DESCRIBES IN BRIEF THE HISTORY, PRESENTATION, CLINICAL FEATURES AND TREATMENT OF LOWER LIMB COMPARTMENT SYNDROME

1. Lower Limb Compartment
Syndrome
MODERATOR
Dr. DEEPAK KUMAR NEGI
Asst. Professor
DEPT OF ORTHPAEDIC SURGERY
PGIMER , Chandigarh
PRESENTATION BY
Dr. PRATIK M. RATHOD
JUNIOR RESIDENT
DEPT. OF ORTHOPAEDIC SURGERY
PGIMER, Chandigarh

2. CONTENTS
• CASE REPORTS for clinical scenarios
• IMPORTANCE/BACKGROUND/HISTORY
• ANATOMY OF LOWER LIMB
• PATHOPHYSIOLOGY
• DIAGNOSIS
• TREATMENT
• SURGICAL STEPS/VIDEOS
• THIGH/FOOT PEARLS
• TAKE HOME MESSAGES

3. CASE REPORT 1
The patient, who worked at a food retail shop, was normally fit not on
any medication.
• He used to run half-marathons, but had not run for at least four
months. no incidental trauma.
• woke up with a dull ache in his left thigh the next morning. This pain
did not inhibit him from going to work over the next week and he was
able to bear all his weight through both legs.
• The pain worsened dramatically on the night of Emergency, such that
he was unable to weight-bear and required copious amounts of
analgesics, with limited effect.

4. ON LOCAL EXAMINATION,
• there was no obvious wound or bruising over the left thigh.
• It was swollen, with a mid-thigh circumference 12 cm larger than on
the right side. It was exquisitely tender as well,
• with an extremely tense anterior compartment.
• The swelling was non-pulsatile with no audible bruit.
• He displayed hyperesthesia in the thigh anterolaterally,
with preserved sensorimotor function and pulses distally in the
limb
*Khan SK, Thati S, Gozzard C. Spontaneous thigh compartment syndrome. Western Journal of Emergency Medicine.
2011 Feb;12(1):134

5. CASE REPORT 2
• 30 year otherwise healthy male after consumption of alcohol, fell from top
of truck and sustained injury and presented to ATC(advanced trauma
centre, PGI Chandigarh) opd on 9th april,2019 after about 30 hrs post initial
injury.
• After initial examination and resuscitation patient had stable vitals, and
had swollen right lower leg with deformity in the lower third of the leg.
• Pulses were non-palpable on palpation, patient had excruciating pain on
passive movements of toes. With intact sensations and little comfort even
on higher analgesics. Compartment of the legs were tense. A clinical
diagnosis of # lower leg both bone # with compartment syndrome was
made and

6. • Within 3 hours of presentation to the Advanced trauma centre patient
underwent dual incison fasciotomy debridement and external fixation for
the fracture.
• Immediate return of pulses were palpated, the muscle were viable.

7. CASE REPORT 3
• A 62-year-old African-American male presented to the Emergency
Department (ED) with left foot pain after a crush injury that occurred
20 min before his arrival. While working on a sanitation truck, his left
foot was crushed between the truck and a car.
• Upon arrival to the ED, the patient complained of severe pain
throughout his left foot.
• He denied sensory deficits. His past medical history included
diabetes. On examination, his left foot was diffusely swollen and
erythematous with no lacerations. Light touch of
Towater LJ, Heron S. Foot compartment syndrome: a rare presentation to the emergency department. The Journal of
emergency medicine. 2013 Feb 1;44(2):e235-8.

8. • The patient’s foot was slightly diminished
• Passive movementexcruciating pain.
• No bony deformities were palpated.
• Strong dorsalis pedis pulse and normal capillary refill.
• X-ray studies of the left lower extremity showed no fractures.
• Multiple doses of fentanyl, with minimal relief of his pain.
• Compartment pressure was over 50 mm Hg, exceeding the diagnostic
threshold of 30 mm Hg for compartment syndrome
Towater LJ, Heron S. Foot compartment syndrome: a rare presentation to the emergency department. The Journal of
emergency medicine. 2013 Feb 1;44(2):e235-8.

9. LET’S RECAPTULATE
• 1881- Richard von volkman described compartment syndrome
following application of external tight bandages for fracture around
elbow.
• 1926- Jepson described effect of prompt decompresson and its effect
• 1928- Sir Robert jones concluded compartment is due to both
external and internal cause
• 1941- Bywater and Beall described crush syndrome and kidney failure
• 1975- whitesides described method of measuring compartmental
pressures using manometer and needle

10. • Owen et al. responsible for describing the pathomechanism of the
ACS
• McQueen and court brown emphasised on delta Pressure as the
critical determinant of need for decompression

11. ANATOMY

14. INTRODUCTION
• AN ORTHOPAEDIC EMERGENCY
• Unique form of ISCHEMIA within a group of muscles enclosed within
a relatively non compliant fascial sheath
• Lower limb compartment syndrome is most commonly seen in
legs>foot>thigh

15. DEFINITION
• An increased pressure within enclosed osteo-fascial space that
reduces capillary perfusion below level necessary for tissue viability

16. COMPARTMENT
SYNDROME
ACUTE
COMPARTMENT
SYNDROME
THIGH
COMPARTMENT
LEG
COMPARTMENT
FOOT
COMPARTMENT
CHRONIC
COMPARTMENT
SYNDROME

17. PATHOPHYSIOLOGY
• local blood flow = (local arterial pressure-venous pressure)/local vascular
resistance
• When the interstitial pressure exceeds the CPP, capillaries begin to
collapse, causing ischemia.
• Ischemic skeletal muscle releases a histamine-like substance that
increases vascular permeability, causing blood sludging and worsening
ischemic conditions.
• Myocytes with lyse-releasing proteins cause water to permeate out of
arterial blood into the compartment and further increasing the
compartment pressure and cause ischemic changes and finally necrosis.
Rasul A, Lorenzo C, Agnew S, et al. Acute compartment syndrome.
http://emedicine.medscape.com/article/307668-overview. Accessed August 25, 2013.

19. EPIDEMIOLOGY
1. YOUNGER > OLDER
1. MORE MUSCLE MASS
2. MORE TOUGHER INELASTIC FASCIA
2. MALES > FEMALES
1. 7.3 PER 1,00,000 IN MALES AS COMPARED TO 0.7 PER 1,00,000
3. LEGS > FOOT> THIGHS
4. # DIAPHYSEAL > PROXIMAL TIBIA > DISTAL TIBIA
5. NON FRACTURED PATIENTS WITH COMPARTMENT SYNDROME ARE
OLDER AND HAVE MORE COMORBITIES
McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is
at risk? J Bone Joint Surg Br.2000; 82:200-203.

20. CAUSE
• A reduction in the volume of the compartment or an increase in its
content can lead to compartment syndrome.
• Reduction in the volume of the compartment can be caused by:
• A bandage or plaster cast that is too tight
• Closure of a fascial defect
• Thermal injury

21. • An increase in the contents of the compartment can be caused
by:
• Edema:
• Post ischemic
• Patient’s own body weight after a drug overdose
• Thermal injuries
• After exercise (THERE IS 20% INCREASE IN QUANTITY OF
MUSCLE)
• Compromised venous return
• Paravascular injection
• Poison (snakebite)
AO HANDBOOK OF ORTHOPEDIC TRAUMA CARE

22. OTHER CAUSES
• Bleeding:
• Clotting disorder (congenital or drug induced)
• Vascular injuries
• Combination of edema and bleeding:
• Fracture or osteotomy
• Soft-tissue injuries

23. CLINICAL PRESENTATION
Clinical signs and symptoms of acute compartment syndrome are:
• Pain (continuous and disproportional, NOT RESPONDING TO ANALGESICS)
• EARLIEST AND MOST IMPORTANT SYMPTOM
• Swollen, tender compartment
• Pain on passively stretching muscles in the affected compartment
• Neurological deficit (sensory)
• DECREASED TWO POINT DISCRIMINATION
• HYPERESTHESIA
• PARESTHESIA
• Muscle weakness

24. 6 Ps

26. DIAGNOSIS
CLINICAL DEVICES DETECTING
PRESSURE CHANGES
WHITESIDES MANOMETER
HAND HELD PRESEURE
GUAGE
WICKS CATHETERMUSCLE PO2, MRI
ULTRASONOGRAPHY
INFRARED IMAGING

27. WHITESIDES MANOMETRY TECHNIQUE

30. SPECIAL SCENARIOS
• The symptom complex may not present fully due to patient-related
factors:
• Noncooperative patient
• Coma
• A child
• Preexisting peripheral neurological disorder
• Use of local anesthetic for pain relief (including epidurals)

31. TREATMENT ALGORITHM CAMPBELL’S
OPERATIVE
ORTHOPAEDICS

32. FASCIOTOMIES FOR LOWER LEG
COMPARTMENT
• DAVEY ET AL. SINGLE INCISION FASCIOTOMY
• LESS FREQUENTLY USED
• EQUIVALENT RESULT
• MUBARAK AND HARGENS DOUBLE INSCISION
• MOST ACCEPTED
• EASIER
• ANTEROLATERAL AND POSTEROMEDIAL INSCISION

34. POST FASCIOTOMY OPTIONS
• PRIMARY CLOSURE
• DELAYED PRIMARY CLOSURE
• SPLIT SKIN GRAFTING
• VAC + CLOSURE/SSG

35. THIGH COMPARTMENT SYNDROME PEARLS
• (SUZUKI ET AL.) 0.027% INCIDENCE OF THIGH COMPARTMENT
• HIGH EVIDENCE OF DEFINITE ARTERIAL INJURIES
• MOST COMMONLY OCCURS WITHOUT A FRACTURE
• GILOOLY ET AL REPORTED NON TRAUMATIC CAUSE OF THIGH
COMPARTMENT INCLUDE TUMOR INFILTRATE, SNAKE BITE, EXRECISE
INDUCED DRUG INDUCED ETC.
• NEED OF CONTINOUS PRESSURE MONITORING TO DECREASE THE
“MISS RATES”
• CLASSICAL SIGNS SEEN ONLY IN 19%

36. • FACIOTOMY DONE IS ON ON LATERAL SIDE ALONE IN MOST CASES,
AND RARELY TWO INCISION FASCIOTOMY

37. • CLOSURE MOST OF THE TIMES IS BY PRIMARY METHODS, RARELY
REQUIRING SSG

38. FOOT COMPARTMENT SYNDROME PEARLS
• (DODD ET AL) ACCOUNTS FOR LESS THAN 5% OF LIMB
COMPARTMENT SYNDROMES
• FCS IS RESULT OF HIGH ENERGY INJURIES
• MOST COMMONLY ASSOCIATED WITH CALCANEAL FRACTURES (10%
OF CASES), LISFRANC AND CHOPART INJURIES, BUT MAY ALSO BE DUE
TO TIBIAL FRACTURES INVOLVING DEEP POSTERIOR COMPARTMENT
OF THIGH
• PAIN, CHRONIC STIFFNESS AND DISBILITY, DEFORMITY ARE
COMMONLY ASSOCIATED WITH UNTTREATED FCS
THAKUR ET AL,PERRY ET AL,MYERSON ET AL, ANDERMAHR ET AL

39. • CLAW TOE, HAMMER TOE AND PES CAVUS ARE RESULTANT
CONSEQUENCES OF UNTREATED FCS

40. • INTRINSIC MUSCLE NECROSIS AND FIBROSIS FOLLOWED BY TAKE
OVER OF EXTEINSIC MUSCLES
• ANATOMY
• MANOLI AND WEBER- 9 COMPARTMENTS
• CENTRAL COMPARTMENT INTO SUP AND DEEP
• INCREASED NUMBER OF INTEROSSEOUS COMP FROM 1 TO 4
• A COMPARTMENT ADDED FOR EHL

41. • REACH ET AL PROPOSED 10TH COMPARTMENT OF THE FOOT WHICH IS
BOUNDED BY SKUN AND CONTAINS EDB AND EHB
• LING AND KUMAR ET AL CONCLUDED THAT INTERMEDIATE AND
LATERAL COMPARTMENT ONLY NEED DECOMPRESSION
• SWELLING IS MOST IMPORTANT CONSISTENT CLINICAL FEATURE
• PAIN IS DESCRIBED AS RELENTLESS BURNING
• PASSIVE DORSIFLEXION DECREASES THE VOLUME OF THE
COMPARTMENT AND CAUSES PAIN

42. FOOT FASCIOTOMY
• USUAL RECOMMENDATION IS 3 INSCISON TECHNIQUE (KAMEL ET AL,
MANOLI ET AL)
• MEDIAL INSCISION 5 CMS FROM HEEL TO 6 CM ANTERIORLY AND END
UP 3 CM ABOVE THE PLANTAR SURFACE
• DORSAL INSCIONS ON 2 AND 4 TH METATARSALS

43. • DUNBAR ET AL SUGGESTED “PIE CRUSTING” FASCIOTOMY

44. • DEFORMITIES CAUSED DUE TO FCS ARE EITHER RIGID OR NON RIGID
• NON RIGID ARE CORRECTABLE BY ORTHOSES AND MANIPULATION
• RIGID DEFORMITIES NEED TENOTOMY AND SOFT TISSUE RELEASE ±
BONY OSTEOTOMIES

45. TAKE HOME MESSAGES
• VIGILENCE/ CLINICAL SUSPICION IS KEY
• CLASSICAL 6 P’s CAN BE DECEIVING
• IN DOUBT? MEASURE COMPARTMENT
• CONSIDER LIBERAL FASCIOTOMY INSCISION
• FASCIOTOMY IS A SIMPLE, STRAIGHT FORWARD TREATMENT WHICH
IS HIGHLY EFFECTIVE IF PERFORMED EARLY.