Trauma

1. Dr. Situ Oladele
Registrar in Trauma, Department of
Surgery, National Hospital, Abuja. Sep.
2015

2. • INTRODUCTION
• CAUSES
• LOCATIONS OF COMPARTMENT SYNDROMES
(COMMON & LESS COMMON)
• EXTREMITY COMPARTMENT SYNDROME
- Pathophysiology of compartment syndromes
- Management :
• General clinical presentation
• Diagnosis and general investigations
• General treatment principles
• Principles of fasciotomy

3. • COMMON ACUTE EXTRIMITY COMPARTMENT
SYNDROMES:
• Compartment syndrome of the leg: applied anatomy and fascitomy
for leg ACS
• Compartment syndrome of the forearm and fasciotomy for ACS of
the forearm
• UNCOMMON UNCOMMON EXTREMITY
COMPARTMENT SYNDROMES
• Compartments of the arm and fasciotomy for ACS the arm
• The hand compartments and ACS of the hand
• Thigh compartment syndrome and management
• The compartments and ACS of the foot
• What to do after fasciotomy
• Differential diagnosis of ACS
• Prevention

4. • Complications and prognosis of extremity compartment
syndrome
• ABDOMINAL COMPARTMENT SYNDROME
• Definition
• Causes and classifications
• Risk factors and grading system
• Clinical effects and clinical recognition
• Treatment
• Effects of difficult abdominal wall closure in Abdominal
compartment syndrome
• Options of abdominal wall closure in abdominal compartment
syndrome
• Prevention
• Prognosis

5. • OTHER COMPARTMENT SYNDROMES
• Thoracic compartment syndrome
• Cranial compartment syndrome
• Acute orbital compartment syndrome
• Cardiac compartment syndrome
• CONCLUSION
• REFERENCES

6. • Rapid elevation of interstitial pressure in an enclosed
myofascial or osseofascial space that results in
microvascular compromise (Also known as Volkmann’s
ischaemia)
• Can occur in any closed fascial space
• Is a clinical emergency and requires rapid recognition,
diagnosis and intervention to achieve a successful
clinical outcome
• Can be acute or chronic (long distance runners)

7. • ↓compartment size
- 1o closure of fascial
defects
- Tight dressings
- Localised external
pressure
• ↑compartment content
- bleeding (post traumatic
or dyscrasias)
- Extravasation of I.V.F
- Muscle hypertrophy
• ↑capillary pressure &
permeability
- Burns
- Trauma
- Exercises
- Venous obstruction
- Seizure
- Intra-arterial drugs
- Nephrotic syndrome
- Snake bites

8. Traumatic
• Crush injuries and Muscle
contusions
• Open or closed fractures
• Gunshot wounds
• Vascular (combined Arterial
& venous) injuries
• Extravasation at arterial and
venous access sites
• Burns
• Osteotomy of tibia and
forearm bones
Non- traumatic
• Snake bites
• Tourniquets
• Constrictive dressings
• Tight casts

9. Common
• Forearm (volar aspect is
commoner)
• Leg
• Abdomen*
• Thoracic
• Cranial
Less Common
• upper arm
• thigh
• Foot
• Palmar spaces
• Pulp spaces
• Shoulder
• Buttocks
• Ocular

11. • Muscle oedema
• Prevention of venous outflow = congestion = muscle
ischemia = more muscle edema
• Healing by fribrosis (Volkmann’s contracture)
• Bleeding and space occupying hematoma
• External restrictive or compressive cast, bandage
• Peripheral nerves & muscles can survive as long as 4
hours under ischemia without irreversible damage, 6hrs=
variable damage, >8hours irreversible damage and
muscle injury

12. • Nerve is capable of regeneration but muscle, once
infarcted, can never recover and is replaced by inelastic
fibrous tissue (Volkmann’s ischaemic contracture).
• In compartment syndrome the ischaemia occurs at the
capillary level, so pulses may still be felt and the skin
may not be pale!

13. • Ischemic muscle pain (earliest and most reliable)
• pressure
• paresthesia
• Pallor
• Paralysis
• Pulselessness (late sign)

14. • High index of suspicion (If three or more clinical signs are
present, the diagnosis is almost certain). REPEATED
CLINICAL SURVEILLANCE OF THE LIMB!
• Invasive and non-invasive monitoring
• Continuous or serial
• Doppler studies
• FBC % Hg
• Urinalysis for myoglobiuria
• EUCr
• Creatinine phosphokinase

15. • Mubarak and Hargens: says absolute tissue pressure of
30mmHg = fasciotomy
• Whitesides and Heckman: change in intra
compartmental Pressure approaches 20 mmHg in the
presence of documented rising pressure, tissue injury or
history of 6hrs of total ischemia time of extremity
• McQueen and Court-Brown: sustained intra
compartmental pressure change of ≥ 30mmHg relative to
diastolic pressure = no problem
• Most Doctors = ΔP ≤ 30mmHg (<4Kilopascals)

16. • Prevention is the key!
• High index of suspicion and serial clinical examination
• 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).
• Administer oxygen to patient
• Fasciotomy would be the last resort when the above fails.

17. • An indication for fasciotmy is identified (clinically ±
investigations)
• Consent is obtained where possible
• General anaesthesia is preferred. A regional blockade
may be used where possible
• Prophylactic antibiotics may be given
• Fasciotomy is a sterile procedure hence appropriate
surgeon & patient draping is needed. Routine skin
cleaning is done.
• Good lighting and instruments are used
• Appropriate landmarks are identified to guide incisions
• Care must be taken to preserve important neurovascular
bundles in path of incision. Avoid muscle cutting!

18. COMPARTMENT SYNDROMES OF THE LEG AND FOREARM

19. • The leg has four compartments
1. Anterior compartmet (4 muscles): Tibialis anterior,
Extensor hallucis longus, Extensor digitorum longus, and
Peroneus tertius)
2. Lateral compartment (2 muscles): Peroneal longus and
Peroneal brevis muscles
3. Superficial posterior compartment (2 muscles):
Gastrocnemius and Soleus muscles
4. Deep posterior compartment (2 muscles): Flexor
hallucis longus, Flexor digitorum longus and Tibialis posterior
NB: The deep posterior compartment is most
commonly affected by the compartment syndrome
followed by the anterior compartment

22. • The deep peroneal nerve may be threatened in an
anterior compartment syndrome, causing pain and
weakness of dorsiflexion and sensory loss in a small area
of skin between the first and second toes.
• The superficial peroneal nerve descends along the
fibula, emerging through the deep fascia 5–10 cm above
the ankle. The muscular portion may be involved in a
lateral compartment syndrome, causing pain in the
lateral part of the leg and numbness or paraesthesia of
the foot; there may be weakness of eversion and sensory
loss on the dorsum of the foot.

25. • The anterior and lateral (peroneal) compartments can be
released with a skin incision 4cm lateral to the anterior
border of the tibia (between the fibular and anterior tibial
crest).
• The superficial peroneal nerve and the lateral
intermuscular septum are identified and the anterior
compartment released inline with the tibialis anterior
muscle

30. • The forearm has three compartments:
• Mobile wad proximally
• Volar compartment
• Dorsal compartment

31. • The incision is made between the thener and
hypotherner muscles, extended transversely across the
wrist flexion crease to ulnar side
• The carpal tunnel release could be done as indicated
• Curvilinear incision over the flexor aspect starting at the
ulnar side of the antecubital fossa and ending on the
ulnar side of the wrist flexor crease again (this prevents
contractures, and avails soft tissue coverage of
neurovascular structures).
• Longitudinal centrally placed incision over the extensor
(dorsal) compartment

33. • At the elbow, just slightly radial to the medial epicondyle,
the skin incision is then curved across the elbow flexion
crease
• At antecubital fossa, fibrous bands of lacertus overlying
the brachial artery and median nerve are CARFULLY
released

35. • The arm has two compartments:
• Anterior (biceps, brachialis) compartment
• Posterior (medial, lateral and long heads of triceps)
compartment

37. 1. lateral skin incision from the deltold insertion to lateral
humeral epicondyle (avoiding large cutaneous nerves)
2. The intermuscular septum between the anterior and
posterior compartments is identified
3. The fascia overlying each compartment is identified and
released with longitudinal incisions (avoiding the radial
nerve as it passes through the intermuscular septum
from the posterior to the anterior compartment

39. • Surgical emergency of the hand and results from
increased pressure within an osseofascial space of the
hand leading to decreased perfusion pressure
• Causes: fracture haematoma, crush, vascular injuries,
circumferential burns, bleeding dyscrasias, reperfusion
after ischemia, tight dressing

40. • The hand has 10 separate fascial compartments:
• 4 Dorsal interossei
• 3 Volar interossei
• The thenar muscles compartment
• The hypotherner muscles compartment
• The Adductor pollicis
• NB: fascial compartments are not well defined in
the fingers

43. • Pain on passive stretch of the muscle in the
compartment
• Paresthesia
• Palor
• Poor capillary refill
• Pulslessness
• Paralysis
• Pressure monitoring of compartment
>30mmHg normal BP or >15-20 in Patient with
low BP

44. • High index of suspicion and vigilance
• Removal of jewelleries and tight casts
• Elevate and rest limb
• Analgesics
• Fasciotomies within 6hrs of diagnosis:
• HAND:
• dorsal incisions over D2 and D4 metacarpals,
• Thenar release incision,
• Hypothenar release incision,
• digital mid axial

48. • The thigh is an uncommon site for an acute
compartment syndrome due to
the high volume of fascial space, and
blending of the thigh’s facial space with the hip
(allowing extravasation of content outside the
compartment)
• The thigh has three compartments
• Anterior (quadriceps)
• Medial (adductors)
• Posterior (hamstrings)

51. • External compression of the thigh (eg cast or bandage)
• Coagulopathy
• Severe blunt trauma
• Cercumferencial burns
• Overlenghtening with skeletal traction (reducing
compartment volumes)
• Systemic hypotension (reduced pefusion pressure)
• Vascuar injury (reducing muscle lood flow)

52. 1. Longitudinal incision over the lateral aspect of the thigh
from the greater trochanter to thelateral epicondyle of
femur
2. To release the anterior compartment, the iliotibial tract is
incised and the vastus lateralis is reflected off the
intermuscular septum bluntly
3. To release the posterior compartment, the intermuscular
septum is then incised along its length (not to close to
the femur to avoid the perforating arteries passing
through the septum)
4. The medial adductor compartment is released through a
separate anteromedial incision

55. • The foot has five compartments:
1. The lateral compartment: bounded dorsally by the 5th
metatarsal shaft, laterally by plantar aponeurosis, and
medially by intermuscular septum
2. The medial compartment: bounded dorsally by the
inferior surface of the 1st metatarsal, medially by plantar
aponeurosis extension & laterally by intermuscular
septum
3. Central compartment: bounded laterally and medially by
intermuscular septum, dorsally by interosseous fascia
and plantarly by plantar aponeurosis

56. 4. The interosseous compartment: bounded medially
by the lateral 1st metatarsal, dorsally by metatarsals and
dorsal interosseous fascia, and plantarly by planter
interosseous fascia
5. The calcaneal compartment: quadratus plantae
muscle
• Caution: A compartment syndrome of the foot (e.g.
following metatarsal fractures) is easily missed if one fails
to test specifically for plantar nerve function.

58. Aetiology: can occur after gunshot wounds, abscesses,
cellulitis, prolonged immobilization (surgery, coma), vascular
injuries (superior gluteal aretery), hip dislocation, bone
marrow biopsy, i.m injections, iliac bone grafting, robotic
assisted prostatectomy, Ehler-Danlos
Clinical: tense, erythema, tenderness, palsy of sciatic
nerve, myoglobinuria

59. • The wounds should be left open and inspected 2 days
later: if there is muscle necrosis, debridement can be
carried out
• Antibiotics and anti-tetanus may be given as indicated
OPTIONS OF WOUND CLOSURE:
• If the tissues are healthy, the wounds can
1. be sutured by delayed primary closure (without tension)
2. Be Allowed to heal by Secondary intension
3. Be Skin-grafted or covered with flaps
4. Be closed using Negative pressure wound therapy
(Vacuum Assisted Closure) could be used

60. • DVT
• Sepsis: cellulitis, myositis, abscess
• Fatigue fracture may be mistaken for a chronic
compartment syndrome
• Snake bite
• Gas gangrene
• Peripheral vascular injury

61. • High index of suspicion
• Prophylactic fasciotomies after osteotomies
• Fasciotomies and escarotomies in circumferential full
thickness burns patients
• Avoid limb nerve blocks in patients with risk of
compartment syndromes
• Removal of devitalised tissues and muscles during
debridement
• Avoid casts in patients in early hours of fracture
• Avoid tight constrictive dressings

62. • If the clinical signs are ‘soft’, the limb should be examined
at 30-minute intervals and if there is no improvement
within 2 hours of splitting the dressings, fasciotomy
should be performed

63. • Limb dysfunction
• Limb amputation
• Death
• Volkmann (Ischemic) Contracture in acute compartment
syndromes
• Pes cavus (high-arched feet)

64. • “constant length phenomenon”
Claw foot rom calf Compartmen
syndrome

66. • Definition:
• Abdominal compartment syndrome (AbCS) can be defined as
increased intra-abdominal pressure(IAP) associated with adverse
physiological consequences/organ dysfunction
• Abdominal wall and diaphragm have good compliance and
abdominal cavity behaves like a good hydraulic system.

67. • Normal IAP ≈ 5-7mmHg or less. It is about 9-14mm in
obese Patients.
• IAP is ≈ 4mmHg at 30O head up
• IAP is ≈ 9mmHg at 45O head up.
• IAP >12mmHg = intra-abdominal hypertension
Abdominal perfusion pressure (APP) = Mean arterial
Pressure (MAP) – Intra-abdominal pressure (IAP)
Aim is to achieve APP >60 mmHg

68. • Classification:
• Primary: abdominal or pelvic pathology present (eg, abdominal
distension)
• Secondary: nil abdominal or pelvic pathology (oedema from
capillary leak or decreased oncotic pressure, ascites following
shock aggressive fluid resuscitation in irreversible shock, severe
haemoperitoneum)

69. (1) Retroperitoneal:
- Retroperitoneal oedema or haemorrhage(e.g AAA rupture)
- Pancreatitis, large abscesses
(2) Intraperitoneal
• Massive abdominal haemorrhage
• Massive pelvic haemorrhage
• Bowel distension: ileus, mechanical obstruction, bowel oedema
• ascites, pneumoperitoneum, Abdominal packing
• Reduction of a large ventral hernia
(3) Abdominal wall
• Circumferential torso burn injury
• Military anti-shock garments

70. • Central obesity
• Pregnancy
• Ascites
• Large intra-abdominal tumors

71. • Multiply injured patient requiring emergency laparotomy
with abdominal packing for staged/abbreviated
laparotomy
• Patients with coagulopathy caused by core hypothermia
or cirrhosis
• Acute resuscitation from shock (who require
vassopressors, large volume of crystalloids and blood
products)

72. GRADE IAP (mmHg)
I 10 –14
II 15 – 24
III 25 – 35
IV >35

73. • CVS:
• ↑vascular resistance, ↓venous return & CO, ↑afterload, ↑cardiac
work, ↓tissue perfusion
• Renal:
• renal dysfuntion from direct parenchymal compression and renal
hypoperfusion and shunting of renal plasma flow, oligouria/anuria,
ATN
• Pulmonary:
• ↓splinting of diaphragm, ↓pulmonary compliance, ↓tidal volume,
respiratory acidosis

74. • Intestine:
• Bowel ishaemia and necrosis = ↑bowel edema
• Gut anastomotic breakdown
• Hepatic dysfunction
• Increased translocation of gut bacteria
• Difficulties with abdominal wall closure
• CNS
• Aggravated Intracranial hypertension from impaired SVC draining
by ↑intra-thoracic pressure
• Cerebral edema, cerebral hypoxia

75. • Pooling of blood in the extremities and pelvis
• Poor wound healing
• Coagulopathy
• ↑DVT and PE risk
• Acidosis from tissue anaerobic respiration

76. • High index of suspicion
• Tensely distended abdomen
• Progressive oligouria inspite of adequate cardiac output
• Hypoxia with increased airway pressures

77. • NB: IAP at which a Patient develops AbCS is patient-
specific hence recognition and treatment are based on
patient physiologic response to AbCS
• PEEP ventilation and prone position affect IAP
1. Bladder pressure measurement:
• 50ml H2O instilled aseptically by foley’s catheter
• Connected to tubing elevated 50-60cm
• 0 point is level of pubic symphysis, midline.

80. • Normal bladder pressure: 0-5mmHg
• Normal Post laparotomy bladder pressures: 10-15mmHg
• >20 mmHg (27 cmH2O): urgent decompression surgery
2. Gastric pressure measurement:
• 50ml via NG tube
• 0 point is mid-axillary line
• Treshhold is ± 2.5cm that of bladder pressure

81. Grading system for
ACS
GRADE IAP (mmHg) TREATMENT
I 10 –14 Normovolemic
resuscitation
II 15 – 24 Hypovolaemic
resuscitation
III 25 – 35 Watch PO2, SaO2,
urine output,
Decompression
laparotomy likely
IV >35 Emergency re-
exploration/decompre
ssion
I.V.F Resuscitation, INO2, ventilation, urethral catheter, work up for surgery as
needed
Percutaneous drainage of ascites

82. • Sutures cut through fascia
• Risk of burst abdomen
• Increased risk of incisional hernia
• Increased risk of catching a bowel loop in a suture during
abdominal wall closure

83. • Restricted fluid
• Mannitol
• Diuretics
• Analgesia, sedation
• NG and rectal tube decompression
• Bogota bag
• polyglycolic acid or polypropylene mesh sewn to the fascia,
• split-thickness skin grafts placed directly on the bowel,
• Staged delayed primary closure
• Suture sterile 3L urobag
• musculocutaneous flaps
• Secondary wound closure

84. • Vacuum assisted closure
• Temporary abdominal wall closure using haemostats, 3L
urologic irrigation bags, bagotta bags
• Percutaneous drainage of ascites
• Absorbable meshes for ventral hernia
• Skin grafts

85. • Untreated ACS leads to mortality on 50%

86. • Similar phenomenon as with abdominal compartment
syndrome
• Causes: acute diaphragmatic hernia, massive
haemothorax, tension pneumothorax, massive
hydrothorax, pulmonary edema, tumors,
• Effects: hypotension, distended neck veins, shift or
widening of midiastinum, respiratorry embarasmments,
chest pains

87. • Monro-kelly doctrine [Scottish Surgeon Alexander Monro
(1733-1817) and his student George Kellie (1758-1829)
during the late 18th century]
• Normal ICP in supine position = 10-15mmHg
• Cerebral prerfusion pressure (CPP) = Mean artrial pressure (MAP)
– intracranial pressure (ICP)
• Goal of CPP >60 – 70mmHg
• ICP in standing adult = -10 – 15mmHg
• Causes: intracranial hemorrhage, cerebral edema,
hydrocephalus, tumors, abscesses, ↑CSF flow

88. • elevated ICP reduces cerebral perfusion pressure (CPP)
= cerebral hypoxia and neuronal dysfunction and death
• Elevated ICP causes brain shifts = brain tissue
compression and/or herniation of the brainstem or other
vital structures.
• When the MAP is less than 65 mm Hg or greater
than 150 mm Hg, the arterioles are unable to
autoregulate, and blood flow becomes entirely
dependent on the blood pressure, a situation defined
as "pressure-passive flow."

89. • Clinical signs: cushion triad, ipsilateral dilated pupils,
vomiting, seizure, loss of consciousness, lateralising
sings,
• Diagnosis: clinical, intracranial pressure transducer
• ICP monitoring may be discontinued when the
ICP remains in the normal range within 48-72
hours of withdrawal of ICP therapy or if the
patient’s neurological condition improves to
the point where he or she is following
commands

91. • Rx:
• Medical: elevation of HOB, O2, mannitol, frusemide, hypothermia,
hyperentilation
• Surgical:
a) Craniotomy and evacuation of epidural or subdural
haematoma
b) Craniectomy & storage of bone flap
c) Ventricular drainage of CSF (internal/external)

92. • Cardiac tamponade: becks triad
• Causes: haemopericardium, hydropericardium, TB
pericarditis, bacterial pericarditis
• Diagnosis: Clinical and USS
• Rx: pericardiocentesis, pericardiectomy

93. • Rare complication of facial trauma
• Acute elevation of pressure within the confined orbital
space
• Aetiology: depressed orbital fracture, retrobulbar
haematoma or edema, post Op complication,
subperiosteal hematoma, orbital emphysema, intraocular
hematoma, abscess, tumor, I.V.F
• Sources of bleed include infraorbital artery, peralaminar
capillaries
• Glaucoma: Timolol

94. • Proptosis
• Ecchymosis of eyelids
• Chemosis
• Opthalmoplegia
• Papilledema
• Decreased visual acuity
• Decreased visual field
• Pale optic disc (late sign)

95. • Pathophysiology: when intraorbital pressure exceeds
central retinal artery pressure = pressure ischemia =
blindness. Also vasospasm from blood product
decomposition
• Treatment :
• High dose steroids, mannitol, ? Beta blockers
• Pressure decompression through orbital fractures
• Surgery
a) Lateral cathotomy
b) Inferior cantholysis
 PROGNOSIS
 Irreversible visual loss after 2 hours of acute orbital
compartment syndrome

96. • Compartment syndrome can occur in any of the body’s
non-expansible or minimally expansible compartment or
space
• Have various aetiologies and can be acute or chronic
• Acute compartment syndromes and sometimes chronic
compartment syndromes are surgical emergencies
• Compartment syndromes are often associated with
increased patients morbidity and mortality of not
decompressed quickly

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Solomon, David Warwick, Selvadurai Nayagam; Hodder
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the biological basis of modern surgical practice. 18th
edition. Sounders Publishers. 2007
• Farquharson’s textbook of operative general surgery,
Margaret Farquharson and Brendan Moran, 9th edition

99. • Schwartz’s principles of surgery, eight edition
• The Washington Manual of Surgery, 5th Edition, Lippincott
Williams and Wilkins, 2008
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the Tropics) by Badoe, Achampong,
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Doherty, Lange Publications 13th Ed, 2010

100. • De Keulenaer BL1, De Waele JJ, Powell B, Malbrain ML:
What is normal intra-abdominal pressure and how is it
affected by positioning, body mass and positive end-
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overview#a6
• War Surgery