasonography:
In evaluating arterial flow
In visualizing any deep venous trombosis(DVT)
Usually aids in the elimination of DD

14. • Confirmation the diagnosis can be made by
measuring the intracompartmental pressures.
• Differential pressure (ΔP) = DBP(diastolic BP)-
CP(intracompartment P)
• < 30 mmHg (4.00 kP) indication for immediate
compartment decompression.

15. MANAGEMENT
 Non-operative:
– Casts, bandages and dressings must be completely removed
– Limb should be nursed flat (elevating the limb causes a further
decrease in end capillary pressure and aggravates the muscle
ischaemia)
 Operative
– The ΔP should be carefully monitored if it falls below 30 mmHg,
immediate open fasciotomy is performed.
– The wounds should be left open and inspected 2 days later
– If there is muscle necrosis, debridement can be carried out, if
– the tissues are healthy, the wounds can be sutured (without
tension) or skin-grafted.

16. COMPLICATION
• Acute:
rhabdomyolysis and kidney failure
• Chronic:
Permanent sensory & motor deficit
Contractures

17. Location for fasciotomy

18. 2 compartment of arm
Anterior compartment
1. biceps brachii
2. brachialis
3. coracobrachialis
-musculocutaneous n.
-brachial a.
Posterior compartment
1. triceps brachii
2. anconeus
-radial n.
-profunda brachii

20. 3 compartment of forearm
• volar
• dorsal
• mobile wad (lateral)
• brachioradialis
• extensor carpi
radialis longus
• extensor carpi
radialis brevis

21. a. volar incision
decompresses volar compartment,
dorsal compartment, carpal tunnel
incision starts just radial to FCU
at wrist and extends proximally
to medial epicondyle
may extend distally to release
carpal tunnel
b. dorsal incision
decompresses mobile wad
dorsal longitudinal incision 2cm
distal to lateral epicondyle
toward midline of wrist

22. 10 compartment of hand
1. hypothenar
2. thenar
3. adductor pollicis
4. Dorsal
interosseous (x4)
5. volar (palmar)
interosseous (x3)

23. a. two longitudinal incisions
over 2nd and 4th metacarpals
decompresses volar/dorsal
interossei and adductor
compartment
b. longitudinal incision radial side
of 1st metacarpal
decompresses thenar
compartment
c. longitudinal incision over ulnar
side of 5th metacarpal
decompresses hypothenar
compartment

24. 3 compartment of thigh
1. anterior compartment
• quadriceps
• Sartorious
• femoral nerve
2. posterior compartment
• Hamstrings
• sciatic nerve
3. adductor compartment
• Adductors
• obturator nerve

25. • anterolateral incision over length of thigh
• may add medial incision for decompression of
adductor compartment

26. 4 compartment of leg

27. • two 15-18cm vertical incisions separated by
8cm skin bridge
– anterolateral incision
– posteromedial incision
• single lateral incision from head of fibula to
ankle along line of fibula

28. 9 compartment of foot
1. medial
abductor hallucis
flexor hallucis brevis
2. lateral
abductor digiti minimi
flexor digiti minimi brevis
3. interosseous (x4)
4. central (x3)
superficial
flexor digitorum brevis
central
quadratus plantae
deep
adductor hallucis
posterior tibial
neurovascular bundle

29. • dorsal medial incision
– medial to 2nd metatarsal
– releases 1st and 2nd interosseous, medial, and deep central compartment
• dorsal lateral incision
– lateral to 4th metatarsal
– releases 3rd and 4th interosseous, lateral, superficial and middle
central compartments
single medial incision used to release
all nine compartments