Compartment syndrome

1. DR. SIDHARTH YADAV
DEPT. OF ORTHOPAEDICS
NKPSIMS
ACUTE COMPARTMENT SYNDROME

2. Compartment Syndrome
Definition
Elevated tissue pressure within a closed osteofascial
space
Reduces tissue perfusion – ischemia
Results in cell death - necrosis

3. History
Volkmann 1881
Richard vonVolkmann published an article
in which he attempted to describe the
condition of irreversible contractures of the
flexor muscles of the hand to ischemic
processes occurring in the forearm
Application of restrictive dressing to an
injured limb

4. History
Hildebrand 1906
First used the term Volkmann ischemic
contracture to describe the final result of any
untreated compartment syndrome.
First to suggest that elevated tissue pressure may
be related to ischemic contracture.

5. History
Thomas 1909
Reviewed the 112 published cases of Volkmann ischemic
contracture and found fractures to be the predominant
cause.
Also, noted that tight bandages, an arterial embolus, or
arterial insufficiency could also lead to the problem

6. History
Murphy 1914
First to suggest that fasciotomy might prevent the
contracture.
Also, suggested that tissue pressure and fasciotomy were
related to the development of contracture

7. History
Ellis 1958
Reported a 2% incidence of compartment syndrome with
tibia fractures, and increased attention was paid to
contractures involving the lower extremities

8. History
Seddon, Kelly, and Whitesides 1967
Demonstrated the existence of 4 compartments in the leg
and to the need to decompress more than just the anterior
compartment. Since then, compartment syndrome has
been shown to affect many areas of the body, including the
hand, foot, thigh, and buttocks

9. Types of compartment syndrome
9
Compartment syndromes can be classified as :
Acute compartment syndrome (ACS)
Chronic compartment syndrome (CCS) depending
on the cause of increased intra-compartmental
pressure and the duration of symptoms

10. Sites of Acute Compartment Syndrome
10
Acute compartment syndrome can develop anywhere
a skeletal muscle is surrounded by a substantial fascia.
ACS may occur in foot, leg, thigh, buttocks, lumbar
paraspinous muscles, hand, forearm, arm and
shoulder.

11. Compartments
11
Foot 9
Leg 4 (anterior,lateral, sup & deep posterior )
Hand 4
Thigh 3 (anterior, posterior, medial )
Forearm 4 (sup &deep volar,dorsal, mobile wad of
Henry)

12. QUADRICEPS

15. MOBILE WAD
VOLAR
COMPARTMENT
DORSAL

16. Pathophysiology of ACS
16
CS develops after prolonged elevated intra-compartmental
pressure , which results from either externally applied or
internally expanding pressure forces.
Increased tissue pressure will decrease capillary blood
flow leading to local tissue necrosis caused by O2
deprivation .
Local blood flow (LBF) =Pa-Pv/R.

17. Pathophysiology of ACS
17
The elevated intra-compartmental pressure increases the
local venous pressure leading to narrowed arteriovenous
perfusion gradient and compartment tamponade,
resulting -if uncontrolled - in nerve injury and muscle
ischemia

18. Etiology of ACS
 External Restriction of Compartment Size :
- casts
- tight dressings
- splints
- lying on limb for long period
- burn eschar
- closure of fascial defect
- lithotomy position

19. Etiology of ACS
19
• Factures (the most common are) :
In adults --- closed and open tibial shaft fracture ,
distal radial fracture
In children --- radial head or neck fracture ,
supracondylar fracture , forearm fractures

20. Etiology of ACS
20
Hemorrhage (e.g. due to vascular injury )
Coagulopathy (e.g. hemophilia , thrombolytics , sickle cell
disease or trait )
Muscle edema (e.g. severe exercise , crush injury, trauma
with or without fx )

21. Etiology of ACS
21
Surgically related (e.g. knee arthroscopy , tibial
osteotomy without drainage , after epidural anesthesia )
Massive crystalloid infusion
Ruptured Backer’s cyst
Muscle hypertrophy ( androgens )

22. Etiology of ACS
22
Intracompartmental fluid infusion (interosseosus
infusion)
Capillary leak syndrome
Intra-arterial injections of sclerosing agents
Post –ischemic reperfusion

23. Compartment Syndrome
Tissue Survival
Muscle
 3-4 hours - reversible changes
6 hours - variable damage
8 hours - irreversible changes
Nerve
2 hours - looses nerve conduction
4 hours - neuropraxia
8 hours - irreversible changes

24. Compartment Syndrome
Pathophysiology
Normal tissue pressure
 0-4 mm Hg
8-10 with exertion
Absolute pressure theory
30 mm Hg - Mubarak
45 mm Hg - Matsen
Pressure gradient theory
< 20 mm Hg of diastolic pressure –
Whitesides
McQueen, et al

25. Compartment Syndrome Diagnosis
Pain out of proportion
Palpably tense compartment
Pain with passive stretch
Paresthesia/hypoesthesia
Paralysis
Pulselessness/pallor

26. Pain
Classically out of portion to injury
Exaggerated with passive stretch of the involved
muscles in compartment
Earliest symptom

27. Paresthesia
Also 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

28. Paralysis
Very late finding
Irreversible nerve and muscle damage present
Paresis may be present early
Difficult to evaluate because of pain

29. Pallor & Pulselessness
Rarely present
Indicates direct damage to vessels rather than
compartment syndrome
Vascular injury may be more of contributing
factor to syndrome rather than result

30. Compartment Pressure
Technique
Whiteside infusion
Stic technique: side port needle
Wick catheter
Slit catheter

31. Whiteside Technique
Simple technique
Readily available supplies
With 18 gauge needle least accurate
More accurate if use side port needle

32. Stryker Stic System
Easy to use
Can check multiple compartments
Different areas in one compartment

33. Management of ACS
33
 Removal of the possible cause (release of tight dressings
or circular constrictive bandages, splitting of casts)
 Correction of coagulopathy
 Positioning of the limb at the level of the heart

34. Management of ACS
34
If symptoms don’t resolve in 30 to 60 min after
appropriate treatment ,pressure measurement
should be repeated,and,if equivocal, fasciotomy is
indicated

36. Management of ACS
36
The definitive treatment of acute compartment syndrome
is FASCIOTOMY
Procedure is done without a tourniquet,each potentially
limiting envelope is opened over the entire length of the
compartment, all muscle groups should be soft to
palpation at the end of the procedure
Muscle debridement should be kept to a minimum

37. FACIOTOMY OF LOWER LIMB
FOR THIGH
Make a lateral incision distal to intertrochantric line
extending to the lateral epicondyle.
Expose the iliotibial band & make aa straight incision in
line with skin incision
Reflect the vastus lateralis off the intermuscular septum

38. • FOR LEG
Single incision faciotomy
Double incision faciotomy
fibuloectomy

41. Chronic Compartment Syndrome
41
Also known as exertional CS, recurrent CS and subacute CS
 Exercise –induced pain
Occur mainly in the lower limb
Typical patient is young (20-30s) athlete (long distance
runner)or military recruits pushed past normal limits of
functional tolerance

42. Pathophysiology of CCS
42
Not yet fully understood
Probably occurs from increased muscle relaxation
pressure during exercise , which causes decreased
muscle blood flow, leading to ischemic pain and
impaired muscle function

43. COMPLICATION OF COMPARTMENT
SYNDROME
Reperfusion injury
Volkmann’s contracture
Weak dorsiflxors
Claw toe
Sensory loss
Chronic pain
Amputation

44. THANK YOU…