Compartment syndrome

WO-SD-PD-VC
• occurs when pressure rises within a confined
space in the body, resulting in a critical
reduction of the blood flow to the tissues
contained within the space.
• Acute compartment syndrome
• Exertional compartment syndrome
• Volkmann ischemic contracture
• Hamilton in 1850
• Richard Von Volkmann : muscle cannot survive
longer than 6 hours with complete
interruption of its blood flow and that 12
hours or less of too tight bandaging
• High energy vs low energy
• Closed vs open
• There remains uncertainty about the exact
physiologic mechanism of the reduction in
blood flow in the acute compartment
syndrome, although it is generally accepted
that the effect is at small vessel level, either
arteriolar, capillary, or venous levels.
 Effects of Raised Tissue Pressure on
Muscle
• Skeletal muscle is the tissue in the extremities
most vulnerable to ischemia.
• Rising tissue pressure leads to a reduction in
muscle blood flow, followed by necrosis.
• Why anterior compartment more vulnerable
to raised ICP?
• Why anterior compartment more vulnerable
to raised ICP?

The muscles of the anterior The gastrocnemius contains

compartment of the leg mainly
contain type I fibers or red type II or white fast twitch fibers
slow twitch fibers
 Effects of Raised Tissue Pressure on
Nerve
• The mechanism of damage to nerve is as yet
uncertain and could result from ischemia,
ischemia plus compression, toxic effects, or
the effects of acidosis.
 Effects of Raised Tissue Pressure on
Bone
• Nonunion is now recognized as a complication
of acute compartment syndrome
 Reperfusion Injury
re-establishment of blood flow to the ischemic tissues

breakdown products of muscle

inflammatory response in the ischemic tissue

 Diagnosis of Acute Compartment
Syndrome
• Delay in diagnosis has long been recognized as
the single cause of failure of the treatment of
acute compartment syndrome
 Clinical Diagnosis
• PAIN is considered to be the first symptom of
acute compartment syndrome (severe and out
of proportion to the clinical situation)
- nerve injury
- deep posterior compartment
• Pain with passive stretch of the muscles
involved is recognized as a symptom of acute
compartment syndrome.
• Paresthesia and hypoesthesia are usually the
first signs of nerve ischemia, although sensory
abnormality may be the result of concomitant
nerve injury
• Paralysis
• Palpable swelling in the compartment
 Compartment Pressure Monitoring
• needle manometer method
• wick catheter
• slit catheter
• solid state transducer intracompartmental
catheter (STIC)
 Measurement Techniques
• Needle Manometer

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and
Trafton PG [eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
 Measurement Techniques
• Continuous Infusion Technique
– Low accuracy: tissue compliance << when
pressure greater than 30 mmHg  artifically high
reading

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and
Trafton PG [eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
 Measurement Techniques
• Wick Catheter
– Polyglycolic acid suture
pulled into tip of piece
of PE60 polyethylene
tubing
– Catheter placement
sleeve + wick catheter
connected to pressure
transducer & recorder
introduced through
a large trocar. Needle is
withdrawn & catheter
is taped to the skin

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and
Trafton PG [eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
 Measurement Techniques
• Slit Catheter
– PE60 Polyethylene tubing with
five 3-mm slits in the end of tube
• Slit Catheter System
• Microcappilary Infusion
• Arterial Transducer
Measurement
• Noninvasive Techniques (Chronic
CS)
– Tc 99m-MIBI Scintigraphy
– Laser Doppler Flow
– Near-Infrared Spectroscopy

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and
Trafton PG [eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
Threshold for Decompression in Acute
Compartment Syndrome
• One level believed to be critical was 30 mm Hg
of ICP
• Some authors felt that 40 mm Hg of tissue
pressure should be the threshold for
decompression, although some recognized a
significant variation between individuals in
their tolerance of raised ICP
• Whitesides et al. were the first to suggest the
importance of the difference between the
diastolic blood pressure and tissue pressure,
or ΔP
• Similar concept that the difference between
mean arterial pressure and tissue pressure
should not be less than 30 mm Hg in normal
muscle or 40 mm Hg in muscle subject to
trauma
• What about the threshold for children?
• What about the threshold for children?
Children have a low diastolic pressure and are
therefore more likely to have a ΔP less than 30
mm Hg
• Mars and Hadley recommend the use of the
mean arterial pressure rather than the
diastolic pressure to obviate this problem.
 Timing
• If the ICP is rising, the ΔP is dropping and less
than 30 mm Hg, and this trend has been
consistent for a period of 2 hours, then
fasciotomy SHOULD BE performed.
• Fasciotomy SHOULD NOT BE performed based
on a single pressure reading except in extreme
cases.
• Some authors have found compartment
pressure monitoring less useful but used
clinical symptoms and signs as their indication
for fasciotomy with pressure monitoring only
as an adjunct
Surgical and Applied Anatomy
Thigh
Leg
Foot
Arm
Forearm
Hand
 Treatment

• Fasciotomy
 Fasciotomy
• Basic principle?
Full and adequate decompression
- Skin incisions must be made along the full
length of the affected compartment
- It is essential to visualize all contained
muscles
Management of Fasciotomy Wounds
• The wounds should be left open and dressed,
and approximately 48 hours after fasciotomy a
“second look” procedure should be
undertaken to ensure viability of all muscle
groups.
• There is no indication to prolong closure
beyond 48 hours unless there is residual
muscle necrosis.
 Complications of Acute
Compartment Syndrome
• Delay to fasciotomy of more than 6 hours is
likely to cause significant sequelae, including
muscle contractures, muscle weakness,
sensory loss, infection and nonunion of
fractures
 AAOS 1
A 14-year-old boy sustains a right leg injury
after being thrown from his motorcycle while
racing. He reports leg pain starting at his knee
and proceeding to distally to include his foot.
In the emergency department 4 hours after
injury, examination shows a large knee
firm compartments of the leg, a palpable posterior tibialis
pulse with a warm, pink foot, and capillary refill of 2 seconds
at the toes. His blood pressure is 100/50 mmHg. Motor
examination is intact, but there is decreased sensation in the
dorsal first interspace and plantar aspect of the foot.
Compartment pressure measurement reveals all four
comparments with pressures of 33, 36, 33, and 38 mm Hg
respectively. Radiographs are shown in Figure 59a and 59b.
The remainder of the skeletal examination is normal.
What is the optimal management for this injury?
1 Emergent four compartment fasciotomies
2 Emergent four compartment fasciotomies and open
reduction and internal fixation of the fracture
3 Elevation of the limb overnight and four compartment
fasciotomies in the morning
4 Elevation of the limb overnight and recheck of compartment
pressures in the morning
5 Emergent MRl of the knee and leg
• PREFERRED RESPONSE: 2
DISCUSSION: The patient has a compartment syndrome based on the firm
compartments of the leg and elevation of intracompartment measure.
Muscle ischemia occurs quickly when compartment pressure are elevated,
and within 6 hrs irreversible damage can occur.
Emergent fasciotomies permit decompression of all four compartments
and re-establish vascular supply to the muscles. Stabilization of the
fracture prevent further soft-tissue injury.
 AAOS 2
Figures 90a and 90b are the radiographs of the right leg of a 30-year-old
man who sustained a crush injury to his right chest, abdomen, and right
leg after being pinned under a hydraulic jack. He has a blood pressure of
170/90 mm Hg. He is intubated and sedated secondary to his pulmonary
injury. Six hours later he has a swollen lower leg. Examination reveals
significant swelling but palpable pulses.
Compartment pressures ranged from 32 to 41 mm Hg. What is the next
step in management?
• 1. MRI of right leg
• 2. Venous doppler of right leg
• 3. Four-compartment fasciotomy
• 4. Follow-up examination the next day
• 5. Serial examinations with compartment pressures
• PREFERRED RESPONSE: 5
DISCUSSION: The patient is at risk for a compartment syndrome. Management
should consist of close follow-up with serial examinations and repeat
compartment pressure measurements as long as the patient cannot give a good
clinical examination. MRI scan of the leg is not needed acutely because the
scenario is suggestive of a crush injury and the most likely problem is muscle
injury. Venous doppler, although important to discern the possibility of a venous
occlusion, is not the most pressing issue. Fourcompartment fasciotomy may
become necessary but based on the available data is not indicated at this time.
The current pressure difference between the diastolic blood pressure and his
compartment pressure is almost 50 mmHg, suggesting the microcirculation is
open.
 AAOS 3
• Figure 91 is the radiograph of a 20-year-old man who kicked a
door while intoxicated. At the emergency department, his leg
is placed into a long-leg cast. After 2 hours, he reports
increasing pain, numbness, and tingling in his toes. What is
the most appropriate initial treatment?
• 1. Elevate leg on pillows
• 2. Administer IV morphine
• 3. Observation of the patient
• 4. Bivalve and spread the cast
• 5. Apply ice to the lower extremity
• PREFERRED RESPONSE: 4
DISCUSSION: The patient appears to have some indications of a
compartment syndrome: increasing pain and signs of nerve compression.
Tibia fractures also should heighten the suspicion for a compartment
syndrome. Two basic mechanisms of compartment syndrome are that an
increase in volume occurs in an enclosed space or there is a decrease in
size of the space. In this situation, both are likely occurring; postfracture
swelling is occurring within a closed space and if a cast is in place that may
constrict the space even more. One way to increase the available space for
swelling would be to bivalve and spread the cast.
THANK YOU