Compartment syndrome is a complication that patients experience following fractures (most common cause), soft tissue trauma, or reperfusion injuries, which leads to arterial obstruction and muscle swelling. This presentation was given to the physicans at Banner Health in Feburary 2014 by David Carfagno, DO, of Scottsdale Sports Medicine

1. A SPORTS MEDICINE PHYSICIAN’S
PERSPECTIVE
DAVID CARFAGNO, D.O., CAQSM
SCOTTSDALE SPORTS MEDICINE

2. 


23 year professional football player left the
game in the 2nd quarter due to lower leg pain
He doesn’t recall a specific injury
Upon inspection, Team Physician felt that there
were no broken bones, muscle weakness,
sprains or strains and declared his discomfort
was due to cramping and had the player
benched

3. 


Following the game, player returned home
Noticed an increase in pain as the night
progressed
Tried to sleep, but awoke with severe lower leg
pain which lead him to call the Team Physician
for help

4. 

Moore was transported to the University of
Colorado Hospital where he was diagnosed
with lateral compartment syndrome
He underwent emergency surgery to have his
fascia opened to relieve increasing pressure

8. Q. Fractures are the cause in less than
25% of cases of compartment
syndrome.
A. True
B. False

10. 




Acute Compartment Syndrome (ACS) is a
complication following fractures, soft tissue
trauma, and reperfusion injury after acute
arterial obstruction.
Common in participants of sports with high
incidence of falls, fractures, contusions, etc.
Difficult to diagnose without clinical testing
Most often associated with fractures of long
bones (e.g., tib-fib)
Poor outcomes assoc. with delayed diagnosis

11. ACS is defined as a compartment pressure of >30
mmHg or within 30 mmHg of diastolic
pressure.
J Bone Joint Surg Br 1996;78:99–104.

12. 




1/3 of all cases involve tibial shaft fractures
Young age: Patients <35 years old more likely
than older patients to develop ACS following
same type of injury
10x more common in males
Most cases associated with fractures of long
bones, although 23.2% of cases associated with
soft tissue injury only
No difference in incidence of ACS in open
compared to closed fractures
J Bone Joint Surg Br. 2000;82:200–203.

17. 


Following an injury
(e.g., fracture), muscl
e swelling
compresses VAN in
compartment
Intracompartmental
pressure rises
Ischemia, followed
by necrosis

18. 

Bleeding: after vascular injuries or from cancellous
bone following fractures
Edema: from increased capillary permeability & fluid
extravasation due to oxygen deprivation caused by
bleeding




Increases perfusion barrier resulting in hypoxia + acidosis
Hypoxia + acidosis further increase capillary permeability &
fluid extravasation
Increases intracompartmental pressure
Restricted intracompartmental space: inelastic
compartment cannot accommodate expansion due to
finite borders defined by surrounding fascia and bone

Arterial compression, ischemia, then cellular death

20. 




Delayed diagnosis often has limb- and lifethreatening consequences.
Despite the relative frequency with which ACS
is seen by orthopedic surgeons, the diagnosis is
difficult.
Clinical signs mimic other conditions
Gold standard: assess intracompartmental
pressure with tonometry; fasciotomy
Refer to orthopedic specialist
Curr Rev Musculoskelet Med. 2012 September; 5(3): 206–213.

21. 





Pain out of proportion to initial injury
Pain on passive stretch of muscles within affected
compartment
Palpably tense compartment
Weakness and paresthesia of areas supplied by nerves
crossing the compartment
Late signs: loss of pulses (due to arterial
occlusion), paralysis
High index of suspicion for compartment syndrome
must be maintained, even if all diagnostic criteria are
not met
Clin Orthop Relat Res. 2010 April; 468(4): 940–950.

22. 6 “P’s”
1.
2.
3.
4.
5.
6.
Pain
Paresthesia
Paralysis/Paresis
Pulselessness
Pallor
Pressure

24. 



Uncomplicated fracture
Cellulitis
Deep Venous Thrombosis
Peripheral Vascular Injuries

25. 



Measure intracompartmental pressures with tonometer
Doppler (rule out DVT)
Serum chemistry studies (rule out rhabdomyolysis)
Imaging (determine nature and severity of fractures)

26. 

Perform
FASCIOTOMY when
difference between
compartment pressure
and diastolic blood
pressure is <30 mm
Hg or when clinical
symptoms are
obvious.
Fasciotomy of all
compartments is
required.
Clin Orthop Relat Res. 2010; 468(4): 940–950.

30. 
May be significant
-Skin grafts over incisions often needed
-Muscle weekness in affected limb can persist

Overall complication rate is 10x higher if
fasciotomy is delayed 12 hours from onset
- amputation rate increased to over 50%
- 8% of pts (untreated) vs 68% (treated) had limb
function return to normal
J Bone Joint Surg Br. 2000; 82 (2):200

31. 

In patients with tibial fractures, McQueen et al.
demonstrated that the time between apparent
onset of compartment syndrome and surgical
release influenced the outcome rather than the
time between trauma and fracture stabilization.
Documentation of clinical findings in ACS is
important since serial examinations are
necessary and the findings over time must be
compared.

33. 





Infection
Contracture
Muscle necrosis
Amputation
Rhabdomyolysis
Renal failure

35. 



PHASE I: Protection and Mobility (Surgery to 2-3 weeks).
Protection, Rest, Ice, Compression, and Elevation.
PHASE II: Light Strengthening (begin after meeting Phase I
criteria, approximately 3-4 weeks following surgery). ROM,
stretching.
PHASE III: Progression of Strengthening (begin after
meeting Phase II criteria, approximately 4-6 weeks following
surgery).
PHASE IV: Impact/Sport Training (Begin after meeting
Phase III criteria, approximately 8-12 weeks following
surgery)
http://www.youtube.com/watch?v=hDHyrhbwq-M

36. 



Tibial Fracture: 12-13
weeks average
healing time, followed
by rehabilitation and
gradual increase in
exercise intensity.
Fibular Fracture: 8-12
weeks
Tib-fib: 6 months or
more
High Ankle Sprain:
weeks to months
Int J Sports Phys Ther. 2011 June; 6(2): 126–141.

37. 


Study: over a 23-year period, 6% of all
malpractice claims against orthopedic surgeons
were related to ACS and greater than 50% were
ruled in favor of the patient.
Linear relationship between the number of
cardinal signs and the time from presentation
to fasciotomy and payment size.
Shadgan et al suggest that poor communication
between physician, other members of the
healthcare team, and the patient is associated
with unfavorable outcomes.
Bhattacharyya ‘04
Shadgan et al, ‘10

38. 



ACS in children most common in leg
Classic signs and symptoms often present later
or are completely absent
Nearly 1/3 of pediatric patients present only
with pain
Average normal resting intracompartmental
pressure is slightly higher in children (13 to 16
mmHg) than in adults (8 mmHg)
J Bone Joint Surg Br. 1996;78:95–98.
Curr Rev Musculoskelet Med. 2012 September; 5(3): 206–213

39. 



Compartment syndrome is a serious syndrome
that needs to be diagnosed early
Palpable pulses don’t exclude compartment
syndrome
If diagnosis and fasciotomy are done early,
prognosis is good
If delayed, complications will develop

40. David Carfagno, D.O., C.A.Q.S.M.



Board Certifications: Internal Medicine, Sports
Medicine (CAQ), Ringside Medicine (ABRM)
Medical Director, Ironman Arizona & Rock and Roll
Marathon Arizona.
Team physician, USA Boxing
10133 N. 92nd Street, Suite 102
Scottsdale, AZ 85258
Office – 480.664.4615
Email – david.carfagno@gmail.com