1. Compartment syndrome and fasciotomy
Supparerk Prichayudh, M.D.

2. What is Compartment Syndrome?
Matsen’s definition 1980
“a compartment syndrome is a condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space.”

5. Where can it occur?
Anywhere there is an enclosed space typically restricted by fascia:
Upper Arm
Forearm
Hand
Thigh
Chest
Abdomen
Raised ICP of the brain

6. Causes of Compartment Syndrome (Primary)
Fracture of the long bones e.g. Tibia
Crush injuries
Burns Eschar
Lithotomy position
Pneumatic tourniquet
High Injury Trauma
Ischemia/Reperfusion
Penetrating injuries

7. Secondary Extremity Compartment Syndrome
Rare, %
part of the post-resuscitation SIRS
significant edema and associated compartment syndromes in 2 to 4 injured or non-injured extremities after massive resuscitation.
Mortality rate 35-70%
should be suspected in any injured patient who presents with profound hypotension, ISS > 25, transfusion of at least 10 units of PRBC
Rx: early detection and early fasciotomy

8. Pathophysiology Tissue Injury + Tissue Ischemia +Tissue Reperfusion
Cellular injury & Tissue swelling
↑ compartment pressure
Compartment syndrome

9. CS Pathogenesis Soft tissue injury/ischemia edema
Tissue Death
As pressure rises VR causing P
Tissue perfusion- arterial compression
Capillaries starting shutting down
Capillary leakage
Cellular Ischemia  superoxide
Radicals, procoagulants (esp. during reperfusion)
Cellular & interstitial edema

10. Local blood flow

11. Compartment pressure (normal 4-7 mmHG) ↑ > Capillary pressure (>25-30 mmHg)
prevents perfusion of tissues
ischemia and ultimately death of tissue.

12. Reactive Oxygen Metabolite ( ROM )
Unpaired outer orbit electron of Oxygen from Anaerobic Glucose Oxidation (Ischemia) + O2 (Reperfusion) → Superoxide Anion ( O2- ) → Hydrogen Peroxide ( H2O2 )/ Hydroxyl Radical (OH-)
- High energy and reactivity with organic molecules → Organic Radicals → Cellular damage (oxidation of unsaturated fatty acid within cell membrane)

13. Body antioxidant (oxygen scavenger)
ROM
OH- Strongest
H2O2
O2- weakest
Body antioxidant (oxygen scavenger)
Glutathione
Catalase
Superoxide dismutase
2O2- + 2H+
Superoxide dismutase
H2O2 + 1O2
H2O + O2
2 H2 O2
catalase

14. What are its consequences?
If not recognised and not treated  myoneural necrosis occurs due to  tissue pH as a result of lactic acidosis from anaerobic metabolism and a release of K+
Myoglobin is released leading to rhabdomyolysis  the products of this lead to acute tubular necrosis (ATN)  acute renal failure (ARF)
sepsis and death can result
So it is important to act swiftly once the diagnosis is suspected

15. Tissue Threshold to Ischemia
Muscle 4-8 hrs
Nerve 4-8 hrs
Fat 12 hrs
Skin 24 hrs
Bone hrs
Therefore for a viable functional limb the upper threshold is about 6 hrs

16. Anatomy

17. Arm Compartments
Anterior
Posterior

18. Forearm compartments Volar Lateral (Mobile WAD) Dorsal
This figure shows a cross section through of a left forearm.
 The compartments are labeled anterior (volar), posterior (dorsal) and the mobile WAD*.
 If you horizontally split the figure above; the top half would be the anterior (volar) compartment, and the lower half the posterior (dorsal) compartment.
 The posterior compartment contains those muscles which extend the wrist and fingers, and is innervated by the Radial nerve.
 The anterior compartment contains the muscles which flex the wrist and fingers,and is innervated mainly by the median nerve.
 *(Mobile WAD is a collective term for the lateral muscles brachioradialis, extensor carpi radialis brevis & extensor carpi radialis longus). 
These three muscles act as flexors at the elbow joint. Brachioradialis = elbow flexor and pronator.
Dorsal

19. Thigh compartments Anterior (flexor) Medial (adductor)
The thigh is usually divided into three compartments, each supplied by a specific nerve:[1]
Medial fascial compartment of thigh: obturator nerve
Posterior fascial compartment of thigh: sciatic nerve
Anterior fascial compartment of thigh: femoral nerve
Posterior (flexor)

20. Compartments of the Leg

21. Compartments of the Lower Limb
Anterior Compartment – main extensors of the leg
Anterior Tibialis, Extensor Hallicus and digitorum Longus, Peroneus
Deep peroneal nerve
1/3 blood supply to lower leg via Dorsalis Pedis and Anterior Tibialis
compartment syndrome– get foot drop
Loss of sensation skin between first and second toes
Weakness of toe extension pain on toe flexion
Deep Posterior Compartment – flexors of the foot and great toe
Flexors of foot and great toe
Tibeal Nerve
2/3 blood supply to lower leg via posterior tibial artery
Superficial Posterior Compartment – superficial flexors
Gastronemius
Soleus
Sural & Tibial Nerves
Plantar flexors
Blood supply posterior tibial
Weakness of toe flexion and ankle inversion, pain on passive extension
Lateral Compartment
Peroneus Longus and brevis
Superficial peroneal nerve
Plantar flexes foot
Tibia
Fibula
Fascia

22. Anterior Compartment is more susceptible to ischemia:
Stronger fascia  lower compliance
(c= v/ p )
More slow type 1 muscle fibres – rely on oxidative metabolism. Other compartments have more fast type 2 which can access their increased glycogen stores more via anaerobic metabolism

23. Clinical Compartment Pressure
Diagnosis
Clinical
Compartment Pressure

24. The 5 components of a physical examination
Inspection (swelling, trauma, skin changes)
Palpation and passive stretch of muscles in the compartments
Evaluation of sensory function
Evaluation of motor function
Evaluation of perfusion

25. Nerves are sensitive to diminished oxygen delivery
Sensory change & Weakness  Late signs
The presence of palpable pulses at the ankle or wrist in the injured extremity does not rule out the presence of a more proximal compartment syndrome.
The signs of a compartment syndrome described above occur at
compartment pressures significantly lower than arterial systolic and
diastolic pressures.

26. CS with high pressure  tapering of major arteries and temporary occlusion of collateral arteries (rare)
Crush injury of forearm
Before fasciotomy
After fasciotomy

27. Clinical Diagnoses Symptoms & Signs:
Deep aching Pain out of proportion to the injury
Incredible pain on passive movement of leg – due to stretched ischemic muscles
As arterial supply cut off - Pulselessness
Paresthesia - distally
Pallor
Perishing Cold
Paralysis
Tight tense swollen limb
Redness, mottling, blisters
6P’s may or may not be present; cannot exclude condition based on their absence

34. Compartment Pressures
(1) when a comprehensive history and physical examination cannot be performed in the preoperative or postoperative period.
(2) when there are no or few “high risk” criteria in a patient with a moderately severe injury to an extremity
(3) when there is concern about performing an unnecessary fasciotomy (ie, conversion of closed to open fracture).

35. NS The regular needle injection technique described by Whitesides and
colleagues33 in 1975 involves the use of a mercury manometer, a 20-mL
syringe, intravenous extension tubing, and an 18-gauge needle.
Movement of the air-saline column after injection of a “small amount of
saline” into the tissue is the point at which the compartment pressure is read
on the manometer.
Because of changes in tissue compliance at higher compartment
pressures, this technique has been reported to yield higher pressures than
actually exist.

36. A-line tubing & transducer
Use of a 16-gauge needle attached to arterial tubing &
connected to a standard transducer/monitor.
After flushing the tubing and needle with saline, the needle is held just above the compartment, and a “0” reading is obtained on the monitor.
The needle is then placed into the compartment, a small amount of saline is flushed, and a direct reading is soon available on the monitor.
When the pressure measurement is inconsistent with the clinical situation, a repeat measurement or more at another site is appropriate.

37. The Stryker Intra-Compartmental Pressure Monitor System (Stryker
Instruments, Kalamazoo, MI) includes a measuring instrument, disposable
syringe preloaded with saline and a side-ported, noncoring 18-gauge
disposable needle73 (Fig 13). After flushing, the hand-held monitor is
placed at the level of the compartment to be measured for a “0” reading.
The compartment pressure is read off the monitor after allowing for a
decrease in the original value over 15 to 20 seconds.

38. Near-Infrared Spectroscopy (NIR)
measures wavelengths of hemoglobin and oxyhemoglobin, but not carboxyhemoglobin or myogloblin, and calculates an StO2 or saturation of tissue oxygenation.
tissue oxygen saturation can be used for early detection of ischemia and/or neuromuscular dysfunction in patients with a compartment syndrome in an extremity.

39. Treatment Prevention and treatment of reperfusion injury
Non operative treatment
3. Fasciotomy

40. 1. Reperfusion Injury
Ischemic phase; Cellular Hypoxia → ↓Energy → ↑Potential to produce ROM( anaerobic glucose metabolism)
Reperfusion phase ( After revascularization, fasciotomy ); O2→ ↑ROM → Tissue destruction, Rhabdomyolysis (↑ CPK)  return of toxic metabolites to systemic circulation (ROM, K+, Bacteria, myoglobin, etc)  Hyperkalemia, sepsis, myoglobinuria, ATN, MOF

41. Rx reperfusion injury 1. Prevention 2. Rx hyperkalemia
Decrease ischemic time
Never reperfuse dead limb !!!
2. Rx hyperkalemia
3. Prevent RF  Prevent myoglobin precipitation in renal tubules
Hydration, promote urine flow > 100cc/hr, alkalinize urine
4. Mannitol  promote diuresis, antioxidant
0.25-2g/kg/dose over 4 hours, total < 200g/d
C/I  hypovolemic, anuric patients
5. antioxidant (vitamin C, E, selenium)
6. Dialysis if indicated

42. 2. Non operative treatment (rarely used, in stable patients with good limb function & perfusion)
Observation
Position of the Extremity
Hyperbaric Oxygen
Mannitol

43. 3. Fasciotomy
a surgical incision or splitting of the fascia to relieve a compartment syndrome
Principles
Timely
Adequate incisions (skin and fascia)

44. Indications for Fasciotomy
S & S of compartment syndrome
compartment pressure > mmHg
∆P (DBP-CP) < 30 mmHg
Prophylactic
any popliteal artery injury
any combined arterial and venous injury
prolonged extremity ischemia > 4-6 h
vascular injury associated with shock; crush injuries; combined skeletal and vascular extremity trauma; and the ligation of a major extremity vein or artery.

45. Fasciotomy is contraindicated for these reasons:
Reis, et al. Israel
J Bone Joint Surg 2005
Fasciotomy is contraindicated for these reasons:
1) A fasciotomy for MMCI does not improve outcome (muscle is already dead).
2) It does increase infection, bleeding and amputation rates.
3) The fasciotomies and subsequent debridements required consume scarce OR resources that could be better used on others
Only indication for fasciotomy  Absence of distal pulse without major arterial injury/ hypotension
Rx  conservative, fluid resuscitation

47. Thigh compartments Anterior (flexor) Medial (adductor)
The thigh is usually divided into three compartments, each supplied by a specific nerve:[1]
Medial fascial compartment of thigh: obturator nerve
Posterior fascial compartment of thigh: sciatic nerve
Anterior fascial compartment of thigh: femoral nerve
Posterior (flexor)

48. Fasciotomy of the Thigh Lateral skin incision  anterior and posterior compartments
Fasciotomy of the Anterior Compartment of the Thigh. First, a 30-cm
anterolateral skin incision is made starting at the intertrochanteric line
laterally and extending to the lateral condyle of the femur. Next, the
iliotibial tract (thickened fascia lata overlying vastus lateralis muscle) is
identified and opened for the length of the skin incision. Manual elevation
of the fascial envelope anteriorly will ensure decompression of the rectus
femoris and remaining vastus muscles.
Fasciotomy of the Posterior Compartment of the Thigh. The exposed
vastus lateralis muscle is mobilized superiorly and medially. In large and
muscular men, this can be difficult and the use of 2 Richardson retractors
for lifting is helpful. Next, the exposed lateral intermuscular septum, a
very thick structure, is then incised for the length of the skin incision to
decompress the posterior compartment.
Fasciotomy of the Medial Compartment of the Thigh. Pressures in the
medial compartment of the thigh often return to the normal range
following decompression of the anterior and posterior compartments.
Therefore, the pressure in the medial compartment is reassessed at this
time to avoid an unnecessary skin incision and fasciotomy. A 30-cm long
medial thigh skin incision is made over the course of the greater
saphenous vein, which is preserved, and extending to the medial condyle
of the femur. The sartorius muscle (anterior compartment) is then identified
and rotated anterolaterally. Last, the medial compartment is opened with a
longitudinal fascial incision for the length of the skin incision.
Decompression of thigh compartments. A, Incision from intertrochanteric line to lateral epicondyle.
B, Anterior compartment is opened by incising fascia lata, and vastus lateralis is retracted medially to expose
lateral intermuscular septum, which is incised to decompress posterior compartment.
C, Drawing of thigh compartments and appropriate incision.

49. Fasciotomy of the Leg 2-skin incision, 4-compartment fasciotomy

50. Fasciotomy of the Anterior and Lateral Compartments of the Leg
First, a 25- to 30-cm anterolateral incision is made 2-cm anterior to
the shaft of the fibula. This incision is approximately halfway between the
anterior border of the tibia and the shaft of the fibula in the average-sized
patient. Next, using rake retractors and the electrocautery device, skin and
subcutaneous tissue flaps are raised anteriorly and laterally to provide
complete exposure of the anterior and lateral compartments under their
investing fascia. A small transverse incision is made exposing the anterior
intermuscular septum if this cannot be clearly seen as it is the boundary
between the anterior and lateral compartments as mentioned above. The
fascia over the anterior compartment is then opened midway between the
anterior border of the tibia and the anterior intermuscular septum for
the length of the skin incision. The fascia over the lateral compartment is
then opened midway between the anterior intermuscular septum and the
shaft of the fibula for the length of the skin incision. Extra caution must
be taken in dividing the fascia over the distal one third of the lateral
compartment since the superficial peroneal (musculocutaneous) nerve
comes through the fascia at this point and continues in a subcutaneous
course. Some authors recommend aiming the scissors (that are used to
open the lateral compartment distally) at the lateral malleolus. The 2
longitudinal fasciotomy incisions performed through the same anterolateral
skin incision are approximately 5 to 6 cm apart.

51. Fasciotomy of the Superficial & Deep Posterior Compartment of the Leg.
Fasciotomy of the Superficial Posterior Compartment of the Leg. A
25- to 30-cm medial skin incision is made 2 cm posterior to the
posteromedial edge of the tibia from the level of the tibial tubercle to 2 cm
proximal to the medial malleolus. Every effort should be made to preserve
the greater saphenous vein and associated saphenous nerve in the
subcutaneous tissue after this skin incision is made. Next, the fascia over
the superficial posterior compartment is then opened 2 cm posterior to the
posteromedial edge of the tibia for the length of the skin incision.
Fasciotomy of the Deep Posterior Compartment of the Leg.133 The
deep posterior compartment of the leg immediately beneath the tibia is
covered by the triceps surae muscles in the proximal one third of the leg.
Therefore, the “soleal bridge” is detached from the tibia with the
electrocautery until the FDS longus and tibialis posterior muscles can be
decompressed for the length of the skin incision.

52. Foot compartments
Intrinsic
Medial
Lateral
Central

53. Fasciotomy of the Foot
Anatomy:     - the 9 compartments of the foot can be placed into 4 groups;     - Intrinsic Compartment:            - 4 intrinsic muscles between the 1st and 5th metatarsals;     - Medial Compartment:            - abductor hallucis;            - flexor hallucis brevis;     - Central Compartment: (Calcaneal Compartment)            - flexor digitorum brevis;            - quadratus plantae;            - adductor hallucis;     - Lateral Compartment:            - flexor digiti minimi brevis;            - abductor digiti minimi;
medial approach:           - this is usually the approach of choice;           - can be used to decompress the medial and central compartments as well as the remaining foot compartments;           - extends from a point below the medial malleolus (3 cm from the sole) to proximal aspect of first metatarsal;           - once the neurovascular bundle (medial plantar nerve and artery) has been retracted out of the way, the fascia overlying the abduction hallucis and FDB is released;           - medial intermuscular septum is opened longitudinally;           - the lateral plantar neurovascular bundle is found coursing over the quadratus plantae (central compartment) as they course laterally;           - the remaining compartments (central, lateral, intrinsic) are entered thru blunt dissection w/ a clamp;3           - lateral compartment is found by retracting the FDB out of the way;     - dorsal approach:           - often the dorsal approach is not necessary unless there is concomitant metatarsal or Lisfranc fractures;           - accomplished through 2 dorsal incisions centered just medial to the 2nd metatarsal and just lateral to the 4th metatarsals (to maximize skin bridge);                  - avoid injury to sensory nerves and extensor tendons;           - superficial fascia is divided and interosseous are elevated off the metatarsals to further decompress the compartments;           - clamp is used to bluntly dissect thru the central, medial, and lateral compartments;           - separate medial incision may be needed to release the abductor;           - fasciotomy incisions may be used for fracture fixation;

54. Arm Compartments
Anterior
Posterior

55. Fasciotomy of the Anterior and Posterior Compartments of the Arm
Using 1 Skin Incision. A 15-cm skin incision is made over the medial
intermuscular septum, carefully avoiding the underlying neurovascular bundle.
Using rake retractors and the electrocautery device, skin and subcutaneous
tissue flaps are raised anteriorly and posteriorly. The fascia over the
anterior compartment is then opened midway between the anterior border of
the biceps muscle and the medial intermuscular septum for the length of the
skin incision. The fascia over the posterior compartment is then opened
midway between the posterior border of the triceps muscle and the medial
intermuscular septum for the length of the skin incision.
Using 2 Skin Incisions. A 15-cm skin incision starting medial to the
bicipital sulcus is extended up the anteromedial arm to the acromion and
through the fascia to decompress the anterior compartment. A 15-cm skin
incision starting at the tip of the olecranon is extended up the posterolateral
arm and through the fascia to decompress the posterior compartment.

56. Forearm compartments Volar Lateral (Mobile WAD) Dorsal
This figure shows a cross section through of a left forearm.
 The compartments are labeled anterior (volar), posterior (dorsal) and the mobile WAD*.
 If you horizontally split the figure above; the top half would be the anterior (volar) compartment, and the lower half the posterior (dorsal) compartment.
 The posterior compartment contains those muscles which extend the wrist and fingers, and is innervated by the Radial nerve.
 The anterior compartment contains the muscles which flex the wrist and fingers,and is innervated mainly by the median nerve.
 *(Mobile WAD is a collective term for the lateral muscles brachioradialis, extensor carpi radialis brevis & extensor carpi radialis longus). 
These three muscles act as flexors at the elbow joint.[
Dorsal

57. Fasciotomy of the Forearm
Fasciotomy of the Volar and Lateral Compartments of the Forearm
(Volar-Ulnar Approach). A transverse incision starting distal to the
antecubital crease on the radial side of the forearm is extended to the ulnar
side of the forearm and then turned 90°. The longitudinal component of
the incision is extended down the ulnar side of the forearm until it
reaches the wrist, where it curves medially to the mid-aspect of the volar wrist. The incision is now extended and curved into the thenar crease of
the palm. By dividing the underlying fascia at the transverse origin of the
incision distal to the antecubital crease, the muscles of the lateral (mobile
wad) compartment are decompressed. The fascia underlying the longitudinal
and wrist components of the skin incision is opened, thereby
decompressing the superficial flexor muscles of the forearm and the
carpal tunnel.151 The space between the FCU and FDS muscles (flexing
the fingers will help differentiate these muscles) is separated with
retractors, and the ulnar nerve and artery are visualized lying on the deep
flexor compartment (Fig 16). The deep flexor compartment is opened
longitudinally after retracting the ulnar artery and nerve laterally and
ligating any small arterial branches in the area where the fasciotomy is to
be performed. Ideally, the fascia over each deep volar muscle should be
incised.149 If there is continued tightness at the level of the wrist, the
tunnels of the median and ulnar nerves should be divided.
Fasciotomy of the Dorsal Compartment of the Forearm. Pressures in
the dorsal compartment of the forearm often return to the normal range
following decompression of the volar and lateral compartments. Therefore,
the pressure in the dorsal compartment is reassessed at this time toavoid an unnecessary skin incision and fasciotomy. After the forearm is
pronated, a longitudinal skin incision from 2 cm lateral to and 2 cm distal
to the lateral epicondyle of the humerus to the mid-aspect of the posterior
wrist is made. A longitudinal fasciotomy to decompress the superficial
muscles of the dorsal compartment is made between the extensor carpi
radialis brevis and extensor digitorum communis muscles (extending the
fingers will help differentiate these muscles).

60. Fasciotomy of the Hand
The hand has thenar, hypothenar, adductor, and 4 interossei compartments.
An injection study published in 1980 demonstrated that the
traditional 4 interossei compartments were actually divided into 3 palmar
and 4 dorsal compartments, bringing the total number of compartments in
the hand to Other anatomic studies have demonstrated a significant
amount of variation in these 10 fascial compartments.154 Fortunately,
despite the described variations, the compartments of the hand can be
adequately decompressed with the traditional 4-incision fasciotomy.155
Fasciotomy of the Hand. Two 4-cm longitudinal incisions are made on
the dorsum of the hand over the metacarpal bones of the index and ring
fingers. Fascial incisions are then made along both sides of these
metacarpals, thereby releasing the 4 dorsal interosseous muscles. The first
palmar interosseous and adductor compartments are opened by blunt
dissection along the ulnar aspect of the index metacarpal bone. The
second and third palmar interosseous compartments are released by
dissection along the radial aspect of the ring and small metacarpal bones.
A longitudinal incision is then made along the radial side of the first
metacarpal bone to release the thenar compartment. A longitudinal
incision is made along the ulnar aspect of the fifth metacarpal bone to
release the hypothenar compartment.

61. Closure Techniques Delayed Primary Closure Shoelace Technique
Mechanical Devices
STAR (Suture Tension Adjustment Reel)
Dynamic Wound Closure Device (DWC)
Vacuum Assisted Closure
Skin Grafting

66. STAR Anchoring shell Winding shell 13 patients after fasciotomy
- wound width ranged from 6 to 8
cm, averaging 7.6 cm.
-The STAR was tightened daily at
the bedside.
- Closure required 2-4 days postplacement, averaging 2.9
days.
The STAR (Suture Tension Adjustment Reel; WoundTEK Inc., Newport,
RI) is a simpler device designed with a similar objective. In a series
from the University of Miami, this device was placed at the completion
of the fasciotomy or on the following day at the bedside.188 The device
consists of 2 shells, 1 anchoring shell, and 1 winding shell, which are
connected by heavy nylon suture. The winder shell was tightened at the
bedside using a wrench, and the wounds were reapproximated and closed
over several days under local anesthesia without a return trip to the
operating room. In this series, 13 patients had successful closure of their
wounds (average initial width 7.6 cm) with only 1 minor infectious
complication.188 The devices were removed at the bedside on final wound
closure. The main advantage of this device over the Sure-Closure device
is its compact size.
McKenney MG, Nir I, Fee T, Martin L, Lentz K. A simple device for closure of
fasciotomy wounds. Am J Surg 1996;172:275-7.

67. Long-Term Sequelae
Fitzgerald, et. Al in 2000  60 patients undergoing 45 leg and 15 forearm fasciotomies  primary closure 25, STSG 35
Fitzgerald AM, Gaston P, Wilson Y, Quaba A, McQueen MM. Long-term sequelae
of fasciotomy wounds. Br J Plast Surg 2000;53:690-3.

68. Conclusions: Compartment Syndrome
Early Dx
Pain, Tense, sensory & motor changes
Compartment pressure
Fasciotomy
Clinical of CS
Compartment pressure > mmHg
Prophylactic in high risk patients
Prevention and treatment of Reperfusion Injury

69. References
Dente CJ, Wyrzykowski AD, Feliciano DV., Fasciotomy. Curr Probl Surg Oct;46(10):
Asensio JA, Trunkey DD, editors. Current therapy of trauma and surgical critical care. Philadelphia: Mosby Elsevier; 2007