This document provides an overview of compartment syndrome, including: - The anatomy of the arm, forearm, hand, thigh, leg, and foot compartments. - The causes, signs/symptoms, and diagnostic criteria for acute compartment syndrome. Tissue damage can become irreversible after 6-8 hours of increased compartment pressure. - Surgical fasciotomy is required if increased compartment pressure does not improve with simple measures like removing external compression. Complete release of all compartments is needed. - Post-operative wound management includes wet-to-dry dressing changes or negative pressure wound therapy to promote healing and prevent infection following fasciotomy.

1. Presenter:
Chong Song Ying
Song Zhi Liang
Song Poh Siang
Emmanuel Xavier Raj
Supervisor: Mr Sanjeevan

2. Anatomy of arm
• Compartment of arm: anterior, posterior

3. Anterior compartment
• Muscles: Bicep brachii,
coracobrachialis, brachialis
• Blood supply: Brachial
artery
• Nerve supply:
Musculocutaneous nerve
• Structures pass through
compartments:
– Musculocutaneous nerve
– median nerve
– ulnar nerve
– Brachial artery
– Basilic vein

6. Posterior compartment
• Muscle: Tricep muscle
• Nerve supply: Radial
nerve
• Blood supply:
Profundus brachiiand
ulnar collateral arteries
• Structure passing
through compartment:
– Radial nerve
– ulnar nerve

8. Forearm compartments
1. volar (most commonly
affected)
I. superficial
II. Deep
2. dorsal
3. mobile wad (lateral)
• rarely involved
• muscles:
– brachioradialis
– extensor carpi radialis longus
– extensor carpi radialis brevis

9. Volar compartment of forearm
Superficial
• Flexor carpi radialis
• Flexor carpi ulnaris
• Flexor digitorum
superficialis
• Palmaris longus
• Pronator teres
Deep
• Flexor digitorum profundus
• Flexor pollicis longus
• Pronator quadratus

10. Dorsal compartment of forearm
• Superficial muscle:
supply by radial nerve
• Deep muscle: supply by
radial nerve

12. Compartment of hand
10 in total
• hypothenar
• thenar
• adductor pollicis
• dorsal interosseous (x4)
• volar (palmar)
interosseous (x3)

14. ANATOMY OF LOWER LIMB

16. COMPARTMENTS OF THIGH

17. COMPARTMENTS OF LEG

22. COMPARTMENTS OF THE FOOT
9 MAIN COMPARTMENTS
MEDIAL
• abductor hallucis
• flexor hallucis brevis
LATERAL
• abductor digiti minimi
• flexor digiti minimi brevis
INTEROSSEOUS (X4)
CENTRAL (X3)
superficial
• flexor digitorum brevis
central
• quadratus plantae
deep
• adductor hallucis
• posterior tibial neurovascular bundle

25. The normal pressure within the compartment is
between 0 mmHg to 8 mmHg
The increased compartment pressure restricts local
tissue perfusion by reducing the arteriovenous
pressure gradient (reduced arterial pressure,
increased venous pressure)
If prolonged, cellular anoxia occurs leading to
damage to nerve and muscle tissues.
A vicious cycle ensues, in which capillary flow
deteriorates owing to an increase in compartment
pressure, which further reduces tissue perfusion,
enhancing blood vessel permeability and further
increasing internal pressure.
Inadequate venous drainage further increases
pressure.
Acute Compartment Syndrome
Oak NR, Abrams RA. Compartment Syndrome of the Hand. Orthop Clin North Am. 2016 Jul;47(3):609-16. doi: 10.1016/j.ocl.2016.03.006. PMID: 27241383.
Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003 Jul;85(5):625-32. PMID: 12892179.

26. Common Causes
• Intrinsic vs Extrinsic causes
– Intrinsic causes (Bleeding, Oedema)
– Extrinsic causes (Tightly applied casts and splints)
• Long bone fractures (75%)
– Tibia
– Comminuted fractures
– Forearm
• Burn injury
– Full-thickness burns
– Large fluid shifts associated with burn resuscitation contribute to tissue edema
– Burn eschar may restrict tissue swelling
• Crush injury
• Snakebite (due to location of most snakebites)
– Most snakes deposit venom into subcutaneous tissue - rarely affects compartment pressure.
– Snakes (eg, rattlesnakes) with longer fangs can inject venom directly into the muscular compartment.
• Extravasation injury-
Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003
Jul;85(5):625-32. PMID: 12892179.

27. Diagnosis Criteria(Clinical)

28. Signs and Symptoms
Physical examination alone has limited sensitivity and specificity for ACS. Serial examinations are
important in patients at risk. Clinical features include:
• Significant extremity pain is the primary feature; pain can be "out of proportion" to apparent
injury.
• Pain and other features can progress rapidly over a few hours.
• Tense, firm compartment (note: deep posterior compartment of the leg cannot be palpated).
• Pain exacerbated by passive stretch of muscle within the compartment.
• Compartment-specific neurovascular findings (eg, paresthesias, reduced sensation, muscle
weakness, diminished pulses).
Other clinical findings that suggest impending ACS include:
• Excessive or disproportionate increase in extremity girth.
• Acidosis or hyperkalemia following reperfusion.
• Clinical evidence of rhabdomyolysis (eg, high CK >30,000 units).

29. Clinical features
Physical examination alone has limited sensitivity and specificity for ACS. Serial examinations are
important in patients at risk. Clinical features include:
•Significant extremity pain is the primary feature; pain can be "out of proportion" to apparent
injury.
•Pain and other features can progress rapidly over a few hours.
•Tense, firm compartment (note: deep posterior compartment of the leg cannot be palpated).
•Pain exacerbated by passive stretch of muscle within the compartment.
•Compartment-specific neurovascular findings (eg, paresthesias, reduced sensation, muscle
weakness, diminished pulses).
¶
Other clinical findings that suggest impending ACS include:
•Excessive or disproportionate increase in extremity girth.
•Acidosis or hyperkalemia following reperfusion.
•Clinical evidence of rhabdomyolysis (eg, high CK >30,000 units).

30. Tissue Survival Rate
Muscle:
3-4 Hr – Reversible changes
6 Hr - Variable damage
8 Hr - Irreversible changes
Nerve:
2 Hr - Loose nerve conduction
4 Hr - neuropraxia
8 Hr - Irreversible changes

31. Measurement of intercompartmental pressure
Needle placement when
measuring pressures for
each of the four leg
compartments:
(A) Anterior
(B) Lateral
(C) Deep posterior
(D) superficial posterior
Horizontal positioning of
the needle for entry is
preferred and may be
required to access the
deep posterior
compartment.

33. Chronic Exertional Compartment Syndrome
• Reversible form of acute compartment syndrome that develops when increased
hydrostatic pressure within a skeletal muscle compartment compromises local
tissue perfusion leading to pain and other symptoms.
• The typical patient with CECS is a young athlete, often a runner, describes
gradually increasing pain in a specific muscle region (usually the lower leg)
during physical exertion.
• Pain develops shortly after the start of exercise and resolves soon (typically within
10 to 20 minutes) after the activity stops. The pain may be described as aching,
squeezing, cramping, or tightness.
• Patients with CECS are typically asymptomatic at rest and during activities of
daily living
• Many conditions can mimic CECS, including medial tibial stress syndrome (shin
splints), stress fracture of the tibia or fibula, tendinopathy, and deep vein
thrombosis.

34. Chronic Exertional Compartment Syndrome

35. Surgical Management of
Compartment Syndrome

36. Immediate management
• Removal of external compressive forces and releasing casts or
dressing down to skin
• Limb should not be elevated, instead kept at the level of heart
• Early assessment of hypovolaemia, metabolic acidosis and
myoglobinaemia is mandatory to avoid potential renal failure
• Intravenous fluids and supplemental oxygen may be needed
• If the clinical features of ACS do not improve following simple
measures, definitive surgical fasciotomy is required
• 8 hour ischemia time can cause irreversible damage to muscle

37. Fasciotomy
Principles
• adequate and extensile incision
• complete release of all compartments
• preservation of vital structure
• thorough debridement
• skin coverage at a later date (7-10 days)

38. Compartments of Thigh

39. Fasciotomy of the thigh
• Single lateral incision is usually
adequate to decompress the thigh
• Medial compartment rarely involved
• Mid lateral skin incision of the thigh

41. Compartments of leg
Most common occur in the anterior
compartment of the leg

42. Fasciotomy of
the leg
• Lateral leg
incision Is
made halfway
between the
tibia and the
fibula for the
release of the
anterior and
lateral
compartent.

43. Fasciotomy of
the leg
• Medial leg
incision is made
2cm posterior to
the tibia for the
release of the
deep and
superficial
posterior
compartment.

46. Fasciotomy of the foot
• Two dorsal incisions centered
over the 2nd and the 4th
metatarsals

47. Fasciotomy of foot
• Medial incision to release medial and central compartment of foot

49. Compartment of the forearm

50. Fasciotomy forearm
Volar part:
• Skin incision
• Release of superficial
volar compartment
• Release of deep volar
compartment

51. Fasciotomy forearm
Dorsal incision
• Skin incision
• Release of dorsal
compartment

55. 10 compartments in the hand

56. • Dorsal incision of the hand in line
with 2nd and 4th metacarpals
Hand Fasciotomy

57. • incision made along radial aspect of 1st metacarpal to release thenar
compartment
• incision made along ulnar aspect of 5th metacarpal to release
hypothenar compartment
Hand Fasciotomy

58. Hand Fasciotomy

59. Hand fasciotomy

60. Wound management
Wet to dry dressing.
• Wet or moist
gauze/cloth is
dressed on the
wound.
• Often be replaced
• Will remove wound
drainage and dead
tissue
• Reduce chance of
infection

61. Wound management
Vacuum dressing
• Negative pressure wound
therapy
• Reduce swelling
• Promote tissue granulation
• Increase tissue perfusion
• Keep the wound cover which
limits the chances of wound
infection.
Benefits :
• Faster wound closure
• Reduce scarring
• Lower complication rate of
following fasciotomy

63. Thank you