COMPARTMENT SYNDROME

BASSEY, A E M.B, B.S

OUTLINE
INTRODUCTION
 DEFINITION
 STATEMENT OF IMPORTANCE
 EPIDEMIOLOGY
 CLASSIFICATION
 AETIOLOGY
 RELEVANT ANATOMY
 PATHOPHYSIOLOGY
 CLINICAL MANIFESTATION
 HISTORY
 EXAMINATION
 MANAGEMENT
 RESUSCITATION
 INVESTIGATION
 DEFINITIVE TREATMENT
 REHABILITATION
 COMPLICATIONS
 PROGNOSIS
 CURRENT TRENDS
 CONCLUSION
INTRODUCTION
INTRODUCTION
 COMPARTMENT SYNDROME IS A POTENTIALLY
LIFE-THREATENING CONDITION RESULTING
FROM INCREASED PRESSURE WITHIN A CONFINED
BODY SPACE, USUALLY A LEG OR FOREARM

 THIS CONDITION WITHOUT INTERVENTION

LEADS TO LOSS OF LIMB OR EVEN LIFE UNLESS
EARLY DIAGNOSIS IS MADE AND TREATMENT
INSTITUTED. IT IS IMPERATIVE FOR TODAY’S
PHYSICIAN TO HAVE ADEQUATE
UNDERSTANDING OF THIS REMEDIABLE MALADY,
MORESO WITH INCREASING INCIDENCE OF
TRAUMA DUE TO ROAD TRAFFIC INJURY,
TERRORIST ATTACKS & COLLAPSING BUILDINGS
EPIDEMIOLOGY
EPIDEMIOLOGY
 FRACTURES ARE RESPONSIBLE FOR 69% OF CASES
OF COMPARTMENT SYNDROME

 M>F

 THE LEG IS THE COMMONEST SITE. TIBIAL

FRACTURE IS COMMONEST CAUSE AND
ANTERIOR COMPARTMENT IS MOST FREQUENTLY
INVOLVED

 FOREARM IS 2ND COMMONEST SITE,

SUPRACONDYLAR FRACTURE IS THE
COMMONEST CAUSE WITH FLEXOR
COMPARTMENT MOST FREQUENTLY INVOLVED
CLASSIFICATION
CLASSIFICATION
 ACUTE

 CHRONIC
AETIOLOGY
AETIOLOGY
 FRACTURES
 GUNSHOT INJURY
 CRUSH INJURY
 BURNS
 IATROGENIC
 DEEP VEIN THROMBOSIS
 ENVENOMATION
 INTENSE MUSCLE ACTIVITY
 ↓ SERUM OSMOLARITY
RELEVANT ANATOMY
RELEVANT ANATOMY
RELEVANT ANATOMY
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
 NORMAL LEG COMPARTMENT
PRESSURES
 NIGERIANS : 3 – 14 mmHg
 CAUCASIANS : 0 – 15 mmHg
 PERIPHERAL INTRAVASCULAR
PRESSURES
 ARTERIES : 80 – 120 mmHg
 ARTERIOLES : 35 mmHg
 CAPILLARIES : 20 mmHg
 VENULES : 12 mmHg
 VEINS : 5 mmHg
PATHOPHYSIOLOGY
TRAUMA
↓
RISE IN INTRACOMP. PRESSURE
↓
VENOUS OBSTRUCTION + MUSCLE/NERVE
ISCHAEMIA
↓
FURTHER RISE IN COMP. PRESSURE
↓
CAPILLARY OBSTRUCTION + MYOCYTE NECROSIS
↓
ARTERIAL OBSTRUCTION
 CLINICAL
MANIFESTATION
CLINICAL MANIFESTATION
 THE 6 Ps
 HISTORY
 DISPROPORTIONATE PAIN
 FEELING OF TENSION
 PARAESTHESIA, NUMBNESS – LATE SYMPTOMS
 HX OF PRECIPITATING EVENT
 EXAMINATION
 INSPECTION : RESTLESSNESS, BULLAE, FRACTURE
BLISTERS
 PALPATION : PAIN ON PASSIVE MUSCLE STRETCH –
EARLIEST CLINICAL INDICATOR, WOODY FEELING
ON DEEP PALPATION
 DECREASED 2-POINT DISCRIMINATION –
CONSISTENT EARLY FINDING
 SENSORY/MOTOR DEFICITS, PULSELESSNESS ARE
LATE FEATURES
MANAGEMENT
MANAGEMENT
 RESUSCITATION

 INVESTIGATION:
 INTRACOMPARTMENTAL PRESSURE
MEASUREMENT – STANDARD OF DIAGNOSIS
GLOBALLY
 PCV
 URINALYSIS
 E,U & Cr
 ULTRASONOGRAPHY
 ANCILLARY INVESTIGATIONS
STRYKER PRESSURE TONOMETER
MANAGEMENT
 DEFINITIVE TREATMENT – PRINCIPLES
 REMOVE ALL CAST, DRESSINGS & BANDAGES
 BIVALVE ALONE WILL NOT SUFFICE

 RENAL PROTECTION
 IV CRYSTALLOID 500ml/hr
 IV MANNITOL 1g/Kg
 ALKALINIZE URINE

 EARLY DECOMPRESSION VIA EMERGENCY

FASCIOTOMY
MANAGEMENT - FASCIOTOMY
 INDICATIONS
 NORMOTENSIVE PATIENT WITH CLINICAL
FEATURES OF COMPARTMENT SYND. AND
COMPARTMENT PRESSURE >30mmHg
 HYPOTENSIVE PATIENT WITH COMPARTMENT
PRESSURE >20mmHg
 UNCONSCIOUS PATIENT WITH
COMPARTMENT PRESSURE >30mmHg
 OBTAIN INFORMED CONSENT
 DONE UNDER GA
 DECOMPRESSION OF
COMPARTMENTS + EXCISION OF
NECROTIC MUSCLE
DOUBLE-INCISION LEG FASCIOTOMY
FOREARM FASCIOTOMY
FASCIOTOMY – POST OP
 ELEVATE LIMB FOR 24 – 48HRS
 ANALGESIA
 ANTIBIOTICS
 DELAYED PRIMARY CLOSURE
 SPLIT-THICKNESS SKIN GRAFT IF
CLOSURE NOT POSSIBLE AFTER 5
DAYS
REHABILITATION
REHABILITATION
 PHYSICAL THERAPY

 OCCUPATIONAL THERAPY
COMPLICATIONS
COMPLICATIONS
 EARLY
 ACUTE RENAL FAILURE
 MUSCLE INFARCTION
 SEPSIS
 LATE
 VOLKMANN ISCHAEMIC CONTRACTURE
 CHRONIC LIMB PAIN
 PARESIS/PARALYSIS
PROGNOSIS
PROGNOSIS
 TIME LAPSE BETWEEN INJURY &
INTERVENTION – MOST IMPORTANT
 FASCIOTOMY WITHIN 6HRS : ≈100% FULL
RECOVERY
 WITHIN 12HRS : 68%
 BEYOND 12HRS : 8%

 SITE OF AFFECTATION
CURRENT TRENDS
CURRENT TRENDS
 HYPERBARIC OXYGEN
CONCLUSION
CONCLUSION
COMPARTMENT SYNDROME HAS
DISASTROUS CONSEQUENCES IF
PERMITTED TO RUN ITS COURSE.

TIMELY INTERVENTION IS INDISPENSABLE

IF A SATISFACTORY OUTCOME IS TO BE
ACHIEVED.
THANKYOU
 REFERENCES
 The clinical diagnosis of compartment syndrome of the lower leg: are
clinical findings predictive of the disorder?
J Orthop Trauma 2002 Sep;16(8):572-7
 Acute compartment syndromes: diagnosis and treatment with the aid
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J Bone Joint Surg Am. 1978 Dec;60(8):1091-5.
 Compartment monitoring in tibial fractures. The pressure threshold for
decompression.
J Bone Joint Surg Br. 1996 Jan;78(1):99-104.
 Fasciotomy in the treatment of the acute compartment syndrome.
J Bone Joint Surg Am. 1976 Jan;58(1):112-5
 emedicine.medscape.com/article/307668-overview
 emedicine.medscape.com/article/2058838-overview
 Bailey & Love’s Short Practice of Surgery, 24th Ed, pp.
 Principles & Practice of Surgery including Pathology in the tropics, 4th
Ed, pg. 90
 Schwartz’s Principles of Surgery, 8th Ed, pg. 349