basics of compartment syndrome

1. Rajesh vardhan

2. HISTORY Volkmann 1881
Richard von Volkmann published an article in which
he attempted to describe the condition of irreversible
contractures of the flexor muscles of the hand to
ischemic processes occurring in the forearm

3. Hildebrand 1906
First used the term Volkmann ischemic contracture to
describe the final result of any untreated compartment
syndrome, and was the first to suggest that elevated
tissue pressure may be related to ischemic contracture.

4. Thomas 1909
Reviewed the 112 published cases of Volkmann ischemic
contracture and found fractures to be the predominant
cause. Also, noted that tight bandages, an arterial
embolus, or arterial insufficiency could also lead to the
problem

5. Murphy 1914
First to suggest that fasciotomy might prevent the
contracture. Also, suggested that tissue pressure and
fasciotomy were related to the development of
contracture

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

7. DEFINITION
Increase in interstitial fluid presuure within an
osseofascial compartment of significant magn
itude to cause compromise in microcirculation
and myoneuralnecrosis

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

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

10. vicious cycle

11. Consequences –vicious cycle

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

13. 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
McQueen, et al
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

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

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

17. CAUSES

18. Drilling &
reaming
Dissection
Tourniquet

19. CAUSES
Tight cast
swelling
Bluish
discolorationnumbness

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

22. 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
 Pulses
 Pallor

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

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

25. 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

26. 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

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

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

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

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

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

33. •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

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

35. 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
CONTRAINDICATION - Missed compartment
syndrome (>24-48 hrs)

36. TYPES
SINGLE INCISION
DOUBLE INCISION

37. SINGLE INCISION
Perifibular Fasciotomy
Matsen et al (1980)
Single incision just
posterior to fibula
Common peroneal nerve

38. DOUBLE INCISION
In most instances it affords better exposure of the
four compartments
2 vertical incisions separated by minimum 8 cm
One incision over anterior and lateral compartments
 Superficial peroneal nerve
One incision located
1-2 cm behind postero
-medial aspect of tibia
 Saphenous nerve and vein

39. Flexor digitorum
longus
Gastroc-soleus

40. Superficial peroneal ner
Intermuscular septum

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

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

44. 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
Primary closure 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

45. 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

46. It may need skin graft

47. Close skin by sutures
after oedema subsides

48. 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

49. 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