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By; 
Sridevi Rajeeve 
Intern 
2008 Batch 
8/28/2014 sridevirajeeve_august2014_ortho 1
DEFINITION 
Compartment syndrome is defined as the 
elevated interstitial tissue pressure within a 
confined space in the ...
ANATOMIC CONSIDERATIONS 
May occur in varied locations where closed 
compartments exist in the body 
Leg (most common) 
Fo...
Classic location - Flexor compartment of the Forearm 
This location has several unique anatomic features that predispose C...
8/28/2014 sridevirajeeve_august2014_ortho 5
8/28/2014 sridevirajeeve_august2014_ortho 6
AETIOLOGY 
1. ACUTE COMPARTMENT SYNDROME 
(1) Increased Compartment Volume 
Fracture 
○ Supracondylar humerus 
○ Forearm b...
• Tetany 
• Eclampsia 
• Seizures 
• Bleeding 
• Bleeding or coagulation disorder (e.g. haemophilia) 
• Anticoagulant ther...
(2) Decreased Compartmental Volume 
 Tight casts/splints 
 Prolonged limb pressure 
 Lengthy surgeries 
 Anaesthesia 
...
PATHOPHYSIOLOGY 
Classical aetiopathogenesis: increased ICP in the 
interstitium over itscapillary perfusion pressure, due...
THE VICIOUS CYCLE – OF DOOM?! 
8/28/2014 sridevirajeeve_august2014_ortho 11
8/28/2014 sridevirajeeve_august2014_ortho 12
Normal resting intramuscular pressure is usually 
less than 6 mmHg 
In compartment syndrome, the intramuscular 
pressure c...
Compartmental pressures more than 30 mmHg 
maintained for more than 8 hours can cause 
irreversible muscle damage 
Type 1 ...
8/28/2014 sridevirajeeve_august2014_ortho 15
DIAGNOSIS 
Medical/Orthopaedic emergency 
Any delay in its diagnosis is the single most 
important cause of morbidity with...
CLINICAL DIAGNOSIS 
Classically, there are 6 "Ps" associated with 
compartment syndrome 
Pain (out of proportion to what i...
Reliability? 
Pain itself is an unreliable and variable 
indicator 
Pain if used as a diagnostic indicator of acute 
compa...
Palpable tenseness of the swollen affected 
compartment is often the earliest sign and 
palpating reproduces the patient’s...
INTRACOMPARTMENTAL PRESSURE 
MEASUREMENT AND MONITORING 
CS is confirmed by measuring the ICP 
Most important investigatio...
ADJUNCT DIAGNOSTICS 
Radiographs 
These are required to investigate for possible 
underlying fractures and fracture disloc...
8/28/2014 sridevirajeeve_august2014_ortho 22
DELAYED DIAGNOSIS! 
Patients prone to delay in diagnosis of 
compartment syndrome 
Head injury 
Cerebrovascular accident 
...
MANAGEMENT 
Goals for the management of acute 
compartment syndrome are 
to restore tissue perfusion to the affected 
musc...
NON-OPERATIVE 
MANAGEMENT 
Ensure patient is normotensive, as hypotension 
reduces prefusion pressure and facilitates 
fur...
Borderline symptomatic patients may be 
monitored with an indwelling catheter 
Persistently borderline or doubtful patient...
OPERATIVE 
MANAGEMENT 
GOLD STANDARD: FASCIOTOMY! 
Open and extensive fasciotomies of all the 
compartments within the par...
FASCIOTOMY 
INDICATIONS 
Unequivocal clinical findings 
Pressure within 15-20 mmHg of DBP 
Rising tissue pressure 
Signifi...
FASCIOTOMY 
Principles 
Make early diagnosis 
Long extensile incisions 
Release all fascial compartments 
Preserve neurova...
FASCIOTOMY 
Fasciotomy not only relieves compartmental 
pressure, but also helps in re-establishing 
tissue perfusion if d...
Leg 
all four compartments must be decompressed, 
usually via two long, longitudinal incisions. 
It will be necessary to d...
8/28/2014 sridevirajeeve_august2014_ortho 32
8/28/2014 sridevirajeeve_august2014_ortho 33
8/28/2014 sridevirajeeve_august2014_ortho 34
POST-FASCIOTOMY 
CARE 
Wound Management after Fasciotomy 
a bulky compression dressing and a splint are 
applied. 
VAC (Va...
COMPLICATIONS RELATED TO 
FASCIOTOMIES 
Altered sensation within the margins of the wound 
(77%) 
Dry, scaly skin (40%) 
P...
COMPLICATIONS OF 
COMPARTMENT SYNDROME 
Volkmann’s contracture 
Weak dorsiflexors 
Claw toes 
Sensory loss 
Chronic pain 
...
CHRONIC COMPARTMENT 
SYNDROME 
Chronic Compartment Syndrome usually occurs in young 
active patients afterintense muscular...
8/28/2014 sridevirajeeve_august2014_ortho 39
Conservative treatment includes rest, anti-inflammatories, 
and manual decompression 
Ideally, the affected limb should be...
VOLKMANN’S ISCHEMIC CONTRACTURE 
Severe manifestation of Compartment 
syndrome of Forearm 
Permanent flexion-contracture d...
Volkmann’s Sign: in established VIC 
Extension of wrist produces exaggeration 
of flexion deformity while on flexion, the ...
Treatment plan 
Moderate VIC 
MAX-PAGE’S MUSCLE SLIDING OPERATION: releasing common 
flexor origin from medial epicondyle ...
THANK YOU! 
8/28/2014 sridevirajeeve_august2014_ortho 44
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Compartment Syndrome

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Compartment Syndrome presented in a compact and easy manner with pictorial accompaniments.

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Compartment Syndrome

  1. 1. By; Sridevi Rajeeve Intern 2008 Batch 8/28/2014 sridevirajeeve_august2014_ortho 1
  2. 2. DEFINITION Compartment syndrome is defined as the elevated interstitial tissue pressure within a confined space in the body (an osseo-fascial compartment) leading to inadequate tissue perfusion and eventually leading to tissue necrosis within the compartment True Orthopaedic Emergency! 8/28/2014 sridevirajeeve_august2014_ortho 2
  3. 3. ANATOMIC CONSIDERATIONS May occur in varied locations where closed compartments exist in the body Leg (most common) Forearm (classic) Arm Thigh Foot Hand Buttock Abdomen 8/28/2014 sridevirajeeve_august2014_ortho 3
  4. 4. Classic location - Flexor compartment of the Forearm This location has several unique anatomic features that predispose CS Strong fascial roof and at its entrance lie two potential obstructions ○ First and lying most superficialis the lacertous fibrous fascia, which fans medially from the biceps tendon as the latter inserts on the proximal radius. ○ The second is the bulky pronator teres muscle, which arises from the medial epicondyle and passes obliquely beneath the inelastic lacertous fibrosus to create a V-shaped sphincter beneath which the brachial artery and the median nerve must pass to enter the flexor compartment. ○ Collateral vessels serving the flexor compartment are minimal Oedema, haematoma or intramuscular haemorrhage in this crucial region may cause sufficient compression of these neurovascular structures to precipitate the ischaemia–oedema vicious cycle. 8/28/2014 sridevirajeeve_august2014_ortho 4
  5. 5. 8/28/2014 sridevirajeeve_august2014_ortho 5
  6. 6. 8/28/2014 sridevirajeeve_august2014_ortho 6
  7. 7. AETIOLOGY 1. ACUTE COMPARTMENT SYNDROME (1) Increased Compartment Volume Fracture ○ Supracondylar humerus ○ Forearm bones ○ Distal radius ○ Tibia Soft-tissue injury ○ Crush syndrome ○ Severe contusion ○ Muscle tear ○ Gunshot wounds Iatrogenic ○ Postoperative inflammation ○ Fracture fixation with oversize implants Exertion (intensive muscle use) 8/28/2014 sridevirajeeve_august2014_ortho 7
  8. 8. • Tetany • Eclampsia • Seizures • Bleeding • Bleeding or coagulation disorder (e.g. haemophilia) • Anticoagulant therapy • Postoperative vascular injury • Traumatic rupture of vascular malformation • Fluid extravasations into soft tissues • Ruptured cysts/ganglia • During arthroscopy with fluid extravasation • Infection (acute haematogenous osteomyelitis) • Increased capillary permeability or pressure • Venous obstruction/ligation • After prolonged ischaemia/tourniquet • Arterial bypass grafting • Ergotamine ingestion • Thermal injury • Electrical injury • Frostbite • Snakebite • Intra-arterial drug injection Most common – FRACTURE! Tibial Diaphyseal > Radial Shaft > Supracondylar 8/28/2014 sridevirajeeve_august2014_ortho 8
  9. 9. (2) Decreased Compartmental Volume  Tight casts/splints  Prolonged limb pressure  Lengthy surgeries  Anaesthesia  Comatose patient  Excessive traction on fractured limb 8/28/2014 sridevirajeeve_august2014_ortho 9
  10. 10. PATHOPHYSIOLOGY Classical aetiopathogenesis: increased ICP in the interstitium over itscapillary perfusion pressure, due to the accumulation of necrotic debris and/or haemorrhage, contents within the closed compartment of the deep fascia swell, raising the ICP to such a high level that blood cannot circulate in this closed compartment Contents undergo varied degrees of necrosis and eventually fibrosis 8/28/2014 sridevirajeeve_august2014_ortho 10
  11. 11. THE VICIOUS CYCLE – OF DOOM?! 8/28/2014 sridevirajeeve_august2014_ortho 11
  12. 12. 8/28/2014 sridevirajeeve_august2014_ortho 12
  13. 13. Normal resting intramuscular pressure is usually less than 6 mmHg In compartment syndrome, the intramuscular pressure can increase to more than 100 mmHg The initial insult causes haemorrhage, oedema or both in the closed fascial compartments of the extremities. Rising compartment pressure ultimately leads to compartmental tamponade, microcirculatory impairment and sustained ischaemia 8/28/2014 sridevirajeeve_august2014_ortho 13
  14. 14. Compartmental pressures more than 30 mmHg maintained for more than 8 hours can cause irreversible muscle damage Type 1 aerobic fibres (red/slow-twitch fibres), are more vulnerable to ischaemia than type 2 anaerobic fibres (white/fast-twitch fibres). That explains why some muscle groups are more vulnerable to ischaemic damage than others Reduces the healing capacity of long bones, by possibly reducing the extra-osseous blood supply and Non-union can be a possible complication 8/28/2014 sridevirajeeve_august2014_ortho 14
  15. 15. 8/28/2014 sridevirajeeve_august2014_ortho 15
  16. 16. DIAGNOSIS Medical/Orthopaedic emergency Any delay in its diagnosis is the single most important cause of morbidity with potential to cause disastrous consequences including Amputation and even Death Diagnosis of acute compartment syndrome is made clinically Confirmed by actual measurement of compartmental tissue fluid pressure A high index of suspicion is important to make a diagnosis! 8/28/2014 sridevirajeeve_august2014_ortho 16
  17. 17. CLINICAL DIAGNOSIS Classically, there are 6 "Ps" associated with compartment syndrome Pain (out of proportion to what is expected based on the physical exam findings) Paraesthesia Pallor Paresis/Paralysis Pulselessness Poikilothermia The first signs of compartment syndrome are numbness, tingling and paresthesia 8/28/2014 sridevirajeeve_august2014_ortho 17
  18. 18. Reliability? Pain itself is an unreliable and variable indicator Pain if used as a diagnostic indicator of acute compartment syndrome has a high proportion of missed or false negative cases It cannot be elicited in unconscious patients and is an unreliable indicator in small children Pain on passively stretching the muscles of the affected compartment (e.g. passively extending the fingers in acute compartment syndrome affecting the volar compartment of the forearm) is a recognized symptom 8/28/2014 sridevirajeeve_august2014_ortho 18
  19. 19. Palpable tenseness of the swollen affected compartment is often the earliest sign and palpating reproduces the patient’s pain The compartment may feel very hard depending on the ICP and the overlying skin often appears shiny Peripheral pulses are almost always present in acute compartment syndrome, unless the injury involves damage to vessels Thus, if pulses are present, it does not exclude the diagnosis of compartment syndrome! 8/28/2014 sridevirajeeve_august2014_ortho 19
  20. 20. INTRACOMPARTMENTAL PRESSURE MEASUREMENT AND MONITORING CS is confirmed by measuring the ICP Most important investigation in ACS Several methods are available to measure the ICP: 1. Needle Manometer Method 2. Wick Or Slit Catheter Technique 3. Continuous Monitoring Infusion Technique 4. Hand-held Transducers (Stryker Intra-compartmental Pressure System) 5. Near-infrared spectroscopy (NIRS) 6. Pressure transducer modules (with a simple intravenous catheter and needle) that are attached to most modern anaesthetic machines 8/28/2014 sridevirajeeve_august2014_ortho 20
  21. 21. ADJUNCT DIAGNOSTICS Radiographs These are required to investigate for possible underlying fractures and fracture dislocation, their reduction and possible radio-opaque foreign bodies Doppler flowmetry and arteriography Doppler flowmetry and arteriography are valuable in verifying a suspected arterial injury, but not for diagnosis of acute compartment syndrome. These investigations should not delay fasciotomy. 8/28/2014 sridevirajeeve_august2014_ortho 21
  22. 22. 8/28/2014 sridevirajeeve_august2014_ortho 22
  23. 23. DELAYED DIAGNOSIS! Patients prone to delay in diagnosis of compartment syndrome Head injury Cerebrovascular accident Spinal cord injury Peripheral nerve injury Anaesthetized patients (general/local) Alcoholic/drug-overdosed patients Mentally disabled patients Burn patients Infants/young patients 8/28/2014 sridevirajeeve_august2014_ortho 23
  24. 24. MANAGEMENT Goals for the management of acute compartment syndrome are to restore tissue perfusion to the affected muscles and nerves of the compartment affected, to prevent or minimize the injury to avoid any residual loss of function Treatment may be Non-operative for Impending Compartment Syndrome Surgical for Established Compartment Syndrome 8/28/2014 sridevirajeeve_august2014_ortho 24
  25. 25. NON-OPERATIVE MANAGEMENT Ensure patient is normotensive, as hypotension reduces prefusion pressure and facilitates further tissue injury Remove cicumferential bandages and cast. Alternative methods of immobilization or fixation should be chosen if necessary to maintain fracture reduction Maintain the limb at level of the heart as elevation reduces the arterial inflow and the arterio-venous pressure gradient on which perfusion depends Supplemental oxygen administration 8/28/2014 sridevirajeeve_august2014_ortho 25
  26. 26. Borderline symptomatic patients may be monitored with an indwelling catheter Persistently borderline or doubtful patients should preferably have a fasciotomy rather than delay treatment Fasciotomy: Prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma 8/28/2014 sridevirajeeve_august2014_ortho 26
  27. 27. OPERATIVE MANAGEMENT GOLD STANDARD: FASCIOTOMY! Open and extensive fasciotomies of all the compartments within the part of the limb affected by CS 8/28/2014 sridevirajeeve_august2014_ortho 27
  28. 28. FASCIOTOMY INDICATIONS Unequivocal clinical findings Pressure within 15-20 mmHg of DBP Rising tissue pressure Significant tissue injury or high risk pt > 6 hours of total limb ischemia Injury known for high risk of compartment syndrome Absolute: >30-35mmHg with positive clinical correlation CONTRA-INDICATION Missed compartment syndrome (>24-48 hrs) 8/28/2014 sridevirajeeve_august2014_ortho 28
  29. 29. FASCIOTOMY Principles Make early diagnosis Long extensile incisions Release all fascial compartments Preserve neurovascular structures Debride necrotic tissues Coverage within 7-10 days 8/28/2014 sridevirajeeve_august2014_ortho 29
  30. 30. FASCIOTOMY Fasciotomy not only relieves compartmental pressure, but also helps in re-establishing tissue perfusion if done timely enough and if there is no arterial injury or compromise 8/28/2014 sridevirajeeve_august2014_ortho 30
  31. 31. Leg all four compartments must be decompressed, usually via two long, longitudinal incisions. It will be necessary to debride necrotic tissue, sometimes several times. Forearm The three compartments (the mobile wad of three, the volar and extensor) can be released via two incisions (one curvilinear volar incision across the elbow and straight to the wrist to include releasing the carpal tunnel and one straight incision along the extensor ulna border) Hand Has 10 compartments(requiring five incisions) Similarly, the foot 8/28/2014 sridevirajeeve_august2014_ortho 31
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  35. 35. POST-FASCIOTOMY CARE Wound Management after 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 Wound is not closed at initial surgery Incision for the fasciotomy usually can be closed after 3 - 5 days 8/28/2014 sridevirajeeve_august2014_ortho 35
  36. 36. 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%) 8/28/2014 sridevirajeeve_august2014_ortho 36
  37. 37. COMPLICATIONS OF COMPARTMENT SYNDROME Volkmann’s contracture Weak dorsiflexors Claw toes Sensory loss Chronic pain Amputation Rhabdomyolysis Renal failure 8/28/2014 sridevirajeeve_august2014_ortho 37
  38. 38. CHRONIC COMPARTMENT SYNDROME Chronic Compartment Syndrome usually occurs in young active patients afterintense muscular activity Usually detected in the anterior compartment (anterior or posterior deep compartment) Main symptoms involve pain, parasthesia of the musclewithin the affected compartment, after intense and continuing (over than 20-30 min) streching of musclegroups. The symptoms recess progressively by interrupting any kind of exercise (15-20min) Differential diagnosis include stress fracture, superficialfibular nerve entrapment syndrome, posterior tibialmuscle tendonitis. 8/28/2014 sridevirajeeve_august2014_ortho 38
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  40. 40. Conservative treatment includes rest, anti-inflammatories, and manual decompression Ideally, the affected limb should be positioned at the level of the heart Patient adviced to decrease the level of activity No relief forthcoming – Surgical Decompression 8/28/2014 sridevirajeeve_august2014_ortho 40
  41. 41. VOLKMANN’S ISCHEMIC CONTRACTURE Severe manifestation of Compartment syndrome of Forearm Permanent flexion-contracture deformity of hand at wrist and fingers Most affected muscles: Flexor digitorum profundus and Flexor pollicis longus Classical claw-hand deformity 8/28/2014 sridevirajeeve_august2014_ortho 41
  42. 42. Volkmann’s Sign: in established VIC Extension of wrist produces exaggeration of flexion deformity while on flexion, the deformities are less marked Extensive scarring of forearm + Thin and fibrotic forearm Joint and soft tissue contractures Neurological deficits Gangrene (rare) 8/28/2014 sridevirajeeve_august2014_ortho 42
  43. 43. Treatment plan Moderate VIC MAX-PAGE’S MUSCLE SLIDING OPERATION: releasing common flexor origin from medial epicondyle and passivele stretching fingers CICATRIX EXCISION NEUROLYSIS TENDON TRANSFERS Severe VIC CICATRIX EXCISION SEDDON’S CARPECTOMY: excising proximal row of carpal bones to shorten forearm to overcome the effects of contacted muscles ARTHRODESIS of wrist in functional position AMPUTATION 8/28/2014 sridevirajeeve_august2014_ortho 43
  44. 44. THANK YOU! 8/28/2014 sridevirajeeve_august2014_ortho 44

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