Acute

Compartment
Syndrome
Marc Hirner

Demographics

Incidence:
Men
Women

7.3/100,000
0.7/100,000

69% due to trauma

36% fx tibia
9.8% distal radius
23% soft tissue injury without fx

10% on anticoagulants

Case 1

Patient with ? Trivial knee injury

Seen in ED and admitted
Registrar to ward , pulseless limb
Was in fact a knee dislocation that
reduced spontaneously
End result popliteal artery repair ,
fasciotomy , ligament reconstruction
and eventual BKA

Case 2

Simple fibula fracture

Referred to White Cross several days
after injury with tight swollen calf
Diagnosed acute compartment
syndrome 5 days late
Fasciotomy of no use as muscles
necrotic

Case 3

Child required IV access so the tibia

was used for rapid infusion
Fluid into the calf
Acute compartment syndrome
Orthopaedics notified late
Fasciotomy no use as muscles necrotic

Etiology

Pathophysiology
Increased compartment pressure
Increased venous pressure
Decrease A-V gradient resulting
in muscle and nerve ischemia.

Diagnosis

History
Clinical exam: the Ps
Compartment pressures
Laboratory tests
CPK
Urine myoglobin

Clinical Diagnosis

The six Ps:

Pressure
Pain
Paresthesia
Paralysis
Pallor
Pulselessness

Pressure

Early finding

Only objective finding

Refers to palpation of compartment

and its tension or firmness

Pain

Out of portion to injury

Exaggerated with passive stretch

Earliest symptom but inconsistent

Not available in obtunded patient

Paresthesia

Early sign
Peripheral nerve tissue is more sensitive
than muscle to ischemia
Permanent damage may occur in 75 minutes

Difficult to interpret

Will progress to anesthesia if pressure

not relieved

Paralysis

Very late finding

Irreversible nerve and muscle damage

present

Paresis may be present early

Difficult to evaluate because of pain

Pallor & Pulselessness

Rarely present

Indicates direct damage to vessels

rather than compartment syndrome

Vascular injury more of contributing

factor to syndrome rather than
result

Compartment Pressure

When

Confirm clinical exam

Obtunded patient with tight compartments
Regional anesthetic
Vascular injury

Technique

Whiteside infusion
Stic technique: side port needle
Wick catheter
Slit catheter

Stryker Stic System

Easy to use
Can check multiple compartments
Different areas in one compartment

Distance From Fracture

Effects Pressure

What is Critical
Pressure?

>30 mm Hg as absolute number

(Roraback)

Treatment

Lower leg to level of the heart

Remove cast

Split all dressings down to skin

Treatment
If concerned refer these patients early

Fasciotomy if continued clinical

findings and/or elevated
compartment pressure

Treatment

Wound Care

Soft tissue coverage by 5-7 days

Delayed closure

Vascular loop lace technique

Split thickness skin graft

Flaps or free tissue transfer

NO ONE EVER BLAMES US FOR

DOING A FASCIOTOMY BUT
MISSING COMPARTMENT
SYDROME IS A DISASTER