COMPARTMENT

SYNDROME
Ali Salim Rasheed
Jallawi Mosa Torkhan
5/9/23 1
 DEFINITION

• Acute compartment syndrome is defined as the elevation of

intracompartmental pressure (ICP) to a level and for a
duration that without decompression will cause tissue
ischemia and necrosis.
• It is an orthopedic emergency .

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 EPIDEMIOLOGY

• 3.1 per 100,000 in Western populations .

• Male-to-female predominance of 10 : 1.
• Higher incidence in younger (<35 years old) men, which may reflect the
increased muscle mass within the compartments in this population.
• Equal incidence of both high- and low-energy injuries.
• Fractures most common cause of ACS (69% of cases).
• Can occur in both open and closed fractures .
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 ETIOLOGY

• High-risk injuries are fractures of the elbow, the forearm bones, the
proximal one-third of the tibia and multiple fractures of the hand or
foot.
• Other precipitating factors are operation (usually for internal fixation)
or infection.
• Be aware that a compartment syndrome may also arise in a crush
injury, a circumferential burn , Bleeding diatheses , Fluid
extravasation (e.g., intravenous fluids ) or even in a tight plaster cast
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and etc. ..
 PATHOPHYSIOLOGY

• Fractures of the arm or leg can give rise to severe ischaemia even if
there is no damage to a major vessel.
• Bleeding, oedema or inflammation (infection) may increase the
pressure within one of the osteofascial compartments .
• There is reduced capillary flow which results in muscle ischaemia,
further oedema, still greater pressure and yet more profound ischaemia
.
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 PATHOPHYSIOLOGY

• This vicious circle will ends, after 12 hours or less , in necrosis of

nerve and muscle within the compartment.
• Nerve is capable of regeneration but muscle, once infarcted, can
never recover and is replaced by inelastic fibrous tissue (Volkmann’s
ischaemic contracture).
• A similar cascade of events may be caused by swelling of a limb
inside a tight plaster cast.
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THE VICIOUS CIRCLE OF VOLKMANN’S
ISCHAEMIA

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 VOLKMANN’S ISCHAEMIC CONTRACTURE

(a) Typical claw-finger deformity due to

contracture of the forearm muscles. With the
wrist extended, the fingers are drawn into
flexion.
(b) when the wrist is allowed to flex, the
fingers can be straightened, thus indicating
that the deformity is due to muscle shortening.
(Volkmann’s sign )

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 CLINICAL FEATURES

The classic features of ischaemia are the five Ps:

• Pain
• Paraesthesia In a compartment syndrome
• Paralysis the ischaemia occurs at the
capillary level, so pulses may
• Pallor still be felt and the skin may
• Pulselessness !not be pale
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 CLINICAL FEATURES
 The earliest of the ‘classic’ features are :
• pain (or a ‘bursting’ sensation) .
• altered sensibility .
• paresis (or, more usually, weakness in active muscle contraction).
 Skin sensation should be carefully and repeatedly checked.
 Ischaemic muscle is highly sensitive to stretch, so when the toes or fingers are
passively hyperextended, there is increased pain in the calf or forearm. ( 6th P :
Positive passive stretch test )
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PASSIVE STRETCH TEST

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 DIAGNOSIS

• Confirmation of the diagnosis can be made by measuring the

intracompartmental pressures .
• Indeed, so important is the need for early diagnosis that some
surgeons advocate the use of continuous compartment
pressure monitoring for high-risk injuries and especially for
forearm or leg fractures in patients who are unconscious.

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 ICP MEASUREMENT

• A split catheter is introduced into the compartment and the

pressure is measured close
to the level of the fracture.
• Resting compartment pressures are 0 to 8 mmHg.
• A differential pressure (ΔP) – the difference between the
general diastolic pressure and the compartment pressure – of
less than 30 mmHg (4.00 kP) is an indication for immediate
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compartment decompression.
 TREATMENT

• The threatened compartment (or compartments) must be promptly

decompressed.
• Casts, bandages and dressings must be completely removed – merely
splitting the plaster is utterly useless –
• The limb should be nursed flat (elevating the limb causes a further
decrease in end-capillary pressure and aggravates the muscle
ischaemia).
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 TREATMENT

• The ΔP should be carefully monitored; if it falls below 30 mmHg,

immediate open fasciotomy is performed.
• In the case of the leg, ‘fasciotomy’ means opening all four
compartments through medial and lateral incisions.
• The wounds should be left open and inspected 2 days later .
• If there is muscle necrosis, debridement can be done; if the tissues
are healthy, the wound can be sutured (without tension), or skin
grafted. 5/9/23 15
 TREATMENT
• If facilities for measuring ICP are not available, the decision to operate will
have to be made on clinical grounds.
• If three or more of the ‘classical’ signs are present, the diagnosis is almost
certain.
• If the signs are equivocal, the limb should be examined at 15 minute intervals
and if there is no improvement within 2 hours of splitting the dressings,
fasciotomy should be performed.
• Muscle will be dead after 4–6 hours of total ischaemia – there is no time to
lose! 5/9/23 16
A fracture at this level is always
dangerous. This man was treated in
plaster.
Pain became intense and when the
plaster was split (which should
have been done immediately after
its application), the leg was swollen
and blistered

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 FASCIOTOMY

Tibial compartment
decompression is best done
through two separate incisions
and requires fasciotomies of all
compartments

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 FASCIOTOMY

• fasciotomy of the forearm in a

case of crush syndrome by
Volar – Henry approach .
• There is necrosis of the
forearm flexors proximally.
• The carpal tunnel has been
decompressed.
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 FASCIOTOMY

Fasciotomy of the thigh

through a single lateral
.incision

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 FASCIOTOMY

• If compartment syndrome is diagnosed late, fasciotomy is of no benefit.

In fact, fasciotomy probably is contraindicated after the third or fourth
day following the onset of compartment syndrome.
• When fasciotomy is performed late, severe infection usually develops in
the necrotic muscle.
• However, if the necrotic muscle is left alone and the compartment is not
open, it can heal with scar tissue. This may result in a more functional
extremity with fewer complications. 5/9/23 21
 COMPLICATIONS
• Complications of acute compartment syndrome are unusual if the condition has
been treated expeditiously.
• Delay in diagnosis has been cited as the single reason for failure in the
management of acute compartment syndrome.
• Delay to fasciotomy of >6 hours is likely to cause significant sequelae ,
including muscle contractures, muscle weakness, sensory loss, infection, and
nonunion of fractures.
• In severe cases amputation may be necessary because of infection or lack of
function. 5/9/23 22
 REFERENCES
• Apley’s and Soloman’s Concise System of Orthopedics and Trauma 4th Ed.2014
.
• Essential Orthopedics and Trauma 5th Ed. 2009 .
• Textbook of Orthopedics . 4th Ed . 2010 .
• Rockwood and Green’s Fractures in Adults . 8th Ed . 2015 .
• Acute Compartment Syndrome , In : Medscape website . At : http://
emedicine.medscape.com/article/307668-overview .

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