COMPARTME

NT
SYNDROME
MODERATOR: Dr. RAVIKUMAR H.S.
CHAIR PERSON: Dr. MANJAPPA C N
AND
Dr. MAHENDRA KUMAR K L

PRESENTER: Dr. ROOPESH SATHAPADI

EXAMPLES
 Ramanna 60y/m, MLC, Self fall at working
place with RIGHT PROXIMAL TIBIA
FRACTURE.
Complaining of pain over the right leg ,3 days
after applying of Above Knee slab.
 DEFINITION
 Compartment Syndrome is an
elevation of Interstitial Pressure in
closed Osteofascial Compartment that
results in Microvascular Compromise.

 It is a true orthopedic emergency

 WHAT IS
COMPARTMENT??
 Compartments are groups of muscles
surrounded by in-elastic fascia.
 AETIOLOGY:
 REDUCED COMPARTMENT SIZE:- Tight
dressing:- bandage or cast localised external
pressure, lying on limb closure of facial
defects.

 INCREASED COMPARTMENT SIZE:-

Bleeding:- fracture , vascular injury , bleeding
dis-orders. Increased capillary permeability:-
ischemia/trauma/burns/exercise/snake
bite/drug injection.
 FRACTURE being the first most common
cause.
 The incidence is directly proportional to

the degree of injury to soft tissue and

bone.
 Most common in low energy injury(lack of

compartment disruption)

 Most common fracture leading to Acute

compartment syndrome:-
1) Tibial diaphysial fracture
2) Distal radius fracture
3) Forearm fractures
Second most common
cause:-
Blunt trauma
TYPES OF COMPARTMENT
SYNDROME :
 Acute Compartment Syndrome :
a. Caused by severe injury/trauma.
b. Acute Exertional compartment Syndrome have
been reported in foot in runners, Basketball
players and other athelets.
Chronic Exertional Compartment
Syndrome :
a. It is recurrence of increased pressure seen most
often in Anterior and deep posterior Compartment of
leg.
b.Also been reported in forearm in weight
lifters,welders.
AREAS INVOLVED:
 Anterior&Posterior Compartment of leg
MOST
 Volar compartment of Forearm
COMMON

 Compartment Syndrome can develop anywhere

Skeletal muscle is surrounded by substantial
fascia such as buttock, thigh,
shoulder,hand,foot,arm &lumbar Paraspinous
muscles.
PATHOPHYSIOLOGY
Normal tissue pressure:- .0-
4mmhg
8-10mmhg with exertion.
 Tissue Necrosis occurs in normal blood flow if intra
compartmental pressure exceeds 30mm Hg for
longer than 8hrs.

Insult to normal local local tissue

tissue homeostasis necrosis

oxygen

deprivation
Increased
Tissue Pressure decreased
TISSUE SURVIVAL:
 Muscle: 3 to 4hours - reversible changes
6 hours - variable damage
8 hours - irreversible changes
 Nerve : 2 hours –looses nerve conduction

4 hours – neuropraxia
8 hours – irreversible change

Delayed diagnosis : Permanent sensory

and motor deficit,
contractures
Infections
Amputations
INCIDENCE :
TYPES OF % OF ACUTE INCIDENCE INCIDE
FRACTURE COMPARTMENT IN ALL AGES NCE <
SYNDROME 35
YEARS
TIBIAL 36% 4.3% 5.9%
DIAPHYSIS (3FOLD)

DISTAL 9.8% 0.25% 1.4%

RADIUS (30
FOLD)
FOREARM 7.9% 3.1% 3.2%
DIAPHYSIS
CLINICAL FEATURES :
 Swelling and tightness(TENSE) compartment
involved.
 Severe pain on passive stretching

 Pain out of proportion to injury

 Pallor/Cyanosis

 Hyperaesthesia/Paraesthesia

 Paralysis

 Pulselessness
HOW DO WE DIAGNOSE?
 Pulse oximeter:-
 pulse oximeter is helpful in identifying limb

hypoperfusion.
 But is not sensitive enough to exclude

compartment pressure.
Others:-
 Compartment pressure monitoring, lab

investigations like
CPK, Urine myoglobulin estimation.
CLINICAL PARAMETERS:
 PAIN:
First symptom
Earliest but inconsistent, minimal in deep
post compartment
Not seen in obtunded patient
PRESSURE:
Early and only objective finding.
PARESTESIA:
Also Early sign
Peripheral nerve tissue is more sensitive than
muscle to ischemia
Permanent damage may occur in 75 minutes
Will progress to anaesthesia if pressure not
PARALYSIS:
* Very late finding
*Irreversible nerve and muscle damage present
*Paresis may present early
*If motor deficit develops, full recovery is rare.

PALLOR AND PULSELESSNESS:

*Rarely present
*Indicate direct damage to vessels rather than
compartment syndrome.
COMPARTMENT
PRESSURE MONITORING:
 In case of suspected compartment
syndrome.
 Pt on ventilator.

 Obtunded pt with tight compartments.

 Regional anesthesia.

 Vascular injury.

 Alcoholics,drug addicts.
DEVICES USED FOR
MEASUREMENT OF
COMPARTMENT PRESSURE:
Newer Non Invasive methods:
 1.Ultrasonography(sensitivity-

77%,specificity-93%)
 2.Infrared Imaging
ACUTE COMPARTMENT
SYNDROME OF THIGH
 Less frequent than lower leg and forearm.
 But associated with high level of morbidity.

Most common causes:

 .Blunt trauma(with or with out fracture)

 .Vascular injury

 .Torniquet(lower leg surgery)

 .Quadriceps tendon rupture

 .Heterotopic ossification
 Most common compartment syndrome of
thigh is ANTERIOR compartment because it is
surrounded by stiffest walls laterally and
medially(fascia lata and illiotibial tract).
TREATMENT OF
COMPARTMENT SYNDROME
OF THIGH:
 In Isolated limb injury, splitting of cast and
underlying padding can decrease compartment
pressure by 50-85%.
 Removal of circular constrictive bandages.
 Positioning of the limb at heart level produces the
highest arterio-venous gradient.
 If symptoms won’t resolve within 30 to 60min
after
appropriate treatment, pressure measurement
should
be repeated.
 If results are equivocal FASCIOTOMY is
indicated.
Fasciotomy:-
Good prognosis: Fasciotomy done in 25 to
30hrs Bad prognosis: delayed diagnosis,
3rd or 4th day
INDICATIONS OF FASCIOTOMY:

1.compartment pressure >30mmhg

2.Arterial disruption for more than 4hrs
3.Compartment syndrome associated with
fracture
should be treated at the time of reduction.
ACUTE COMPARTMENT
SYNDROME OF LEG:
 Associated with
tibial fractures(36%)- first most common

 soft tissue injury due to blunt trauma-

Second most common
TWO TECHNIQUES FOR RELEASE
OF
COMPARTMENT OF LOWER LEG:-
 Single incision perifibular fasciotomy
(useful if soft tissue of the limb is not
extensively distorted)
 Double incision fasciotomy (safer,more

effective)
SINGLE INCISION
FASCIOTOMY:-
 DAVEY,RORABECK AND
FOWLER TECHNIQUE :-
 A. lateral skin incision from fibular neck to 3

to 4cm proximal to lateral malleolus.

 B. Skin is undermined anteriorly and

fasciotomy of anterior and lateral

compartments performed.
 C. Skin is undermined posteriorly and

fasciotomy of superficial posterior

compartment is performed.
 D.Interval between superficial posteriorand

lateral compartment is develop

CHRONIC EXERTIONAL COMPARTMENT
SYNDROME:
 reversible ischemia secondary to a non
compliant osteofascial compartment that is
unresponsive to expansion of muscle volume
that occurs with exercise.
 Muscle volume can increase upto 20% of its

resting size during exercise.

ETIOLOGY:
 Rear foot landing,over pronation
 Muscle hypertrophy

 Anabolic steroid and creatine use also

increase muscle volume

 Recreational runners

 Elite athletes

 Military recruits

 Anterior and posterior compartments are

most
commonly effected,and symptoms are bilateral
in
75% of patients.
DIFFERENTIAL DIAGNOSIS
CHRONIC EXERTIONAL
COMPARTMENT SYNDROME:
 Medial tibial stress syndrome (shin splints)
 Stress fracture
 Tenosynovitis
 Periostitis
 Dvt
 Nerve entrapment syndrome
 Lumbosacral radiculopathy
 Neurogenic claudication
 Popliteal artery entrapment syndrome
 Vascular claudication
 Infection
 Myopathy
 tumors
DIAGNOSTIC CRITERIA OF CHRONIC
EXERTIONAL COMPARTMENT SYNDROME:-
 Pre-excercise resting pressure of 15mmhg or
more.
 Pressure of 30mmhg or more 1 minute after

exercise.
 Pressure of 20mmhg or more 5 minutes after

exercise.
 Post exercise MRI

 Near Infrared spectroscopy

 Triple phase bone scan

 Methoxyisobutyl isonitrile(MIBI) perfusion

imaging
 Tallous chloride scintigraphy
TREATMENT FOR CHRONIC EXERTIONAL
COMPARTMENT SYNDROME:

 Non operative
 Operative
NON OPERATIVE:

  Rest
  Anti inflamatory medications

  Manual therapy

  Streching and strengthening of involved

muscles
  Orthotics

  If symtoms persists,pressures extremely

elevated,or
 athlete desired to continue activity at same

level
 fasciotomy of involved compartment indicate
OPERATIVE PROCEDURES
 Anterior compartent fasciotomy (80-90%
success rate).
 Deep posterior compartment fasciotomy

(50-70%).
 Types: 1.Double-Mini Incision Fasciotomy for

chronic anterior compartment syndrome.

 2.Single-Incision Fasciotomy for chronic

anterior and lateral compartment syndrome.

 3.Double-Incision Fasciotomy for chronic

posterior compartment syndrome

Dorsal – extensor hallucis brevis
extensor digitorum brevis
Plantar – 1st layer
Abductor hallucis
Flexor digitorum brevis
Abductor digiti minimi
2nd layer
Quadratus plantae
Lumbricles muscle
3rd layer
Flexor hallucis brevis
Adductor hallucis
Flexor digiti minimi brevis
4th layer
dorsal interossei
plantar interossei
COMPARTMENT SYNDROME OF
FOREARM:
 Anatomy :-
4 compartments of foream
 1.The Superficial volar compartment.

 2.The Deep volar compartment.

 3.The Dorsal compartment.

 4.The compartment containing mobile wad of

Henry(brachioradialis, extensor carpi radialis

longus and brevis)
 In hand each interosseous muscle is
surrounded by a tough investing fascial layer
 Each making an individual compartment as

shown by injection dissections of Halpern and

Mochizuki.
 The adductor pollicis muscle and thenar and

hypothenar muscles form 3 separate

compartments.
 Thenar compartment:
Abductor pollicis brevis
Flexor pollicis brevis
Oppenens pollicis
Adductor pollicis
 Hypothenar compartment:
Abductor digiti minimi
Flexor digiti minimi brevis
Opponens digiti minimi
ETIOLOGY
 Fractures (18%)
 Soft tissue injuries (23%)

 Distal radial fractures (0.3%)

 Ipsilateral Elbow injuries (15%)

 In children;supracondylar fractures

most frequent
 After intramedullary fixation of forearm in

children
 Chronic exertional compartment synd. Of 1st

dorsal interisseous muscle and volar muscles

seen in motorcyclists.
 Any situation that causes a decrease in
compartment size or increase in
compartment
pressure can initiate compartment
syndrome.
 Muscle necrosis occur with a rise in pressure

to
Within 20mm below diastolic pressure
DIAGNOSIS
 Volar and dorsal forearm is tender and tense with
swelling.
 Sensibility of finger tips is diminished.

 Two-point discrimination and 256cycles/vibratory

testing can be helful in determining Nerve Ischemia.

 Compartment syndrome in a neonate may

manifest as sentinel bullous or ulcerative skin

lesion over dorsum of the forearm,wrist,hand.
 Compartment pressure over 30mmhg or with in

20mmhg of the diastolic pressure are indicative of

compartment syndrome
MANAGEMENT :
 Fasciotomy should be performed in
 1.normotensive patient with positive clinical

findings and compartment pressure >30mmhg

 2.duration >8hrs

 3.uncooperative or unconscious patients

with
pressure >30mmhg
 4.patients with low blood pressure and

compartment pressure >20mmhg

COMPLICATIONS OF COMPARMENT
SYNDROME:

 Volkmann ischemic contracture

 Rhabdomyolysis

 Acute renal failure