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Compartment Syndrome

This document provides information about compartment syndrome, including its history, definition, sites, mechanisms, pathophysiology, risk factors, diagnosis, management, and complications. Compartment syndrome is a condition caused by increased pressure within an enclosed osteofascial space that reduces blood flow. It can affect the upper and lower extremities. Surgical fasciotomy is the primary treatment when compartment syndrome is diagnosed and involves releasing the fascial compartments to reduce pressure. Early diagnosis and treatment are important to prevent serious complications like contractures, infection, and amputation.

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Manoj Bhatta
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27 views53 pages

Compartment Syndrome

This document provides information about compartment syndrome, including its history, definition, sites, mechanisms, pathophysiology, risk factors, diagnosis, management, and complications. Compartment syndrome is a condition caused by increased pressure within an enclosed osteofascial space that reduces blood flow. It can affect the upper and lower extremities. Surgical fasciotomy is the primary treatment when compartment syndrome is diagnosed and involves releasing the fascial compartments to reduce pressure. Early diagnosis and treatment are important to prevent serious complications like contractures, infection, and amputation.

Uploaded by

Manoj Bhatta
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Dr.

Niraj Ranjeet
Asso. Professor- Dept of Orthopedics
Fellow – Ilizarov Surgery
Fellow – Hand Surgery
History

 Volkmann 1881 (described)


 Petersen 1888 (treatment)
 Hildenbrand 1906 (ischaemic contracture)
 Rowlands 1910 (reperfusion)
 Murphy 1914 (fasciotomy)
 WW2 (arterial spasm)
 Kelly & Whitesides (1967) 4 Compartment Leg
 McQueen & Court-Brown (1990’s)
Definition:
Increased pressure within an enclosed
osteofascial space that reduces the
capillary blood perfusion below a level
necessary for tissue viability.

Bruce et al
Rockwoods and Green: Fractures in adults 5th Edition
331-351
Sites:
 upper extremity
 shoulder
upper humeral areas
forearm
hand
 Lower extremity
buttock
 thigh
 leg
 foot
Mechanism:

↑ in volume within an ↓ in size of the space


enclosed space  Too tight cast
 Haemorrhage  Constrictive dressing
 Trauma  Pneumatic antishock
○ Fractures garment
○ Crush  Closure of fascial defect
 Post-ischaemic swelling
 Reperfusion
 A-V fistula (Dialysis)
Pathophysiology:

↑ tissue pressure > intramuscular arteriolar pressure

↓capillary blood flow

Microcirculatory ischaemia
TIME

Necrosis of tissue within compartment


Pathophysiology:

Injury
Swelling

Blood Muscle
Supply Ischaemia
WHO IS AT RISK ???

Mc Queen et al
J Bone Joint Surg [Br] 2000;82-B:200-3.
Mc Queen et al
J Bone Joint Surg [Br] 2000;82-B:200-3.
Mc Queen et al
J Bone Joint Surg [Br] 2000;82-B:200-3.
 most important determinant of a poor outcome
from acute compartment syndrome after injury
is delay in diagnosis
Diagnosis:
 made from a constellation of clinical findings

 High degree of suspicion


Diagnosis:
5 P's
Pain
Pulselessness
Pallor
Paresthesias
Paralysis
Diagnosis:
Pain:
 Excessive
 Not relieved by usual dose of analgesics
 Stretch test:
 Earliest & most sensitive clinical finding in a developing
compartment syndrome
 passively stretching the muscles in opposite direction
Diagnosis:
 Delay in diagnosis is often due either to
 inexperience
 lack of suspicion
 indefinite and confusing clinical presentation

 Delay in treatment can be catastrophic


 Contracture
 Infection
 Myoglobinuria and Renal failure
 Amputation
Diagnosis:
Compartment Pressure Measurements
 direct compartment pressure measurement
reaches 40 mm Hg

 Differential pressures ≤ 30 mm Hg
(Diastolic BP– Compartment Pressure)

Whitesides et al
Acute compartment syndrome: update on diagnosis and treatment
J Am Acad Orthop Surg 1996;4:209–218
How to Measure Compartment Pressure ?????

 4 techniques:
 Whitesides infusion technique
 Stic technique
 Wick catheter
 Slit catheter technique
Diagnosis:
Compartment Pressure Measurements
 Whitesides infusion technique
Diagnosis:
Compartment Pressure Measurements

 Stic technique
○ easily equilibrated,
○ measurements are made directly from a scale on the
device.
○ very portable
○ relatively inexpensive
The area to be tested is cleaned with betadine.
Device is held parallel with the floor….
The syringe is filled with fluid…
and then zeroed
After introducing the needle through the fascia, the plunger is
gently advanced to cause inflow of a small amount of fluid and
the pressure is allowed to equilibrate.
The patient’s diastolic BP = 74 mmHg
Measurement = 66
(74 - 66 = 8)
Thus a compartment syndrome is diagnosed
Management
 Precaution
 Surgical decompression
Precautions:
 cast - bivalved
 remove - all external compression
 safe tourniquet time
 1½ hours, followed by decompression of
the tourniquet for a 5- 7-minute interval,
followed by reinflation for another 1½ hours.
Surgical decompression
 common areas
forearm
hand
lower leg
foot
Surgical decompression: Forearm
 3 compartments
 Carpal tunnel
 Median nerve at
lacertus fibrosis
proximal edge of
the pronator teres
proximal arch of
FDS
Surgical decompression: Hand
 4 dorsal interosseous
 3 palmar interosseous
 adductor compartments
 Hypothenar
 Thenar
Surgical decompression: Hand
Surgical decompression: Leg
INCISION

Location of incision - just anterior to the fibula.


After the skin and subcutaneous tissue is incised, care is taken
to spread and cut only which is visible above the fascia.
ANTERIOR
COMPARTMENT FASCIA

After release of the subcutaneous tissue,


the anterior compartment fascia is released.
EDGES OF RELEASED ANTERIOR
COMPARTMENT FASCIA

The stripping above the anterior compartment fascia visualized


SUPERFICIAL PERONEAL NERVE

Care must be taken when releasing the fascia not to damage the
superficial peroneal nerve.
SUPERFICIAL PERONEAL NERVE

…and in the distal part of the wound.


FASCIA OF LATERAL
COMPARTMENT

Retraction of the superficial tissue demonstrates


the lateral compartment fascia.
A knife or Metzenbaum scissors can be used to
release the lateral compartment fascia.
Appearance after anterior and lateral compartment release.
SUPERFICIAL POSTERIOR
COMPARTMENT

Further dissection, allows for release of the deep posterior fascia


through this incision as well.
Double-Incision
Fasciotomy

 anterolateral approach
utilized to decompress the anterior and lateral
compartments
incision is positioned halfway between the fibular shaft
and the tibial crest
 posteromedial approach
utilized to decompress the superficial and deep posterior
compartments
2 cm posterior to the posterior tibial margin
Deompression of foot:
 medial, central, lateral, interosseous,
calcaneal
Skin closure:
 depend on the severity and cause

 Majority: closed in 5 days by undermining


the skin flaps

 By 10 days, if the skin is not easily closed


secondarily, STSG should be applied
Closure:

shoe-lace technique of skin closure


allow gradual closure of the skin over several days
size of the skin graft may be decreased / avoided
secondary closure accomplished
When to do fasciotomy ?
 Differential pressure ≤ 30 mm Hg
 worsening clinical condition
 documented rising tissue pressure
 significant tissue injury
 history of 6 hours of total ischemia of an
extremity
Take home message……
 Know your patient at risk………
 High degree of clinical suspicion……
 Early fasciotomy………
Complications:
 RSD
 Amputation
 Infection
Thank you for your patience……..

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