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Compartment Syndrome

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Piyumal Fernando
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13 views23 pages

Compartment Syndrome

Uploaded by

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

Syndrome
Case Scenario
Patient: A 25-year-old male
History: The patient was involved in a motorcycle accident, resulting in a high-impact collision with a stationary
object. He was wearing protective gear, but his right leg was trapped under the bike, sustaining significant trauma.
Presentation: The patient was brought to the emergency department with complaints of severe pain in the right
leg. On arrival, the leg appeared swollen and tight, with a large bruise over the anterior compartment. He rated the
pain as 10/10, describing it as deep, constant, and worsening despite intravenous analgesics. The pain increased
significantly with passive stretching of the toes.
Physical Examination:
Swelling: Marked swelling and tense anterior compartment of the right leg
Pain: Excruciating pain disproportionate to the visible injury
Sensation: Numbness in the foot, especially over the dorsum
Motor function: Weakness in dorsiflexion
Pulses: Palpable, but the foot appeared cool to touch
Investigations:
X-ray: No fractures
What is a
Compartment
Closed area of muscles , nerves
and blood vessels surrounded by
fascia.

Ex: Leg – Anterior, lateral, deep


posterior and superficial posterior
compartments

Normal pressure within a


compartment is less than
10mmHg
What is compartment syndrome

 An elevation of the interstitial pressure in a


closed osseofascial compartment that results in
microvascular compromise.
 Compartment syndrome may occur anywhere that skeletal muscles are
surrounded by fascia .
 But most commonly
 Leg- Anterior compartment
 Thigh
 Hand
 Foot
 Shoulder
 Buttocks
 Paraspinous muscles
Acute compartment syndrome
 Medical emergency
 Caused by a severe injury
 Leads to permanent muscle damage

Acute and Chronic compartment syndrome


Chronic  Known as exertional compartment
Compartment syndrome
Syndrome
 Not a medical emergency
 Most often caused by athlete exertion
 Reversible with rest
Pathophysiology of
Acute
Compartment
Syndrome
 Other causes for increased ICP
 External compression - with casts
 Decrease in the size of compartment
Viscious Cycle
Limb
1)Fractures
High risk injuries– Proximal one third tibia , fracture of elbow and forearm
bones ,multiple fractures of hand and foot
Most commonly occurs in closed fractures
But open fractures can also lead to compartment syndrome
2)Vascular
Haemorrhage
Ischaemia reperfusion injury
3)Soft tissue injury
Contusions – compression
Aetiology Crush injury – tissue oedema
Severe circumferential burn – tissue oedema
4)Iatrogenic
External compression by cast
Massive IV fluids
5)Haemophilia or people on anticoagulation therapy
Abdominal
1) Trauma – blunt / penetrating
2) Haemorrhage
3) Post operative
4)Ruptured AAA
Signs and symptoms
 6 Ps
1. Pain out of proportion (10/10) – Usually the first symptom
2. Paresthesia
3. Pallor
4. Pulselessness
5. Poikilothermia
6. Paralysis

 Tense ,swollen compartment


 Pain on passive stretching –When toes or fingers are passively extended ,increased pain in the
calf or forearm
 However ischaemia occurs at the capillary level. So pulses can be still felt and skin may not be
pale.
Diagnosis
 Mainly a clinical diagnosis
 Suspect in a patient with relevant aetiological history and any of the 6P symptoms
 Passive stretching of the affected muscle will cause extreme pain – diagnostic of
compartment syndrome
 ICP measurement only used for diagnosis in the unconscious patients where the
classic signs of extreme pain on passive stretching can not be elicited
 ICP > 30mmHg is suggestive of compartment syndrome
How to measure
Intracompartment
pressure
 ICP is measured with a manometer
 That detects Intracompartmental pressure by
measuring the resistance that is present when a
saline solution is injected into the compartment.

Indications
 Polytrauma patients
 Unconscious patients
 Inconclusive physical findings

Technique
 Should be performed within 5cm of fracture site
Complications

 Loss of function
 Necrosis and gangrene of affected limb
results in amputation
 Rhabdomyolysis
 Irreversible nerve damage
 Volkmann’s ischaemic contracture
 Infections
Volkman’s Ischaemic Contracture

 Irreversible muscle contractures in the forearm ,wrist and


hand that result from muscle necrosis
 Contracture positioning
• Elbow flexion
• Forearm pronation
• Wrist flexion
• Thumb adduction
• MCP joints extension
• IP joints flexion
Treatment

 Definitive treatment
 Urgent decompression by fasciotomy
 Should be done as soon as possible to minimize complications

 Bi-valving the cast and loosening the dressings –Full extent , upto skin
 Limb should be nursed flat – Elevation of limb can aggregate the ischaemia
Fasciotomy
of Leg
Double incision fasciotomy
• Anterolateral incision
decompresses anterior and
lateral compartment
• Posteromedial incision
decompresses superficial and
deep posterior compartments

Single incision fasciotomy


• Single lateral incision from
head of fibula to ankle along
line of fibula
• All four compartments are
released
Fasciotomy
of Forearm
 Emergent fasciotomy of all
involved compartments
 Volar incision
Decompresses volar
compartment and carpal
tunnel
 Dorsal incision
Decompresses dorsal
and lateral compartments
Fasciotomy of Hand

 There are ten separated osseofascial compartments in the hand


• Hypothenar
• Thenar
• Adductor policis
• 4 Dorsal interosseous
• 3 Palmer interosseous
Technique
 Four total incisions
 Two longitudinal incisions over 2nd and 4th
metacarpals
Decompress volar and dorsal
interosseous and adductor compartments

 Longitudinal incision radial side of 1st


metacarpal
Decompresses thenar compartment

 Longitudinal incision over ulnar side of 5th


metacarpal
Decompresses hypothenar compartment
Fasciotomy Wound Closure

 Early wound closure is not recommended.


 Once fasciotomy has been performed the skin incision is left open for 2 days .
 This is to assess for any dead tissue that need to be debrided . If the remaining
tissues are healthy, the wound can then be closed.
Conclusion

 Acute compartment syndrome is a medical emergency.


 Palpable pulse doesn't exclude compartment syndrome.
 If diagnosis and fasciotomy is done within 24 hours, prognosis is good.
 If delayed, complications may develop.
References

 Alley’s and Solomon’s Concise System of Orthopaedics and Trauma


 ATLS
 Orthobullets site
Thank you

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