compartment syndrome acute, chronic presentation, DDm management

1. Compartment Syndrome
Dr. Doha Rasheedy

2. Case 1
• 28 male athlete (runner) started to experience
recurrent bilateral exercise induced lower leg
pain after 25 minutes from exercise start,
followed by numbness and sometimes if
continues exercising foot drop occurs.
• 20- 30 minutes after rest, the symptoms resolve.
1. What is the DD?
2. How to approach this case?

3. Case 2
• There was a 20 year old college junior who was complaining of leg
pain in both legs when she was running. She also was feeling
numbness and tingling in the legs, as well as a sense of tightness.
• In the past she was diagnosed with stress fractures and shin splints.
• Her history was consistent with exertional compartment syndrome.
• We obtained compartment pressure testing which showed
elevation of the pressures in her legs.
• She subsequently underwent anterior and lateral compartment
releases for exertional compartment syndrome of both her legs.
• She is now 3 months out from surgery and she has returned to
running over 2 miles each time and is gradually advancing her
distances without any signs of symptoms.

4. Case 3
• A healthy 37-year-old man experienced innocuous blow to the
right anterior lower thigh during a rugby match.
• The only notable symptom was mild thigh swelling and
immediate ache.
• After initially reporting mild tenderness, his pain gradually
developed 1 h after sustaining the injury and he was admitted
to the local emergency department 3 h postinjury.
• The patient had a multiligament surgical reconstruction on his
left knee 5 years prior to this presentation. The patient has
also had hypertension for the last 4 years, which has been
successfully managed pharmacologically. The patient had not
sustained any previous injury to his right knee.
• Following admission, the circumference of each thigh was
measured. The circumference of the patient's right mid-thigh
was 6 cm larger than his left, and was comparatively more
painful and tender. The pressure reading of the right anterior
thigh compartment was 38 mm Hg.

5. Case 4
• A 46-year old female patient was admitted to the emergency room in an unconscious
state after a sudden attack of tachycardia and dyspnea.
• The morbidly obese patient with a BMI of 85 kg/m2 (240 kg weight and 168 cm height)
had a history of weight gain that had increased within the last three years following her
divorce, due to a sedentary lifestyle, diabetes mellitus (DM), hypertension (HT),
hypothyroidism, and sleep disorders. Her next of kin reported that she did not receive
regular treatment for these conditions.
• The physical examination, laboratory tests, ECG and radiological assessments performed
in the emergency room revealed a high troponin level, right bundle branch block in the
ECG, negative T-waves in the V1–V4 chest derivations, enlarged right ventricular outflow
tract in the echocardiography with preserved left ventricular functions, hypotension,
90% oxygen saturation and normal chest X-ray.
• The patient was diagnosed with pulmonary embolism and admitted to the emergency
room where she was started on PE therapy.
• Since the catheterisation effort through the right brachial artery was unsuccessful, 100
mg of standard-dose tPA therapy was administered through the left brachial artery. At
the end of the thrombolytic therapy, heparin treatment was started at a dose of 1000
IU/h and the dose was adjusted up to 2000 IU/h based on the aPTT and AST (SGOT)
results.
• The patient was observed to be haemodynamically stable and clinically relaxed during
the early phase following the thrombolytic treatment.

6. • When swelling, tautness, pain and ecchymoses were observed in
the upper right extremity at the 4th hour of the thrombolytic
therapy, the heparin treatment was stopped and the treatment was
continued with low-molecular weight heparin. Following
orthopedic consultation, based on the massive swelling in the
upper right extremity, taut skin, paresthesia in the fingers, and
increased pain with passive movements, which was unresponsive
to the analgesic treatment, the clinical diagnosis of compartment
syndrome was reached. An urgent surgical intervention was
planned

7. Case 5
• Our client, Mrs A, suffered from osteoarthritis and was preparing for knee
replacement surgery at her local NHS Treatment Centre. During a review
however, her surgeon noted a Baker’s cyst behind her knee and she was
advised to have this removed first.
• Mrs A had surgery to remove the cyst in January 2009 and initially seemed
to make a good recovery. However in February she had pain and swelling
in her knee after stumbling and was referred to A&E where doctors
suspected deep vein thrombosis (DVT) and a recurrent Baker’s cyst. She
was prescribed anticoagulants (blood thinning medication) and
discharged.
• In the following days the swelling in Mrs A’s leg increased and she had
severe pain in her calf. She returned to her surgeon who noted tension
and tenderness in her left leg and a haematoma in her calf, which he
drained. However he felt that there was no clinical evidence of
compartment syndrome.

8. • Mrs A had surgery (a fasciotomy) to evacuate the haematoma and release
the pressure in the compartment. Her recovery was slow however; she
needed vacuum-assisted therapy and skin grafts, and has been left with
significant tissue damage and scaring. She also suffers with ongoing
discomfort and is less mobile than previously.
• Our client required care and support for the rest of 2009. She was also
unable to do many of the activities that she had previously enjoyed, such
as gardening, walking her dog and exercising.
• This case was conducted by medical negligence solicitor Claire Levene
who, as part of her investigations, researched possible treatment of
Baker’s cysts and found that surgical removal of these cysts is considered
to be inadvisable.
• Claire also consulted a knee replacement expert who confirmed that
surgery to remove the cyst wasn’t actually required in this case. He also
advised that the bleed which led to the haematoma wouldn’t have
occurred if Mrs A hadn’t had the unnecessary surgery initially.
• The hospital trust admitted that the removal of the cyst had been clinically
unnecessary and that the cyst would have resolved without surgery after
Mrs A had had her knee replacement. Following this admission of liability,
we entered into negotiations and the claim settled for £50,000.

9. • Compartment syndrome may affect any
compartment, including the hand, forearm,
upper arm, abdomen, buttock, and entire
lower extremity.
• Almost any injury can cause this syndrome,
including injury resulting from vigorous
exercise.
• Clinicians need to maintain a high level of
suspicion when dealing with complaints of
extremity pain.
• Fractures account for approximately 75 percent
of cases of ACS, The tibia is involved most often

10. Types
• Two distinct types of compartment syndrome
have been recognized.
• The first type is associated with trauma to the
affected compartment, as seen in fractures or
muscle injuries.
• The second form, called exertional compartment
syndrome, is associated with repetitive loading or
microtrauma related to physical activity.
• Thus, compartment syndrome may be acute or
chronic in nature.

11. Acute compartment syndrome
• Acute compartment syndrome occurs when
the tissue pressure within a closed muscle
compartment exceeds the perfusion pressure
and results in muscle and nerve ischemia.

12. Pathophysiology:
• When fluid is introduced into a fixed-volume compartment,
tissue pressure increases and venous pressure rises. When the
interstitial pressure exceeds the capillary perfusion pressure (a
narrowed arteriovenous [AV] perfusion gradient), capillary
collapse and muscle and tissue ischemia occur.
• Skeletal muscle responds to ischemia by releasing histamine
like substances that increase vascular permeability.
• Plasma leaks out of the capillaries, and relative blood sludging
in the small capillaries occurs, worsening the ischemia. The
myocytes begin to lyse, and the myofibrillar proteins
decompose into osmotically active particles that attract water
from arterial blood to cause a further rise in intramuscular
pressure.
• When tissue blood flow is diminished further, muscle ischemia
and subsequent cell edema worsen. This vicious cycle of
worsening tissue perfusion continues to propagate.

13. Predisposing factors
1. Fracture: compartment syndrome was seen in 1-9% of leg fractures.
2. Crush injury
3. Burn
4. Snake bite
5. vascular injury: The frequency of compartment syndrome is much higher in patients who have an
associated vascular injury.
6. Intensive muscle use (eg, tetany, vigorous exercise, seizures)
7. Attempts at cannulating veins and arteries of the arm in patients on systemic anticoagulants or
patients treated with thrombolytic drugs
8. Gastrocnemius or peroneus muscle tear (lower extremity)
9. Ruptured Baker cyst
10. Vasculitis
11. Influenza myositis
12. Deep venous thrombosis
13. Lying on a limb can cause compartment syndrome common in drug overdoses.
14. Tight splints, casts, dressings
15. Chemotherapy drugs can produce true compartment syndrome. Alternatively, extravasation of
these drugs can cause pain and swelling that mimics compartment syndrome.
16. Anticoagulation therapy and bleeding disorders (eg, hemophilia) significantly increase the
likelihood of compartment syndrome. Compartment syndrome requiring fasciotomy has been
observed after simple venipuncture in an anticoagulated patient.
17. Revascularization procedures and treatments, such as extremity bypass surgery, embolectomy, and
thrombolysis, increase the risk for ACS]. This phenomenon is known as postischemic compartment
syndrome and is due to tissue swelling from reperfusion. The syndrome can occur from a few
hours following the procedure up to several days late

14. The varied etiologies of a compartment
syndrome
• Burns Electrical, thermal
• Coagulopathies Bleeding disorders, Coumadin, hemophilia, heparin
• Iatrogenic Arterial line placement, closure of fascial defects,
embolectomy, fracture reduction, intravenous line infiltration, orthopedic
surgery, prolonged operating room positioning, prolonged tourniquet
use, tight casts and splints, tight dressings
• Infection Gas gangrene, necrotizing fasciitis
• Miscellaneous Cardiac catheterization, ergotamines, intra-arterial
drug injections, immobility, intravenous infiltration, nephrotic syndrome,
reperfusion injury, tetany, venous occlusion
• Overuse syndromes Exercise, weight lifting
• Trauma Bleeding, contusions, crush injuries, fractures, gunshot
wounds, high pressure injection injuries, seizures, snake bite

15. Site
• Compartment syndrome may occur at any compartment.
• The lower leg is divided into 4 compartments. A fifth compartment has been
documented,
1. Anterior
2. Lateral
3. Superficial posterior
4. Deep posterior
5. Tibialis posterior
• Forearm: Four interconnected compartments of the forearm are recognized, as follows:
1. Superficial volar (flexor)
2. Deep volar
3. Dorsal (extensor) compartment
4. Compartment containing the mobile wad of Henry
• Hand: The hand has 10 compartments, as follows:
1. Dorsal interossei (4 compartments)
2. Palmar interossei (3 compartments)
3. Adductor pollicis compartment
4. Thenar compartment
5. Hypothenar compartment
The anterior distal lower extremity is the most common studied
site of compartment syndrome.

16. Suspect
• Keep high index of suspicion
• In risky patients
• a painful tense muscle compartment

17. Presentation
1. pain out of proportion to the injury (burning or
deep and aching) worsened by passive stretching
of the involved muscles.
2. Paresthesia or numbness is an unreliable early
complaint. decreased 2-point discrimination is a
more reliable early test and can be helpful to
make the diagnosis. Sensory nerves tend to be
affected before the motor nerves
3. Pulselessness: Venous injury may also cause
compartment syndrome, so the clinician should
not be misled by the presence of palpable pulses.

18. • The most common presenting symptom is pain
which is worse when the involved muscles are
stretched passively
• The pain is usually severe and grows
progressively worse.
• Swelling and palpable tenderness over a
compartment are other early signs.
• Pulselessness and pallor often imply arterial
involvement through either arterial compression
or transection
• Paresthesias and paralysis typically are late signs
and indicate some degree of nerve ischemia.

19. Differential Diagnoses
• Cellulitis
• Deep Venous Thrombosis
• Gas gangrene
• Rhabdomyolysis
• Peripheral Vascular Injuries
• Necrotizing Soft-Tissue Infections

20. Hand compartment syndrome
• Compartment syndrome in the hand most often
occurs following iatrogenic injury in a patient who
is obtunded in an intensive care unit.
• Symptoms may be nonspecific
• Early recognition of this complication is based on
physical examination and a high index of suspicion.
• Compartment syndrome in the hand, unlike cases
elsewhere in the body, does not cause
abnormalities in the sensory nerves, as no nerves
are found within the compartments.
• Consider the diagnosis when nonspecific aching of
the hand, increased pain, loss of digital motion,
and continued swelling are present.

21. • The patient is a 37-year-old Asian male who is right hand
dominant. He initially presented to an outside emergency
department (ED) after a motor vehicle collision.
• He was restrained in the front passenger seat when his vehicle
rear-ended another vehicle. He extended his right upper
extremity against the dashboard just before the impact.
• At the first ED, the patient was noted to have right wrist
tenderness as well as lacerations over the dorsal surfaces of the
2nd and 3rd digits. The degree of swelling and presence of
tenderness were not noted. Plain radiographs were obtained.
They were read as notable for fractures of the distal radius,
scaphoid, triquetral, and capitate bones. An anterior dislocation
of the lunate bone was also present.
• Closed reduction of the lunate dislocation was attempted
unsuccessfully a total of three times. The hand lacerations were
then irrigated and sutured closed.
• The hand was placed in a splint in the position of function
(intrinsic plus). He was then discharged on Cephalexin and
acetaminophen with codeine and instructed to follow up at our
ED for further evaluation later that day.

22. • The patient was seen in our ED approximately 19 hours
after discharge from the first hospital ED.
• The history was confirmed.
• The right hand and forearm were noted to be swollen,
tense, and very tender. Light touch and two-point
discrimination were diminished but present. Capillary
refill was 2 seconds in all digits. The motor exam was
remarkable for marked diminution of strength
secondary to pain. Radiographs obtained confirmed
the presence of the fractures noted at the first hospital.
Compartment pressures were measured using a Stryker
Intracompartmental Pressure Monitoring System in
select areas of the forearm and hand. They were
significantly elevated in all compartments tested

23. acute compartment syndrome (ACS) of
the thigh
• In the absence of obvious trauma, diagnosis of
acute compartment syndrome (ACS) of the
thigh can easily be delayed, as disproportional
pain is not always present.

24. Late manifestations of compartment
syndrome
1. Absence of a distal pulse
2. Pallor
3. Hypoesthesia
4. Extremity paresis
5. If left untreated or if inadequately treated, the
muscles and nerve within the compartment
undergo ischemic necrosis, and a limb
contracture, called a Volkmann contracture,
results.
6. Severe cases may lead to renal failure and death.

25. • Crush syndrome is distinct from compartment
syndrome; it is defined as a severe systemic
manifestation (eg, rhabdomyolysis) of trauma
and ischemia involving soft tissues, principally
skeletal muscle, as a result of prolonged
severe crushing.
• Crush syndrome trauma or rhabdomyolysis
may also lead to an acute compartment
syndrome.

26. Work up
• The diagnosis of a compartment syndrome is primarily a clinical
one.
• In cases where the diagnosis is in question, intracompartmental
pressures may be a useful supplemental tool.
• Measurement of intracompartmental pressures remains the
standard for diagnosis of compartment syndrome. Perform this
procedure as soon as a diagnosis of compartment syndrome is
suspected. The Stryker pressure monometer is widely used. The
normal pressure of a tissue compartment falls between 0 and 8
mmHg
• Laboratory investigations not needed for diagnosis:
• consider performing a workup for rhabdomyolysis, with measurement of the following:
1. Creatine phosphokinase (CPK):serial CPK measurements may show rising
levels indicative of a developing compartment syndrome.
2. Renal function studies
3. Urinalysis
4. Urine myoglobin

28. • Capillary blood flow becomes compromised
when tissue pressure increases to within 25 to 30
mmHg of mean arterial pressure.
• Pain may develop as tissue pressures reach
between 20 and 30 mmHg.
• Ischemia occurs when tissue pressures approach
diastolic pressure
• higher compartment pressures may be necessary
before injury occurs to peripheral nerves in
patients with systemic hypertension, while ACS
may develop at lower pressures in those with
hypotension or peripheral vascular disease

29. • the difference between the diastolic blood
pressure and the compartment pressure
(delta pressure) of 30 mmHg or less be used
as the threshold for diagnosing ACS
• The delta pressure is found by subtracting the
compartment pressure from the diastolic
pressure.
• Many clinicians use the delta pressure of 30
mmHg to determine the need for fasciotomy,
while others use a difference of 20 mmHg

30. Acute Compartment Syndrome
• The definitive surgical therapy for
compartment syndrome is emergent
fasciotomy (compartment release), with
subsequent fracture reduction or stabilization
and vascular repair, if needed.
• The goal of decompression is restoration of
muscle perfusion within 6 hours.

31. Treatment ACS
• The treatment of choice for acute compartment syndrome is
early decompression (dequate decompressive fasciotomy).
• Following fasciotomy, fracture reduction or stabilization and
vascular repair can be performed, if needed.
• If a developing compartment syndrome is suspected, place the
affected limb or limbs at the level of the heart. Elevation is
contraindicated because it decreases arterial flow and narrows
the arterial-venous pressure gradient.
• All bandages and casts must be removed.
• Administer antivenin in cases of snake envenomation
• Correct hypoperfusion with crystalloid solution and blood
products.
• Analgesics should be given and supplementary oxygen
provided
• Hyperbaric oxygen has been described as adjunct treatment

32. Renal Protection from rhabdomyolysis
1. Correct hypovolemia with crystalloid solution
2. Infuse 500 mL/hr of crystalloid solution and 22.4 mEq
bicarbonate (12 L/day, forcing diuresis of
approximately 8 L/day)
3. If diuresis is less than 300 mL/hr, administer mannitol
dose of 1 g/kg
4. If blood pH is greater than 7.45, administer 250 mg
acetazolamide
5. Monitor vital signs and urine pH level and volume
hourly
6. Assess osmolarity and electrolytes and arterial blood
gas every 6 hours

33. Prognosis, Complications• Rorabeck and Macnab reported almost complete recovery of limb function
if fasciotomy was performed within 6 hours.
• Matsen found necrosis after 6 hours of ischemia, which currently is the
accepted upper limit of viability.
• when fasciotomy was delayed 12 hours or longer, only 8% of patients had
normal function.
• With late diagnosis, irreversible tissue ischemia can develop in the acute
setting. Thus, permanent muscle and nerve damage, along with chronic
pain, may occur. Hypesthesia and painful dysesthesia can also result from
compartment syndrome.
• Volkmann contracture is the residual limb deformity that results over
weeks to months following untreated acute compartment syndrome or
ischemia from an uncorrected arterial injury. Approximately 1-10% of
patients develop a Volkmann contracture.
• Calcific myonecrosis of lower extremity muscles has been identified as an
uncommon late complication of posttraumatic compartment syndrome.
• Recurrent compartment syndrome has been reported in athletes.
• Infection is a serious complication of compartment syndrome.

34. Chronic Exertional Compartment
Syndrome.
• Chronic compartment syndrome (CCS) is a
recurrent painful syndrome during exercise or
work.
• CCS is characterized by pain and disability that
subside when the precipitating activity is stopped
but that return when the activity is resumed.
• Although CCS is more common in the anterior
compartment of the lower leg, it has been
described in the forearm of motocross racers and
other athletes.

35. Chronic exertional compartment
syndrome- 2
• In a retrospective review of 131 patients referred for chronic exertional leg
pain, 45 patients (34%) were found to have CCS, as determined by
elevated intracompartmental pressure measurements.
• cases of CECS in non-athletes and cases involving compartments of the
foot, thigh, forearm, and hand have been described
• Presentation: recurrent exercise-induced pain in one compartment of the
leg , The pain may be described as aching, squeezing, cramping, or
tightness.
• Pain generally begins within several minutes of starting the inciting
activity, often at a specific point in training that patients recognize.
• Pain resolves completely with rest, although not immediately upon
stopping exercise. Complete resolution of symptoms occurs shortly (10 to
20 minutes) after activity is stopped
• CECS often occurs bilaterally.
• Neurologic symptoms such as paresthesias, numbness, and foot-drop can
occur. The structures found in the muscle compartments of the upper and
lower extremities,

36. Examination CCS
• It can be helpful to examine the patient after
they exercise to the point of eliciting symptoms.
• The involved compartment may be tender.
Relative weakness of muscles in the involved
compartment may be noted when compared
with a pre-exercise evaluation.
• Muscle hernias are frequently present, occurring
in 20 to 60 percent of cases
• Physical exam is often unrevealing except for
malalignment and gait abnormalities (e.g.,
hyperpronation), if present

37. CCS pathophysiology
1. Exercise increases blood flow to active
muscles causing them to expand.
2. If constricted by surrounding noncompliant
fascia, such swelling increases pressure
within the muscle compartment.
3. Ultimately, the increased pressure within the
compartment reduces blood flow, leading to
muscle ischemia and pain when metabolic
demands cannot be met

38. Risk factors for the development of
CCS
• anabolic steroid and creatine use
• overuse, eccentric exercise
• previous traumas
• hyperpronation of the foot.
• Diabetes due to vasomotor disturbances or
soft tissue alterations

39. Diagnosis of CCS
Intramuscular pressure criteria are met: (only validated tool)
1. Preexercise pressure ≥15 mmHg
2. 1 minute postexercise pressure of ≥30 mmHg
3. 5 minute postexercise pressure ≥20 mmHg
Magnetic resonance imaging is more sensitive postexercise.
1. An increase in T2-weighted signal intensity correlates well
with increased ICP.
2. Muscular oedema, muscular swelling, fascial thickening,
and fatty infiltration of the muscle
Near-infrared spectroscopy: to detect the haemoglobin
saturation of tissues.
1. Patients with an elevated ICP show a larger decrease in
saturation after exercise, compared to healthy controls

40. DD of CCS
• Neurogenic claudication
• Vascular claudication
• Deep vein thrombosis
• Lumbar radiculopathy
• Popliteal artery entrapment
• Stress fracture of the tibia or fibula

42. Management
1. Discontinuing the activity that elicits pain or
decreasing the intensity of training are
generally sufficient to avoid symptoms and
treat the problem.
2. if the patient does not want to modify his or
her activity, fasciotomy is the only definitive
treatment.

43. • Other conservative management options have
been described and report high failure rates.
1. resting period, followed by slowly increasing the
exercise level
2. arch support orthotics to reduce pronation
3. avoiding running on hard surfaces
4. changing footwear
5. Changing running techniques
6. deep tissue massage; ultrasound
7. Stretching before exercise
8. osteopathic manipulation techniques