Compartment Syndrome :Compartment Syndrome


Compartment SyndromeDefinition :Compartment SyndromeDefinition Elevated tissue pressure within a closed fascial space Reduces tissue perfusion - ischemia Results in cell death - necrosis True Orthopaedic Emergency


Acute Compartment Syndrome Of The Upper Arm :Acute Compartment Syndrome Of The Upper Arm


Slide 4:trapezius m. latissimus dorsi m. levator scapulae m. rhomboideus major m. rhomboideus minor m. serratus anterior m. infraspinatus m. supraspinatus m. subscapularis m. teres minor m. teres major m. deltoid m. Extrinsic shoulder mm. Intrinsic shoulder mm. Anterior thorax mm. 1) pectoralis major and minor mm. 2) subclavius m.


Brachium :Brachium biceps brachii m. long head short head brachialis m. coracobrachialis m. triceps brachii m. lateral head medial head long head anconeus m. Antr compartment Postr compartment


Anatomy of compartment :Anatomy of compartment Deep fascia Shape to muscles Assists in contraction of muscles by attaching with bones and making compartment closed space problem


Compartment Syndrome :Compartment Syndrome A condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space.


Compartment Syndrome :Compartment Syndrome when pressure within a closed muscle compartment exceeds the perfusion pressure it will results in muscle and nerve ischemia.


History :History Volkmann 1881 Richard von Volkmann 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


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


History :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


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


History :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


History :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


Incidence :Incidence McQueen et al; JBJS Br 2000 164 pts with CS, 149 male, 15 female Most pts were usually under 35 69% with associated fx, about half were tibial shaft 23% soft tissue injury without fx Ranges of 2-12% have been published


Incidence :Incidence McQueen et al; JBJS Br 2000


Compartment SyndromeEtiology :Compartment SyndromeEtiology Compartment Size tight dressing; Bandage/Cast localised external pressure; lying on limb Closure of fascial defects Compartment Content Bleeding; Fx, vas inj, bleeding disorders Capillary Permeability; Ischemia / Trauma / Burns / Exercise / Snake Bite / Drug Injection / IVF


Compartment SyndromeEtiology :Compartment SyndromeEtiology Fractures-closed and open Blunt trauma Temp vascular occlusion Cast/dressing Closure of fascial defects Burns/electrical Exertional states GSW IV/A-lines Hemophiliac/coag Intraosseous IV(infant) Snake bite Arterial injury


compartment syndrome of upper arm :compartment syndrome of upper arm Rare Trauma Burns Infection Fracture neck of Humerous Triceps avulsion steroid use in athletes thrombolytic therapy prolonged pressure on the arm during sleep or unconsciousness as a result of alcohol or other drugs(binge drinking)


Fracture :Fracture The most common cause incidence of accompanying compartment syndrome of 9.1% The incidence is directly proportional to the degree of injury to soft tissue and bone occurred most often in association with a comminuted, grade-III open injury to a pedestrian Blick et al JBJS 1986


Blunt Trauma :Blunt Trauma 2nd most common cause About 23% of CS 25% due to direct blow McQueen et al; JBJS Br 2000


Compartment SyndromePathophysiology :Compartment SyndromePathophysiology 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


Compartment SyndromeTissue Survival :Compartment SyndromeTissue 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


Compartment SyndromeDiagnosis :Compartment SyndromeDiagnosis Pain out of proportion Palpably tense compartment Pain with passive stretch Paresthesia/hypoesthesia Paralysis Pulselessness/pallor


Clinical Evaluation :Clinical Evaluation “Pain and the aggravation of pain by passive stretching of the muscles in the compartment in question are the most sensitive (and generally the only) clinical finding before the onset of ischemic dysfunction in the nerves and muscles.” Whitesides AAOS 1996


Clinical Evaluation :Clinical Evaluation Beware of epidural analgesia Strecker JBJS 1986 Morrow J. Trauma 1994 Beware long acting nerve blocks Hyder JBJS Br 1995 Beware controlled intravenous opiate analgesia


Clinical Evaluation :Clinical Evaluation Pain – most important. Especially pain out of proportion to the injury (child becoming more and more restless /needing more analgesia) Most reliable signs are pain on passive stretching and pain on palpation of the involved compartment Other features like(5 p) pallor, pulselessness, paralysis, paraesthesia etc. appear very late and we should not wait for these things. Willis &Rorabeck OCNA 1990


Lab :Lab W.B.C raised urea creatinine K GGT creatinine kinase (C.K) normal 10-186 u/l).


management :management check pressure :10-30 mmHg higher than diastolic needs fasciotomy immediately. Abnormal Nerve function after 1/2 hour Functional impairment after 2-4 hours Irreversible function loss after 4-12 hours Acute Renal Failure : Rhabdomyolysis


Compartment SyndromePressure Measurements :Compartment SyndromePressure Measurements Measurements must be made in all compartments Anterior and deep posterior are usually highest Measurement made within 5 cm of fx Marginal readings must be followed with repeat physical exam and repeat compartment pressure measurement Heckman, Whitesides JBJS 1994


Compartment SyndromeEmergent Treatment :Compartment SyndromeEmergent Treatment Remove cast or dressing Place at level of heart (DO NOT ELEVATE to optimize perfusion) Alert OR and Anesthesia Bedside procedure Medical treatment


Compartment SyndromePressure Measurements :Compartment SyndromePressure Measurements Infusion manometer saline 3-way stopcock (Whitesides, CORR 1975) Catheter wick slit wick Arterial line 16 - 18 ga. Needle (5-19 mm Hg higher) transducer monitor Stryker device Side port needle


Compartment SyndromePressure Measurements :Compartment SyndromePressure Measurements Arterial line Zero at the level of the affected limb


Compartment SyndromePressure Measurements :Compartment SyndromePressure Measurements Simple Needle 18 gauge Least accurate Usually gives falsely higher reading Slit Catheter and Side ported needle No significant difference More accurate Side port Moed et al JBJS 1993


Patient Positioning :Patient Positioning Leaving the calf free when the leg is placed in the hemilithotomy position instead of using a standard well-leg holder Increases the difference between the diastolic blood pressure and the intramuscular pressure May decrease the risk of compartment syndrome Meyer, Mubarak JBJS 2002


Patient positioning :Patient positioning Meyer, Mubarak JBJS 2002


Compartment SyndromeDifferential Diagnosis :Compartment SyndromeDifferential Diagnosis Arterial occlusion Peripheral nerve injury Muscle rupture


Compartment SyndromePressure Measurements :Compartment SyndromePressure Measurements Suspected compartment syndrome Equivocal or unreliable exam Clinical adjunct Contraindication Clinically evident compartment syndrome


SUSPECTED COMPARTMENT SYNDROME :SUSPECTED COMPARTMENT SYNDROME Unequivocal + Findings FASCIOTOMY Pt. not alert/polytrauma/inconc. Comp. pressure measurement w/i 30 mm Hg >30 mm Hg of DBP Serial exams FASCIOTOMY McQueen JBJSB 1996


Threshold for fasciotomy :Threshold for fasciotomy McQueen, Court-Brown JBJS Br 1996 116 pts with tibial diaphyseal fx had continuous monitoring of anterior compartment pressure for 24 hours 53 pts had ICP over 30 mmHg 30 pts had ICP over 40 mmHg 4 pts had ICP over 50 mmHg Only 3 had delta pr(DBP-ICP) of < 30, they had fasciotomy None of the patients had any sequelae of the compartment syndrome Decompression should be performed if the differential pressure level drops to under 30 mmHg


Medical Management :Medical Management Ensure patient is normotensive ,as hypotension reduces prefusion pressure and facilitates further tissue injury. Remove cicumferential bandages and cast Maintain the limb at level of the heart as elevation reduces the arterial inflow and the arterio-venous pressure gradient on which perfusion depends. Perfusion pressure = A pr(30-35mmHg) – V pr(10-15mmHg) Supplemental oxygen administration.


Medical Management :Medical Management Compartmental pressure falls by 30% when cast is split on one side Falls by 65% when the cast is spread after splitting. Splitting the padding reduces it by a further 10% and complete removal of cast by another 15% Total of 85-90% reduction by just taking off the plaster! Garfin, Mubarak JBJS 1981


Surgical Treatment :Surgical Treatment Fasciotomy, Fasciotomy, Fasciotomy, All compartments !!!


Fasciotomy Principles :Fasciotomy Principles Make early diagnosis Long extensile incisions Release all fascial compartments Preserve neurovascular structures Debride necrotic tissues Coverage within 7-10 days


Surgical incision for decompression of upper arm compartment :Surgical incision for decompression of upper arm compartment


Surgical incision extending to forearm for decompression :Surgical incision extending to forearm for decompression


Compartment SyndromeSurgical Treatment :Compartment SyndromeSurgical Treatment Fasciotomy - prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma. Fracture care – stabilization Ex-fix IM Nail


Compartment SyndromeIndications for Fasciotomy :Compartment SyndromeIndications for Fasciotomy Unequivocal clinical findings Pressure within 15-20 mm hg of DBP Rising tissue pressure Significant tissue injury or high risk pt > 6 hours of total limb ischemia Injury at high risk of compartment syndrome CONTRAINDICATION - Missed compartment syndrome (>24-48 hrs)


Use a Generous Incision :Use a Generous Incision Lengthening the skin incisions to an average of 16 cm decreases intracompartmental pressures significantly. The skin envelope is a contributing factor in acute compartment syndromes of the leg and The use of generous skin incisions is supported Cohen, Mubarak JBJS Br 1991


Compartment SyndromeLower Leg :Compartment SyndromeLower Leg 4 compartments Lateral: Peroneus longus and brevis Anterior: EHL, EDC, Tibialis anterior, Peroneus tertius Supeficial posterior-Gastrocnemius, Soleus Deep posterior-Tibialis posterior, FHL, FDL .


Compartment SyndromeHand :Compartment SyndromeHand non specific aching of the hand disproportionate pain loss of digital motion & continued swelling MP extension and PIP flexion difficult to measure tissue pressure


Single Incision :Single Incision Perifibular Fasciotomy Matsen et al (1980) Single incision just posterior to fibula Common peroneal nerve


Double Incision :Double Incision In most instances it affords better exposure of the four compartments 2 vertical incisions separated by minimum 8 cm One incision over anterior and lateral compartments Superficial peroneal nerve One incision located 1-2 cm behind postero-medial aspect of tibia Saphenous nerve and vein Mubarak et al JBJS 1977


Forearm Fasciotomy :Forearm Fasciotomy Volar-Henry approach Include a carpal tunnel release Release lacertus fibrosus and fascia Protect median nerve, brachial artery and tendons after release


Forearm Fasciotomy :Forearm Fasciotomy Protect median nerve, brachial artery and tendons after release Consider dorsal release


Interim Coverage Techniques :Interim Coverage Techniques Simple absorbent dressing Semipermeable skin-like membrane Vessel loop “bootlace” “VAC” (Vacuum Assisted Closure)


Compartment SyndromeForearm :Compartment SyndromeForearm Anatomy-3 compartments Mobile wad-BR,ECRL,ECRB Volar-Superficial and deep flexors Dorsal-Extensors Pronator quadratus described as a separate compartment


Fasciotomy of Hand :Fasciotomy of Hand 10 separate osteofascial compartments dorsal interossei (4) palmar interossei (3) thenar and hypothenar (2) adductor pollicis (1)


Compartment SyndromeOther Areas :Compartment SyndromeOther Areas Can occur anywhere in the body Hand-dorsal incisions, thenar, hypothenar Arm-lateral incision Buttock-posterior (Kocher) approach Abdominal- with the Trauma surgeons


Fasciotomy: Medial Leg :Fasciotomy: Medial Leg Flexor digitorum longus Gastroc-soleus


Fasciotomy: Lateral Leg :Fasciotomy: Lateral Leg Superficial peroneal nerve Intermuscular septum


Complications related to CS :Complications related to CS Late Sequelae Volckmann’s contracture Weak dorsiflexors Claw toes Sensory loss Chronic pain Amputation


Delayed FasciotomyIs it Safe? :Delayed FasciotomyIs it Safe? Sheridan, Matsen.JBJS 1976 infection rate of 46% and amputation rate of 21% after a delay of 12 hours 4.5 % complications for early fasciotomies and 54% for delayed ones Recommendations If the CS has existed for more than 8-10 hrs, supportive treatment of acute renal failure should be considered. Skin is left intact and late reconstructions maybe planned.


Delayed FasciotomyIs it Safe? :Delayed FasciotomyIs it Safe? Finkelstein et al. J Trauma 1996 5 pts, nine fasciotomies in lower limbs Avg delay 56 h. (35-96 hrs). 1 pt died of septicaemia and multi organ failure, the others required amputations Recommendations: In delayed cases, routine fasciotomy may not be successful


Wound Management :Wound Management Wound is not closed at initial surgery Second look debridement with consideration for coverage after 48-72 hrs Limb should not be at risk for further swelling Pt should be adequately stabilized Usually requires skin graft DPC possible if residual swelling is minimal Flap coverage needed if nerves, vessels, or bone exposed Goal is to obtain definitive coverage within 7-10 days


Wound Management :Wound Management After the fasciotomy, a bulky compression dressing and a splint are applied. “VAC” (Vacuum Assisted Closure) can be used Foot should be placed in neutral to prevent equinus contracture. Incision for the fasciotomy usually can be closed after three to five days


Wound Closure :Wound Closure STSG Delayed primary closure with relaxing incisions


Complications Related to Fasciotomies :Complications Related to Fasciotomies Altered sensation within the margins of the wound (77%) Dry, scaly skin (40%) Pruritus (33%) Discolored wounds (30%) Swollen limbs (25%) Tethered scars (26%) Recurrent ulceration (13%) Muscle herniation (13%) Pain related to the wound (10%) Tethered tendons (7%) Fitzgerald, McQueen Br J Plast Surg 2000


Medical/Legal Pitfalls :Medical/Legal Pitfalls Most frequent cause of litigation In 1993, Templeman reported an average litigation award of $280,000 for 8 cases of missed CS. In all 8 cases, compartment pressures were never measured. Failure to consider potential errors in compartment pressure measurements Equipment errors occur, and needles are misplaced into tendons, fascia, or a wrong compartment. Interpret all pressure readings within the context of the clinical presentation.


Summary :Summary Keep a high index of suspicion Treat as soon as you suspect CS If clinically evident, do not measure pressures Fasciotomy Reliable, safe, and effective The only treatment for compartment syndrome, when performed in time