Acute Compartment Syndrome

in Extremities
Diagnostic and Management

Nucki N. Hidajat
Department of Orthopedic & Traumatology
Medical Faculty Padjadjaran University
Dr Hasan Sadikin General Hospital.
 Introduction

 Acute

 Compartment
Closed anatomic space bound
by relatively rigid walls of bone
and fascia

 Syndrome

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 Osseofascial compartment

Thigh 3 Osseofascial compartment

Cruris 4 Osseofascial compartment
Forearm 3 Osseofascial compartment
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 Introduction
 Acute Compartment
Syndrome (ACS) is a
potentially devastating
condition in which the
pressure within an
osseofascial compartment
rises to a level that decreases
the perfusion gradient across
tissue capillary beds, leading
to cellular anoxia, muscle
ischemia and death

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 ACUTE COMPARTMENT SYNDROME

Incidence

• 45% ACS caused by tibial fx

• 23% ACS caused by soft tissue injury

•16% ACS caused forearm fx

• Tibial fx : 1 – 10% develop ACS

• Close tibial fx : 1,5 – 29%

• Open tibial fx : 1,2 – 10,2%

• Vascular injury : - 19 – 30% develop ACS

• - other ref. 0 – 21%

 Incidence
 7.3 per 100.000 in men ( 30 years old)
 0.7 per 100.000 in women ( 44 years old)
 1,2 % of patients with Closed Tibia
fractures developed CS
 Mc Quenn et al: studied 164 pts with ACS
• 69 % was fractured, 36 % Tibial diaphyses; 9,8 %
Distal radius
• 23.2 % Soft tissue injury (fracture - ), 10 % pts
taking anticoagulants or bleeding disorder
• High or Low energy was equal

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 Why Important !!!!!!

 Timely Diagnosis & Management

 The medical-legal aspects !!

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 Outcomes
ACS underwent fasciotomy
 Sheridan and Matsen 1)
 Clinical outcomes of 44 pts
 Before 12 hours 68 % had normal lower
extremity function
 After 12 hours 8%
 Finkelstein et al.2)
 Reported 5 pts underwent fasciotomy after 35
hours
 One died directly related MOF
 Four pts required amputation
1) Sheridan GW, Matsen FA: Fasciotomy in the treatment of the acute compartment
syndrome. JBJS Am, 1976;58:112-115.
2) Finkelstein JA, Hunter GA, Hu RW: Lower limb compartment syndrome: Course
after delayed fasciotomy. J Trauma 1996; 40:342-344
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Pathophysiology
of Ischemia

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Causes of Compartment Syndrome
 Fracture
 Soft-tissue trauma without fracture
 Intracompartmental bleeding
 Extravasations of intravenous infusion
 Venous obstruction
 Reperfusion injury following prolonged
ischemia
 Snake envenomation
 Penetrating trauma
 Tight casts, dressings, or external wrappings
 Thermal injury, burn eschar

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 Diagnostic
 Patient history
 Associated risk factors
 The classic clinical diagnosis
Six Ps
1. Pain
2. Pressure
3. Pulselessness
4. Paralysis
5. Paresthesia
6. Pallor

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 Pain
In Patient alert and cooperative:
 One of the earliest
 Most sensitive clinical sign
 Pain out of proportion to the injury
 Aggravated by Passive stretching of muscle
group
• Pain perception may diminished or absent in the
Obtunded patient
• Superimposed by central or Peripheral neural deficit
• Pain will  after pressure induced ischemia affects
conductivity of nerves  painless state !
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 Pressure
 Pressure or firmness in the compartment
 Direct manifestation of increased intra-
compartment pressure

Pulselessness
• Peripheral pulses are palpable, unless a major
arterial injury is present
• Collateral artery
• Rarely in the compartment pressure elevated
sufficiently to occlude arterial pressure
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  Paresthesia
Early sign of CS that, without treatment
Progresses to hypoesthesia and
anesthesia
First indication of nerve ischemia

 Paralysis
A late finding
Caused by prolonged nerve compression
or irreversible muscle damage

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Compartment Pressure Measurement
Indications for Compartment Pressure Measurement
 One or more symptoms of compartment syndrome with confounding
factors (eg, neurological injury, regional anesthesia, under medication)

 No symptoms other than increased firmness or swelling in the limb in an

awake, alert patient receiving regional anesthesia for postoperative pain
control

 Unreliable or unobtainable examination with firmness or swelling in the

injured extremity

 Prolonged hypotension and a swollen extremity with equivocal firmness

 Spontaneous increase in pain in the limb after receiving adequate pain

control

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 ACUTE COMPARTMENT SYNDROME

Diagnosis
Direct ICP measurement / objective method
1/. Injection/infusion technique (Whitesides) 
equipment in expensive and readily available
in most hospitals, emergency rooms  NOT accurate
2/. Wick catheter (Mubarak)
3/. Slit catheter (Rorabeck)
4/. Solid state transducer intracomp catheter (STIC)
1 – 4 : Fluid filled system
5/. Fiber optic transducer tipped  very expensive
6/. Latest device : Electronic Transducer Tipped Catheter
 best device
 The measurement
devices

 Δ P value of 30 mm Hg to
diastolic blood pressure is
an absolute indicator for
fasciotomy

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 Location inserted needle within 5 cm
of the level injury

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 ACUTE COMPARTMENT SYNDROME

Interpretation of ICP measurement

 Absolute : 30 mm Hg as cut off point

for fasciotomy
 Differential Pressure (Whitesides) :
“Delta Pressure”  Diastolic BP minus ICP
cut off point < 30 mm Hg
 Many UNNECESSARY fasciotomies can be
avoided
 Laboratory tests
 Serum Creatinine Phosphokinase (CK)
 Determine level of muscle necrosis
 High CK level should alert the physician to possible
rhabdomyolysis
 Decompression should result in downward trend of
CK
 Renal function
 Blood Urea Nitrogen (BUN) & creaetinine are
measured
 Potassium level
 Urinalysis
 Evidenced by myoglobinuria
 Can be misinterpreted as hematuria
 For Occult blood use urine Benzedrine test

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 Management : Medical therapy
 Place the affected limbs at the level of the
heart
 Elevation is contraindicated because
decreased arterial flow & narrows the arterial
venous pressure
 Releasing the cast
 Correct hypo-perfusion with crystalloid and
blood products
 In case of snake envenomation, administration
of antivenom

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 Management : Surgical therapy
 The definitive surgical
therapy is Emergent
Fasciotomy
 Within 6 hours
 One or two incisions
 Subsequent :
 Fracture stabilization
 Vascular repair if needed

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 One incision

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 Two incisions

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 ACUTE COMPARTMENT SYNDROME

Complication
 Volkmann contracture : 1 – 10% of all cases
of ACS
 Infection : Matsen in late cases surgical
decomp. 11/24 cases develop infection
 5 cases need AMPUTATION
 Hypesthesia / Painful dysesthesia
 Systemic : Acute Renal Failure, sepsis,
Acute Resp Distress Syndrome (ARDS)
 Upper extremity

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 Post Operative care
 Monitor haemodynamic status and maintain
adequate blood pressure
 If rhabdomyolysis occurs,
 continue hydration
 monitor urine output and
 kidney function
 Potassium status closely
 Re-dress wound daily
 IV lines adequate Antibiotic
 Delayed primary suture or STSG within 7 days

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 Complication

 Volkmann contracture : 1 – 10% of all cases

of ACS
 Infection : Matsen in late cases surgical
decomp. 11/24 cases develop infection
 5 cases need AMPUTATION
 Hypoesthesia / Painful dysesthesia
 Systemic : Acute Renal Failure, sepsis,
Acute Resp Distress Syndrome (ARDS)

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 Conclusions

 Acute Compartment Syndrome is true

emergency case

 Timely diagnose and management

 Clinical diagnose quite simple & easy

 Surgical treatment within 6-8 hours

 Delayed treatment caused high morbidity and

mortality

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Question
 Be persistent
Look for hapiness in every day
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