Compartment syndrome, acute, chronic, anatomy and operation

Ext.Sawanya Saowapap
Hadyai hospital

Compartment Syndromes
Definition
Types
Pathophysiology
Etiology
Clinical evaluation
Diagnosis
Management
Complications

2

Definition
An elevation of the interstitial pressure in a closed

osteofascial compartment that results in
micrvascular compromise.

S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.
.Philadelphia, Pensylvania. Mosby Elsevier, 2003

3

Types of compartment syndrome
Acute compartment syndrome (ACS)
 medical emergency
 caused by a severe injury
 can lead to permanent muscle damage.
Chronic compartment syndrome (CCS)
 known as exertional compartment syndrome
 not a medical emergency
 most often caused by athletic exertion.


4

Pathophysiology of ACS
The vicious cycle of
Volkmann's ischemia
 Increased intracompartmental P

 increases local venous P
 narrowed AV perfusion gradient
 compartment tamponade
 decrease capillary blood flow
 O2 deprivation
 local tissue necrosis
 nerve injury and muscle
ischemia

S. Terry Canele. Campeell’s Operative
.Orthopedics Volume 3. 11th edition

5

Pathophysiology of ACS
Whiteside' Theory:
The development of a compartment syndrome also depends
on
MPP = DBP(Diastolic BP) – CP(Intracompartment P)
Muscle perfusion pressure(MPP) < 30 mmHg

 Tissue hypoxia


6

Etiology of ACS


Decrease compartment size

Tight dressings/closure of fascial defect
 External pressures : casts, splints , burn
eschar, lying on limb for long period,
lithotomy position



7

Etiology of ACS
 Increase compartment contents
Fractures : the most common are
•In adults --- closed and open tibial shaft fx ,
distal radial fx
•In children --- radial head or neck fx ,
supracondylar fx , forearm fx


8

Etiology of ACS
 Increase compartment contents
• Hemorrhage -- vascular injury, coagulopathy
• Muscle edema -- severe exercise , crush injury
• Burn -- increase capillary permeability


9

Increase compartment
contents

S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. 10

Clinical Evaluation of ACS
Clinical presentations :
Swelling/ Tightness of compartment
Inappropiated and uncontrolled pain
Severe pain at rest or passive stretching
Pallor/Cyanosis
Hyperesthesia/Paresthesia
Paralysis : full recovery is rare

, www.wheelessonline.com : Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site
.Duke Orthopaedics : North Calorina, 2013 11

Clinical Evaluation of ACS
Physical examination :
 Pain at compartment on passive stretching :

test each compartment separately
Thigh : - anterior compartment - passive knee flexion

- posterior compartment - passive knee extension
- medial compartment - passive hip abduction
 Hyperesthesia/Paresthesia

Peripheral pulses absent - amputation usually inevitable


Measurement of
Compartment pressures
Indications : High risk injuries in
polytrauma patients
patient not alert/unreliable
inconclusive physical exam findings

Technique : performed each compartments at close to the fracture

site as possible (highest pressure) or maximal swelling area

Measurement of
Compartment pressures
Devices

Stryker hand-held system

Stryker slit catheter


, Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com

Early management of ACS
Remove cast/bandage
Positioning of the limb at the level of the heart

- Do not elevate the affected limb
 decreases arterial pressure
IV hydration
Oxygen supplement

.Philadelphia, Pensylvania. Mosby Elsevier, 2003 16

Early management
reevaluation&

S. Terry Canele. Campeell’s
.Operative Orthopedics Volume 3
, 11th edition. Philadelphia
.Pensylvania. Mosby Elsevier, 2003

Treatment
Nonoperative
observation
 delta

p > 30 mmHg, no clinical presentation of compartment
syndrome

Operative
emergent fasciotomy
 Positive

clinical presentation
 CP = 30-45 mm Hg
 delta p < 30 mmHg
 Contraindications : Missed compartment syndrome
(Various stage of muscle infarction)

Anatomy of Compartments
Arm 2 compartments
Forearm 4 compartments
 Hand 4 compartments
Thigh 3 compartments
Leg 4 compartments
Foot 9 compartments

19

2 Compartments of arm
1. Anterior
1. Biceps,Bracialis

2. Musculocutaneous n.
3. Brachial a.

2. Posterior
1. Triceps
2. Radial n.

”Mark Karafsheh.MD, “Compartment Syndrome
.on www.Orthobullets.com, Havard university, 2013 20

.on www.Orthobullets.com, Havard university, 2013

21

4 Compartments of forearm
most commonly affect volar

1. Mobile wad
: Brachioradialis,
Radial n
2,3. Dorsal superficial

&deep
:Posterior interoseous n & a

Dorsal incision


4. Volar superficial
&deep
:Median and Ulnar n.
Radial a., Ulnar a.,
ant. interosseous a.
22

10 Compartments of hand


23

3 Compartments of thigh
 Anterior
femoral

n
quadriceps
sartorious

 Posterior
sciatic

n
hamstrings

 Medial
obturator
adductors


24

n

4 Compartments of leg
1. Anterior
: Tibialis anterior, EDL,EHL
Peroneus
2. Posterior-Superficial
: Gastrocnemius, soleus,
plantaris
3. Posterior-Deep
: FDL, FHL,Popliteus,
Tibialis posterior, Tibial a,v,n.
4. Lateral
: Peroneus longus and
brevis,peroneal n

26


27


28

9 Compartments of foot

”Karafsheh.MD, “Compartment Syndrome
.Mark on www.Orthobullets.com, Havard university, 2013
29

Dorsal dual incision

Medial incision

30

Fasciotomy - post op care
Skeletal fixation can all be applied at time of initial surgical

decompression

After decompression care : sterile dressing (saline soaks ),

splinting in functional position

Return to OR for 2nd look in 2-5 days

- If no muscle necrosis  the skin is loosely closed.
- If closure is not accomplished
 Debridement after another 72- h interval
 Skin closure or skin grafting

Complications of ACS
Myonecrosis : after an ischemic insult of > 8 hrs.

Treatment
fasciotomy + debridement of the muscles + neurolysis

may lead to myoglobinuria and eventually renal
failure. Diuresis ( by mannitol,diuretics or IV fluids )
should be prompted to increase the tubular flushing
and eliminate the proteinaceous material

Volkmann ischemic contracture : myonecrosis replaced

with fibrous tissue  myotendinous adhesion formation.

Treatment
 Non-surgical (physiotherapy & bracing involve the joints)
 Surgical





contracture release,
nerve compression release,
amputation
reconstruction with tissue transfers


 Reperfusion syndrome : influx of myoglobin, potassium, and

phosphorus into the circulation
 characterized by hypovolemic shock and hyperkalemia

Evaluation :
 Fluid

loss, Shock
 Acidosis
 Hyperkalemia
 Myoglobinuria, Renal failure : need fluid 12 Lt over 48-hour

Management :
 Prioperative

hydration

 Mannitol
 Bicarbonate


Neurovascular injury
Infection
Amputation
Death


Chronic Compartment Syndrome
Known as exertional CS, recurrent CS and subacute

CS
 Typical patient is young (20-30s) athlete (long
distance runner)or military recruits
Occur mainly in the lower limb


Pathophysiology of CCS
Not yet fully understood
Probably from increased muscle relaxation pressure

during exercise
 decreased muscle blood flow
 ischemic pain and impaired muscle function


Physical Exam in CCS
Exercise –induced pain
Tenderness over the compartment
Bilateral involvement is common ( up to 82% )
Fascial hernias ( 39% in one of the studies )


DDx of CCS
Periostitis
Entrapment of the superficial peroneal nerve
Tendinitis of the posterior tibial tendon
Stress fracture of tibia
Intermittent claudication


Work up of CCS
Plain x-rays : will show 90% of stress fx
Bone scan : diffuse uptake ……..periostitis

localized uptake……stress fx
Tinel test : may be positive in superficial peroneal
nerve entrapment
NCS : could be helpful
MRI : promising results reported
Robert J. Duggan. “ How To Diagnose And Treat Chronic Exertional
Compartment Syndrome” Podiatry Today Volume 22 ,2009

41

Diagnosis of CCS
 Intracompartmental testing is the hallmark of
1)
2)
3)

diagnosis (as reported by Pedwotiz et al ) :
Pre-exercise resting pressure of 15 mm Hg or
more.
Pressure of 30 mm Hg 1 minute after the exercise.
Pressure of 20 mm Hg or more 5 minutes after the
exercise.

Robert J. Duggan. “ How To Diagnose And Treat Chronic Exertional
Compartment Syndrome” Podiatry Today Volume 22 ,2009

42

Treatment of CCS
 Non-operative :
 NSAIDs
 Electrostimulation
 Muscle relaxants
 Ultrasound
 Cessation or significant reduction of athletic activities


Treatment of CCS
 Operative treatment



Single incision fasciotomy
Double incision fasciotomy

 After surgery :
Early ROM exercises are encouraged.
Weight bearing on crutches is allowed on POD1.
Light jogging is allowed at 2-3 weeks if no swelling or

tenderness


References
S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th

edition. Philadelphia, Pensylvania. Mosby Elsevier, 2003.
Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site :
www.wheelessonline.com, Duke Orthopaedics : North Calorina,
2013.
Mark R. Brinker. Fundamental of orthopedics. Bathesta,
Maryland : University of Texan Health Sciences Center, 1992.
Robert J. Duggan. “ How To Diagnose And Treat Chronic
Exertional Compartment Syndrome” Podiatry Today Volume 22 ,
2009
Mark Karafsheh.MD, “Compartment Syndrome” on
www.Orthobullets.com, Havard university, 2013.
45

Compartment syndrome, acute, chronic, anatomy and operation

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