Compartment syndrome is a painful condition caused by increased pressure within the fascial compartments of the body, usually in an arm or leg. This pressure decrease blood flow and can lead to muscle and nerve damage. It is often caused by trauma, fractures, bleeding, or swelling. Symptoms include severe pain not relieved by painkillers, numbness, pale skin, and tense swelling. Diagnosis involves measuring compartment pressure. Treatment for mild cases involves reducing swelling but severe or increasing cases require surgical release of the fascial compartment (fasciotomy) to relieve pressure within 12 hours to prevent permanent damage. Complications can include muscle necrosis, contractures, sensory loss and potentially limb amputation if not treated promptly.

1. COMPARTMENT
SYNDROME
Classification, Clinical features, Diagnostics and
Treatment

2. Definition...
CP is a symptom complex, in which there is an increase in subfascial pressure
in the closed fascial space, which leads to ischemia and necrosis of the contents
of the fascial nook and the development of ischemic contracture. For the first
time the term "compartmental syndrome" was used by P. A. Reszel (1963).
It is a painful and dangerous condition caused by pressure build-up from
internal bleeding or swelling of tissues. The pressure decreases blood flow,
depriving muscles and nerves of require nourishment.

3. • The reasons for the increase in subfascial pressure are as follows:
1. Post-traumatic hematoma, gunshot wounds, fractures and dislocations of bones.
2. Positional compression.
3. Syndrome of late revascularization.
4. Reperfusion damage in unsuccessful or even successful reconstructive operations on
vessels.
5. Inflammatory diseases of so tissues.
6. Tumor-like formations.
7. Frostbites and burns.
8. Iatrogenic lesions (during intramedullary osteosynthesis, IV regional anesthesia, with
tight bandage of limbs or applying tourniquets to the extremities, with arthroscopic
operations, imposition of skeletal traction)

4. Pathophysiology...
• The compartment syndrome is caused by ischemic edema of the muscles,
enclosed in dense fascial sheathes (forearm, shin). As a result of edema
subfascial pressure rises. This leads to a disorder of microcirculation of the
muscles and the growth of ischemic edema. There is a "vicious circle",
leading to secondary microcirculatory infarctions and necrosis of nerves and
muscles located in the bone-fascial case. Great vessels blood flow is often
preserved ("water pipe syndrome" – Wasserleitung-syndrom), and ischemic
syndrome progresses up to the gangrene of the limb. Irreversible
neuromuscular lesions occur after 12 hours from the onset of clinical
manifestations

5. Clinical Features...
1. Severe pain in the limb, which is not stopped even by narcotic drugs.
2. Skin discoloration, blanching.
3. Tensed swelling of the so tissues of the limb.
4. Reduction or absence of active muscle movements of the injured limb.
5. Numbness or paresthesia in the zone of autonomic innervation of a damaged
nerve.
6. Increase in subfascial pressure.
7. Decreased temperature of the limb.

6. Classification according to severity...
• Light degree – the distal segment of the limb is warm to the touch, the
pulse on the main arteries is preserved. The level of subfascial pressure is
30–40 mm Hg lower than diastolic pressure (the lower criterion for
diagnosing compartmental syndrome).
• Medium degree – the temperature of the skin of the affected limb is
reduced. Hyposthesis or anesthesia of the limb fingers is observed. The
pulse is weakened. Subfascial pressure is equal to diastolic pressure.
• Severe degree – there is no pulse on the great arteries. The fingers are
anesthetized. The level of subfascial pressure is higher than the diastolic
level.

7. Compartment syndrome can also be -
ACUTE :
A severe irreversible form of abnormally elevated intramuscular pressure that
leads to tissue necrosis and permanent loss of function if left untreated.
 CRONIC :
Painful conditions in which increased intramuscular during exercise impedes
local muscle blood flow and impairs the neuromuscular function of a tissue
within a compartment.

8. Diagnosis...
The consequence of the compartmental syndrome is Volkmann's ischemic
contracture.
Measurement of subfascial pressure is a mandatory manipulation to confirm the
diagnosis of compartmental syndrome. The subfascial pressure was measured by
the injection method according to Whiteside. At present, subfascial pressure
measurement is performed by the device of "Stryker Intra Compartmental Pressure
Monitor System". Normally, the pressure in the limb myofascial space does not
exceed 8–9 mm Hg. If it is less than the diastolic pressure by 30–40 mm Hg
"compartmental syndrome" can be diagnosed. For example, if the patient has a
blood pressure of 140/90 mm Hg, the pressure in the myofascial space is 50 mm
Hg.

11. • The compartmental syndrome should be differentiated with such injuries
and diseases as:
1. Damage to the main vessels and thrombosis of the arteries and veins.
2. Damage to nerve trunks.
3. Clostridial and non-clostridial myositis.
Differential diagnosis is carried out according to the following criteria:
Presence of peripheral pulsation; the presence of edema; impaired limb sensitivity; the
presence of intoxication and leukocytosis in the blood; subfascial pressure level. Peripheral
pulsation will be preserved in all cases, except for damage and thrombosis of the main
vessels (there will also be no impairment of sensitivity). Edema will be absent only in the
defeat of nerve trunks. The presence of intoxication is typical exclusively for the infectious
process (clostridial and non-clostridial myositis). An increase in the level of subfascial
pressure is typical for compartmental syndrome and infectious myositis.

12. Treatment...
• Conservative treatment of compartment syndrome
1. Unnecessary compression (pressure) on the affected segment must be prevented. This
means the removal of pressure bandages, the dissection of the plaster bandage. These
treatment measures are aimed at preventing increasing ischemia.
2. Improvement of peripheral circulation by removing vasospasm (papaverine, platyphylline,
no-spa).
3. Improvement of rheological properties of blood (Rheosorbilact, Rheopolyglukin,
Pentoxifylline).
4. Anesthesia (in the first day, the use of narcotic analgesics is permissible, in the
subsequent – the transition to non-narcotic analgesics, non-steroidal anti-inflammatory
drugs).

13. 5. Drugs that increase tolerance of muscle tissue to ischemia
(Actovegin solution, Solcoseryl, Actovegin tableted, vitamins of group B,
vitamin E, Preductal, enzymes – Wobenzym, Phlogenzym).
6. Reduction of the edema of the affected limb (L-lysine escinate, mannitol,
furosemide).
7. Hyperbaric oxygenation, magnet therapy.
Surgical treatment
The compartment-syndrome is treated with an operative method in the case of
ineffective conservative therapy. In this case, decompression fasciotomy is
performed. Decompression fasciotomy is an operation aimed at preventing and
treating ischemic myoneural deficit resulting from increased subfascial pressure
in compartmental syndrome.

14. Decompression fasciotomy - prophylactic fasciotomy
It is an operation performed in a patient without signs of increased subfascial
pressure during a fasciotomy (for example, a period of more than 6 hours
between vascular injury and revascularization or severe damage to the veins
that required a large vein ligation).
The main indications for preventive fasciotomy:
1. Severe venous insufficiency.
2. Damage to the popliteal artery or vein.
3. Unsuccessful arterial reconstruction.
4. Late arterial reconstruction (> 6 hours a er injury).
5. Severe swelling of the so tissues of the limb.
6. Hemostatic Esmarch bandage, imposed for 2 hours

15. Therapeutic fasciotomy
 An operation performed to a patient with signs of elevated subfascial pressure,
determined by clinical examination or by measuring subfascial pressure (or both).
Subfascial pressure is more than 30 mm Hg should be considered as pathological.
Elevated subfascial pressure is an absolute indication for the performance of therapeutic
fasciotomy.
 Any of the following clinical symptoms should be considered as an indicator of
increased subfascial pressure:
 1. The tension of subfascial tissues and muscles with (or without) paresthesia.
 2. The pain that occurs with passive extension of the fingers is a late and serious
symptom.
 3. Paralysis in the absence of nerve damage.
 4. Weakening of the peripheral pulse in the absence of damage to the main vessel.

17. Timings of fasciotomy - True orthopedic emergency
• Within 6 hours - almost complete recovery
• Within 12 hours - 60-70% normal limb function
• More than 12 hours – only 8% chances of normal limb function.
Complications of fasciotomy -
• Gangrene or loss of limb viability requiring amputation
• ischemic contracture and loss of function
• rhabdomyolysis and renal failure

18. COMPLICATIONS OF COMPARTMENT SYNDROME
• Volkmann’s contracture
• Weak dorsi-flexors
• Claw toes
• Sensory loss
• Chronic pain
• Amputation

19. THANK YOU
BY,
ADITI SANTOSH JAIN
GROUP 29