Compartment syndrome- causes, pathogenesis, diagnosis and treatment.

1. COMPARTMENT SYNDROME
PRESENTATION BY:-
DR K TARUN RAO MBBS D.ORTHO
DNB PGT[CMRI]

2. A 55yr old pt came with alleged h/o RTA on
15/10/16 at 4:30pm c/o pain in the rt leg,
a/w abdomen and head injury.

3. DEFINITION :-
 Compartment Syndrome is an elevation of
Interstitial Pressure in closed Osteofascial
Compartment that results in Microvascular
Compromise.
 It is a true orthopedic emergency.

4. Compartment?
 Compartments are groups of muscles surrounded
by in-elastic fascia.

5. AETIOLOGY:-
REDUCED COMPARTMENT SIZE:-
Tight dressing:- bandage or cast
localised external pressure, lying on limb
closure of facial defects.
INCREASED COMPARTMENT SIZE:-
Bleeding:- fx , vascular injury , bleeding dis-orders.
Increased capillary permeability:-
ischemia/trauma/burns/exercise/snake bite/drug injection.

6. Etiology : (cont…)
 FRACTURE being the first most common cause.
 The incidence is directly proportional to the
degree of injury to soft tissue and bone.
 Most common in low energy injury(lack of
compartment disruption)
 Most common fx leading to ACS:-
1) Tibial diaphysial #
2) Distal radius #
3) Forearm #
Second most common cause:- Blunt trauma

7. TYPES OF COMPARTMENT SYNDROME :
 Acute Compartment Syndrome :
• Caused by severe injury/trauma.
• Acute Exertional compartment Syndrome have been
reported in foot in runners, Basketball players and other
athelets.
 Chronic Exertional Compartment Syndrome :
• It is recurrence of increased pressure seen most often in
Anterior and deep posterior Compartment of leg.
• Also been reported in forearm in weight
lifters,rowers,welders.

8. Involved Areas:-
 Anterior & Posterior Compartment of leg most common
 Volar compartment of Forearm
 Compartment Syndrome can develop anywhere
Skeletal muscle is surrounded by substantial fascia
such as buttock, thigh, shoulder,hand,foot,arm
&lumbar Paraspinous muscles.

9. Pathophysiology : Insult to normal
local tissue
homeostasis
Increased Tissue
Pressure
Decreased
Capillary Blood
Flow
Oxygen
Deprivation
Local tissue
Necrosis
• Tissue Necrosis
occurs in normal
blood flow if intra
compartmental
pressure exceeds
30mm Hg for longer
than 8hrs.

10. Tissue survival:-
 Muscle:- 3 to 4hours- reversible changes
6 hours variable damage
8 hours irreversible changes
 Nerve :- 2 hours –looses nerve conduction
4 hours – neuropraxia
8 hours – irreversible changes
 Delayed diagnosis : permanent sensory and motor
deficit.
contractures
Infections
Amputations

11.  Normal tissue pressure:-
.0-4mmhg
.8-10mmhg with exertion.

13. CLINICAL FEATURES :-
HOW DO WE DIAGNOSE?
CLINICALLY:- 5 P’s
 Swelling and tightness(TENSE) compartment involved.
 Severe pain on passive stretching
 Pain out of proportion to injury
 Pallor/Cyanosis
 Hyperaesthesia/Paraesthesia
 Paralysis
 pulselessness

14.  Pulse oximeter:-
pulse oximeter is helpful in identifying limb hypo-
perfusion. But is not sensitive enough to exclude compartment
pressure.
NOTE:- Pain and aggrevation of pain by passive
stretching of the muscles in the compartment in question are the
most sensitive(and generally only) clinical finding before the onset
of ischemic dysfunction in the nerve and muscle.
Others:-
Compartment pressure monitoring, lab investigations like
CPK, Urine myoglobulin estimation.

17. Compartment pressure monitoring:-
 In case of suspected compartment syndrome.
 Pt on ventilator.
 Obtunded pt with tight compartments.
 Regional anesthesia.
 Vascular injury.
 Alcoholics,drug addicts.

18. Devices used for measurement of
compartment pressure:-
1.Synthes hand-held monitor(most commonly used)
2.Whitesides threeway stopcock apparatus
3.Wick Catheter
4.Styker STIC catheter (solid-state tranducer
intercompartmental catheter) for continous pressure
monitoring.
Newer Non Invasive methods:
1.Ultrasonography(sensitivity-77%,specificity-93%)
2.Infrared Imaging

19.  Hand held monitoring device or arterial line
monitering system connected to either a straight
needle,aside port needle or slit catheter is
preffered.
 BOODY found that arterial line manometer with
slit catheter is more accurate technique.
 Use of side port needles and slit catheters were
more accurate.
 Where as straight needles tend to over-estimate
the pressure.

20. Whitesides threeway stopcock (in 1975)

21. Synthes handheld device:-

24. Acute compartment syndrome of thigh:-
 Less frequent than lower leg and forearm.
 But associated with high level of morbidity.
 Most commomn causes:
.Blunt trauma(with or with out fracture)
.Vascular injury
.Torniquet(lower leg surgery)
.Quadriceps tendon rupture
.Heterotopic ossification

25.  Thigh is divided into 3 distinct compartments by
intermuscular fascial extensions:-
.Anterior compartment
.Medial compartment
.posterior compartment
Most common compartment syndrome of
thigh is ANTERIOR compartment because it is
surrounded by stiffest walls laterally and medially
(fascia lata and illiotibial tract).

27. MEDIAL ANTERIOR POSTERIOR
Adductor brevis,
Adductor
Magnus,
Adductor Longus
Quadriceps
femoris,
Sartorius
Biceps Femoris
Semi
Membranosus
Pectineus,obtura
tor
externus,gracilis
muscles.
Semi Tendinosus
Obturator Nerve Femoral Nerve
Saphaneous N.
Sciatic nerve
Profunda Femoris
Artery
Obturator A.
Femoral Artery
Femoral Vein
Arterial Br. Of
Profunda Femoris

28. Diagnostic criteria for Acute compartment
syndrome of thigh
Anterior posterior Medial
pain with passive
strech
Passive knee flexion
with hip in
extension
Passive knee ext.
with hip in flexion
Passive hip
abduction with knee
in ext.
Motor deficit Knee extension Knee flexion,plantar
flexion(sciatic tibial
branch),dorsiflexion
, great toe
ext(peroneal
branch).
Hip abduction
Sensory deficit Passive hip
abduction with knee
in ext.
Hip abduction Proximal medial
thigh(obturator
nerve cutaneous
branch)

29. Treatment of compartment syndrome of
thigh:
 In Isolated limb injury, splitting of cast and underlying
padding can decrease compartment pressure by 50-
85%.
 Removal of circular constrictive bandages.
 Positioning of the limb at heart level produces the
highest arterio-venous gradient.
 If symptoms wont resolve with in 30 to 60min after
appropriate treatment, pressure measurement should
be repeated.
 If results are equivocal FASCIOTOMY is indicated.

30. Fasciotomy:-
 Good prognosis: Fasciotomy done in 25 to 30hrs
 Bad prognosis: delayed diagnosis, 3rd or 4th day.
 Indications of Fasciotomy:
.compartment pressure >30mmhg
.Arterial disruption for more than 4hrs
.Compartment syndrome associated with fracture
should be treated at the time of reduction.

31. Fasciotomy for Acute comparment
syndrome of thigh:
 Tarlow ET AL. technique:
.incision from
intertrochanteric line to lateral
epicondyle
.anterior compartment is
opened by incising fascia lata
and vastus lateralis is
retracted medially to expose
lateral intermuscular septum,
which is then incised to
decompress posterior
compartment.

33. Comparitive study of compartment
syndrome of thigh
 In one study 23 pt with acute compartment
syndrome.
 4 pt (17%) required amputation.
 In another study of 18 pt more than half did not
recover full thigh muscle strength and had long term
functional deficits.

34. Comparitive study of fasciotomy
 Need for fasciotomy varied widely according to Mechanism
of injury
.<1% after motor vehicle accidents to almost 9% after
gunshot wounds
 Type of injury
.2% with closed fracture to 42% with combined vascular
injury.
 A review of out comes of fasciotomy found that 68% of pt
treated with in 12 hrs of symptom onset had normal
function.
 Compared with only 8% in those treated more than 12hrs
after symptom onset.

35. Acute compartment syndrome of leg:-
 Associated with
.tibial fractures(36%)- first most common
.soft tissue injury due to blunt trauma-Second
most common

36. Compartments in Leg:-

38. Diagnosis and treatment of Acute
compartment syndrome of leg :-

39. Two Techniques for release of
compartment of lower leg:-
 Single incision perifibular fasciotomy(useful if soft
tissue of the limb is not extensively distorted)
 Double incision fasciotomy(safer,more effective)

40. Single incision fasciotomy:-
DAVEY,RORABECK AND
FOWLER TECHNIQUE :-
A. lateral skin incision from fibular neck to
3 to 4cm proximal to lateral malleolus.
B. Skin is undermined anteriorly and
fasciotomy of anterior and lateral
compartments performed.
C. Skin is undermined posteriorly and
fasciotomy of superficial posterior
compartment is performed.
D.Interval between superficial posterior
and lateral compartment is developed.

42. Double incision fasciotomy:-
Decompression of anterior and
lateral compartments of leg.
A. Anterio lateral incision(20 –
25cm) between fibular head and
tibial crest.
B. Posteriomedial incision 2cm
posterior margin of tibia.
C. Decompression of all four
compartments of leg.
Mubarak and Hargens

43. Delayed primary closure after fasciotomy
with vessel loop shoelace tecnique:-

44. Chronic Exertional Compartment
Syndrome:-
 Defined as reversible ischemia secondary to a non
compliant osteofascial compartment that is
unresponsive to expansion of muscle volume that
occurs with exercise.
 Muscle volume can increase upto 20% of its resting
size during exercise.

45. Etiology:-
 Rear foot landing,over pronation
 Muscle hypertrophy
 Anabolic steroid and creatine use also increase
muscle volume
 Recreational runners
 Elite athletes
 Military recruits
 Anterior and posterior compartments are most
commonly effected,and symptoms are bilateral in
75% of patients.

46. Clinical evaluation:-
 20-30yrs old pt describes exercise induced pain
and a feeling of tightness that begins after 20 to
30 minutes of running.
 Pain usually resolves within 15 to 30minutes of
cessation of exercise.
 Paresthesias of nerves.

47. Differential diagnosis chronic exertional
compartment syndrome:
 Medial tibial stress syndrome (shin splints)
 Stress fracture
 Tenosynovitis
 Periostitis
 Dvt
 Nerve entrapment syndrome
 Lumbosacral radiculopathy
 Neurogenic claudication
 Poplitela artery entrapment syndrome
 Vascular claudication
 Infection
 Myopathy
 tumors

48. Diagnostic criteria of chronic
exertional compartment syndrome:-
 Pre-excercise resting pressure of 15mmhg or more.
 Pressure of 30mmhg or more 1 minute after exercise.
 Pressure of 20mmhg or more 5 minutes after exercise.
 Post exercise MRI
 Near Infrared spectroscopy
 Triple phase bone scan
 Methoxyisobutyl isonitrile(MIBI) perfusion imaging
 Tallous chloride scintigraphy

49. Treatment for chronic exertional
compartment syndrome:-
 Non operative
 Operative

50. Non operative:-
 Rest
 Anti inflamatory medications
 Manual therapy
 Streching and strengthening of involved muscles
 Orthotics
 If symtoms persists,pressures extremely elevated,or
athlete desired to continue activity at same level
fasciotomy of involved compartment indicated

51. operative procedures:-
 Anterior compartent fasciotomy (80-90% success rate).
 Deep posterior compartment fasciotomy (50-70%).
 Types: 1.Double-Mini Incision Fasciotomy for
chronic anterior compartment syndrome.
2.Single-Incision Fasciotomy for chronic
anterior and lateral compartment syndrome.
3.Double-Incision Fasciotomy for chronic
posterior compartment syndrome

52. Double mini incision fasciotomy for
anterior compartment syndrome:
 Moushine ET AL
technique:
.make two verticle 2cm
skin incision 15cm apart.
.identify subcutaneous
flap by blunt dissection.
.with the help of
retractors retract skin
anteriorly and posteriorly
to allow anterior and
lateral fasciotomy under
direct vision.

53. Single incision fasciotomy for chronic
anterior and lateral compartment synd:
 Fronek ET AL technique:
A.make 5cm longitudinal
incision between fibula and
tibial crest over anterolateral
intermuscular septum,when no
fascial hernia exists.
B.In presence of fascial hernia
incision is directly over fascial
defect.
C.Defect is enlarged across
intermuscular septum.(1)
D & E.complete longitudnal
release of ant. Compartment(2
& 3) and lateral compartment
(4 & 5)

54. Double incision fasciotomy for chronic
posterior compartment syndrome:
 RORABECK technique:
A.Two vertical
incisions;saphenous vein Is
identified and retracted
anteriorly.
B.Superficial compartment
is entered and released.
c.Deep fascia is incised and
deep posterior
compartment is released.

57.  Dorsal – extensor hallucis brevis
extensor digitorum brevis
 Plantar – 1st layer
Abductor hallucis
Flexor digitorum brevis
Abductor digiti minimi
2nd layer
Quadratus plantae
Lumbricles muscle
3rd layer
Flexor hallucis brevis
Adductor hallucis
Flexor digiti minimi brevis
4th layer – dorsal interossei
plantar interossei

59. Compartment Syndrome of forearm:-
 Anatomy :- 4 compartments of foream
1.The Superficial volar compartment.
2.The Deep volar compartment.
3.The Dorsal compartment.
4.The compartment containing mobile
wad of Henry(brachioradialis,
extensor carpi radialis longus and brevis)

61.  In hand each interosseous muscle is surrounded by
a tough investing fascial layer
 Each making an individual compartment as shown
by injection dissections of Halpern and Mochizuki.
 The adductor pollicis muscle and thenar and
hypothenar muscles form 3 separate
compartments.

62. B and C:-dorsal and volar interosseous compartments and
adductor compartments to thumb
A and D :- thenar and hypothenar compartments

63.  Thenar compartment:
Abductor pollicis brevis
Flexor pollicis brevis
Oppenens pollicis
Adductor pollicis
 Hypothenar compartment:
Abductor digiti minimi
Flexor digiti minimi brevis
Opponens digiti minimi

64. Neurovascular bundles of each digit are comparmentalised
by fascial layers making them vulnarable to swelling.

65. Etiology
 Fractures (18%)
 Soft tissue injuries (23%)
 Distal radial fractures (0.3%)
 Ipsilateral Elbow injuries (15%)
 In children;supracondylar fractures most frequent
 After intramedullary fixation of forearm in children
 Chronic exertional compartment synd. Of 1st dorsal
interisseous muscle and volar muscles seen in
motorcyclists.

66. Traumatic ischemia cycle by Eaton and
Green:

67.  Any situation that causes a decrease in
compartment size or increase in compartment
pressure can initiate compartment syndrome.
 Muscle necrosis occur with a rise in pressure to
within 20mm below diastolic pressure.

68. Diagnosis:
 Volar and dorsal forearm is tender and tense with
swelling.
 Sensibility of finger tips is diminished.
 Two-point discrimination and 256cycles/vibratory
testing can be helful in determining Nerve Ischemia.
 Compartment syndrome in a neonate may manifest as
sentinel bullous or ulcerative skin lesion over dorsum
of the forearm,wrist,hand.
 Compartment pressure over 30mmhg or with in
20mmhg of the diastolic pressure are indicative of
compartment syndrome.

69. Management :
 Fasciotomy should be performed in
 1.normotensive patient with positive clinical
findings and compartment pressure >30mmhg
 2.duration >8hrs
 3.uncooperative or unconscious patients with
pressure >30mmhg
 4.patients with low blood pressure and
compartment pressure >20mmhg.

70. Foream fasciotomy and Arterial
exploration
 Dorsal fore arm fascia is
released through the interval
between the extensor carpi
radialis brevis and extensor
digitorum communis.
 Volar curvilinear incision is
used that allows release of
lacetrus fibrosus proximally
and carpel tunnel distally.
 Interval between the flexor
carpi ulnaris and flexor
digitorum sublimis is used for
release of deep and
superficial compartments.

71. Vessel loop shoelace technique
 Arm elevated for 24 to 48
hours.
 Closure not possible within 5
days,a split thickness skin
graft should be applied.
 Closure of fasciotomy by vessel
loops are tightened
progressively during dressing
changes.
 Wound closure can be
accomplished in 2 weeks.
 Vaccum assisted wound closure
dressing is used in
management.

72. HAND FASCIOTOMY  A.longitudinal incision over
second and fourth
metacarpals and extending
just distal to wrist.
 Passively flex the
metacarpophalyngeal joints
and extend the proximal
interphalyngeal joints to
strech the muscles,ensuring
that all are adequately
released.
 Release the thenar and
hypothenar muscles by
making palmar radial and
ulnar incisions.
 B.Midaxial incision of finger

73. Complications of comparment
syndrome:
 Volkmann ischemic contracture
 Rhabdomyolysis
 Acute renal failure