Compartment syndrome and

fasciotomy
Supparerk Prichayudh, M.D.
 What is Compartment
Syndrome?
• Matsen’s definition 1980
– “a compartment
syndrome is a condition in
which increased pressure
within a limited space
compromises the
circulation and function of
the tissues within that
space.”
 Where can it occur?
• Anywhere there is an enclosed space
typically restricted by fascia:
– Upper Arm
– Forearm
– Hand
– Thigh
– Chest
– Abdomen
• Raised ICP of the brain
 Causes of Compartment
Syndrome (Primary)
• Fracture of the long bones e.g. Tibia

• Crush injuries

• Burns Eschar

• Lithotomy position

• Pneumatic tourniquet

• High Injury Trauma

• Ischemia/Reperfusion

• Penetrating injuries
 Secondary Extremity
Compartment Syndrome
• Rare, 0.08-0.148%
• part of the post-resuscitation SIRS
• significant edema and associated compartment
syndromes in 2 to 4 injured or non-injured
extremities after massive resuscitation.
• Mortality rate 35-70%
• should be suspected in any injured patient who
presents with profound hypotension, ISS > 25,
transfusion of at least 10 units of PRBC
• Rx: early detection and early fasciotomy
 Pathophysiology
Tissue Injury + Tissue Ischemia +Tissue Reperfusion

Cellular injury & Tissue swelling

↑ compartment pressure

Compartment syndrome
CS Pathogenesis
Soft tissue injury/ischemia

edema
As pressure rises VR causing P

Tissue perfusion- arterial compression

Capillaries starting shutting down

Capillary leakage Tissue Death

Cellular Ischemia  superoxide

Radicals, procoagulants (esp. during reperfusion)

Cellular & interstitial edema

Local blood flow
 Compartment pressure
(normal 4-7 mmHG) ↑ > Capillary
pressure (>25-30 mmHg)

prevents perfusion of tissues

ischemia and ultimately death of tissue.

Reactive Oxygen Metabolite ( ROM )
- Unpaired outer orbit electron of Oxygen
from Anaerobic Glucose Oxidation
(Ischemia) + O2 (Reperfusion) →
Superoxide Anion ( O2- ) → Hydrogen
Peroxide ( H2O2 )/ Hydroxyl Radical (OH-)
- High energy and reactivity with organic
molecules → Organic Radicals → Cellular
damage (oxidation of unsaturated fatty
acid within cell membrane)
• ROM • Body antioxidant
– OH- Strongest (oxygen scavenger)
– H2O2 – Glutathione
– O 2- weakest – Catalase
– Superoxide dismutase

-
2O2 + 2H+
H2O2 + 1O2
Superoxide dismutase
2 H2 O2
H2O + O2
catalase
 What are its consequences?
• If not recognised and not treated  myoneural
necrosis occurs due to  tissue pH as a result
of lactic acidosis from anaerobic metabolism and
a release of K+
• Myoglobin is released leading to
rhabdomyolysis  the products of this lead to
acute tubular necrosis (ATN)  acute renal
failure (ARF)
• sepsis and death can result
• So it is important to act swiftly once the
diagnosis is suspected
 Tissue Threshold to
Ischemia
• Muscle 4-8 hrs
• Nerve 4-8 hrs
• Fat 12 hrs
• Skin 24 hrs
• Bone 72-96 hrs
• Therefore for a viable functional
limb the upper threshold is about 6
hrs
Anatomy
Arm Compartments
Anterior

Posterior
 Forearm compartments
Volar

Lateral
(Mobile WAD)

Dorsal
 Thigh compartments

Anterior (flexor) Medial (adductor)

Posterior (flexor)
Compartments of the Leg
 Compartments of the Lower
Anterior Compartment Limb Deep Posterior
– main extensors of
the leg Compartment – flexors
Superficial Posterior
of the foot and–great
Compartment
•AnteriorCompartment
Lateral Tibialis,
toe
superficial flexors
Extensor Hallicus and
•Peroneus Longus and
digitorum Longus, •Flexors of foot and
•Gastronemius
brevis
Peroneus Tibia great toe
•Soleus
•Superficial
•Deep peroneal
peroneal nerve
•Tibeal Nerve
nerve
•1/3 blood supply to •Sural & Tibial Nerves
lower leg via Dorsalis •2/3 blood supply to
•Plantar flexes foot Fibula •Plantar flexors
Pedis and Anterior Tibialis lower leg via posterior
tibial
•Blood artery
supply
•compartment
syndrome– get foot drop posterior tibial

•Loss of sensation skin •Weakness of toe

between first and second flexion and ankle
toes inversion, pain on
•Weakness of toe passive extension
extension pain on toe
flexion Fascia
• Anterior Compartment is more susceptible
to ischemia:
• Stronger fascia  lower compliance
(c= v/ p )
• More slow type 1 muscle fibres – rely on oxidative
metabolism. Other compartments have more fast
type 2 which can access their increased glycogen
stores more via anaerobic metabolism
 Diagnosis

Clinical
Compartment Pressure
 The 5 components of a physical
examination
• Inspection (swelling, trauma, skin
changes)
• Palpation and passive stretch of muscles
in the compartments
• Evaluation of sensory function
• Evaluation of motor function
• Evaluation of perfusion
• Nerves are sensitive to diminished oxygen
delivery
– Sensory change & Weakness  Late signs
• The presence of palpable pulses at the
ankle or wrist in the injured extremity does
not rule out the presence of a more
proximal compartment syndrome.
CS with high pressure  tapering of major arteries and
temporary occlusion of collateral
arteries (rare)

Crush injury of forearm After fasciotomy

Before fasciotomy
 Clinical Diagnoses
Symptoms & Signs:
• Deep aching Pain out of proportion to the injury
• Incredible pain on passive movement of leg – due to
stretched ischemic muscles
• As arterial supply cut off - Pulselessness
• Paresthesia - distally
• Pallor
• Perishing Cold
• Paralysis
• Tight tense swollen limb
• Redness, mottling, blisters
• 6P’s may or may not be present; cannot exclude
condition based on their absence
 Compartment Pressures
• (1) when a comprehensive history and physical
examination cannot be performed in the
preoperative or postoperative period.
• (2) when there are no or few “high risk” criteria in
a patient with a moderately severe injury to an
extremity
• (3) when there is concern about performing an
unnecessary fasciotomy (ie, conversion of
closed to open fracture).
NS
 A-line tubing & transducer
• Use of a 16-gauge needle attached to arterial tubing &
connected to a standard transducer/monitor.
• After flushing the tubing and needle with saline, the
needle is held just above the compartment, and a “0”
reading is obtained on the monitor.
• The needle is then placed into the compartment, a small
amount of saline is flushed, and a direct reading is soon
available on the monitor.
• When the pressure measurement is inconsistent with the
clinical situation, a repeat measurement or more at
another site is appropriate.
 Near-Infrared Spectroscopy (NIR)
• measures wavelengths of hemoglobin and
oxyhemoglobin, but not
carboxyhemoglobin or myogloblin, and
calculates an StO2 or saturation of tissue
oxygenation.
• tissue oxygen saturation can be used for
early detection of ischemia and/or
neuromuscular dysfunction in patients with
a compartment syndrome in an extremity.
 Treatment
1. Prevention and treatment of
reperfusion injury
2. Non operative treatment
3. Fasciotomy
 1. Reperfusion Injury
- Ischemic phase; Cellular Hypoxia →
↓Energy → ↑Potential to produce ROM(
anaerobic glucose metabolism)
- Reperfusion phase ( After revascularization,
fasciotomy ); O2→ ↑ROM → Tissue
destruction, Rhabdomyolysis (↑ CPK) 
return of toxic metabolites to systemic
circulation (ROM, K+, Bacteria, myoglobin,
etc)  Hyperkalemia, sepsis, myoglobinuria,
ATN, MOF
 Rx reperfusion injury
- 1. Prevention
- Decrease ischemic time
- Never reperfuse dead limb !!!
- 2. Rx hyperkalemia
- 3. Prevent RF  Prevent myoglobin precipitation in renal
tubules
- Hydration, promote urine flow > 100cc/hr, alkalinize urine
- 4. Mannitol  promote diuresis, antioxidant
- 0.25-2g/kg/dose over 4 hours, total < 200g/d
- C/I  hypovolemic, anuric patients
- 5. antioxidant (vitamin C, E, selenium)
- 6. Dialysis if indicated
 2. Non operative treatment
(rarely used, in stable patients with good limb
function & perfusion)
• Observation
• Position of the Extremity
• Hyperbaric Oxygen
• Mannitol
 3. Fasciotomy
• a surgical incision or
splitting of the fascia
to relieve a
compartment
syndrome
• Principles
– Timely
– Adequate incisions
(skin and fascia)
 Indications for Fasciotomy
• S & S of compartment syndrome
• compartment pressure > 30 - 35 mmHg
• ∆P (DBP-CP) < 30 mmHg
• Prophylactic
– any popliteal artery injury
– any combined arterial and venous injury
– prolonged extremity ischemia > 4-6 h
– vascular injury associated with shock; crush injuries;
combined skeletal and vascular extremity trauma; and
the ligation of a major extremity vein or artery.
 Reis, et al. Israel
J Bone Joint Surg 2005

• Fasciotomy is contraindicated for these reasons:

– 1) A fasciotomy for MMCI does not improve outcome
(muscle is already dead).
– 2) It does increase infection, bleeding and amputation
rates.
– 3) The fasciotomies and subsequent debridements
required consume scarce OR resources that could be
better used on others
• Only indication for fasciotomy  Absence of
distal pulse without major arterial injury/
hypotension
• Rx  conservative, fluid resuscitation
 Thigh compartments

Anterior (flexor) Medial (adductor)

Posterior (flexor)
 Fasciotomy of the Thigh
Lateral skin incision  anterior and posterior compartments

Decompression of thigh compartments. A, Incision from intertrochanteric line to lateral epicondyle.

B, Anterior compartment is opened by incising fascia lata, and vastus lateralis is retracted medially to expose
lateral intermuscular septum, which is incised to decompress posterior compartment.
C, Drawing of thigh compartments and appropriate incision.
Fasciotomy of the Leg
2-skin incision, 4-compartment fasciotomy
 Fasciotomy of the Anterior and
Lateral Compartments of the Leg
Fasciotomy of the Superficial &
Deep Posterior Compartment of
the Leg.
 Foot compartments

Intrinsic

Medial

Lateral

Central
Fasciotomy of the Foot
Arm Compartments
Anterior

Posterior
Fasciotomy of the Anterior and
Posterior Compartments of the
Arm
 Forearm compartments
Volar

Lateral
(Mobile WAD)

Dorsal
Fasciotomy of the Forearm
Fasciotomy of the Hand
 Closure Techniques
• Delayed Primary Closure
• Shoelace Technique
• Mechanical Devices
– STAR (Suture Tension Adjustment Reel)
– Dynamic Wound Closure Device (DWC)
• Vacuum Assisted Closure
• Skin Grafting
 Anchoring shell STAR

Winding shell

-13 patients after fasciotomy

- wound width ranged from 6 to 8
cm, averaging 7.6 cm.
-The STAR was tightened daily at
the bedside.
- Closure required 2-4 days
postplacement, averaging 2.9
days.

McKenney MG, Nir I, Fee T, Martin L, Lentz K. A simple device for closure of
fasciotomy wounds. Am J Surg 1996;172:275-7.
 Long-Term Sequelae
• Fitzgerald, et. Al in 2000  60 patients undergoing 45 leg and 15
forearm fasciotomies  primary closure 25, STSG 35

Fitzgerald AM, Gaston P, Wilson Y, Quaba A, McQueen MM. Long-term sequelae

of fasciotomy wounds. Br J Plast Surg 2000;53:690-3.
 Conclusions: Compartment
Syndrome
• Early Dx
– Pain, Tense, sensory & motor changes
– Compartment pressure
• Fasciotomy
– Clinical of CS
– Compartment pressure > 30-35 mmHg
– Prophylactic in high risk patients
• Prevention and treatment of Reperfusion
Injury
 References
• Dente CJ, Wyrzykowski AD, Feliciano DV.,
Fasciotomy. Curr Probl Surg. 2009
Oct;46(10):779-839.
• Asensio JA, Trunkey DD, editors. Current
therapy of trauma and surgical critical care.
Philadelphia: Mosby Elsevier; 2007