1. MUHAMMAD FARRUKH BASHIR
Compartment syndrome
MUHAMMAD FARRUKH BASHIR
FCPS(ortho)

2. Increase in hydrostatic pressure in closed osteofascial space resulting in decreased perfusion of muscle and nerves within compartment

3. Symptoms resulting from increased pressure within a limited space
Definition
Symptoms resulting from increased pressure within a limited space
compromising
circulation
function

4. Local Blood Flow is reduced as a consequence of compression.
Pathophysiology
Local Blood Flow is reduced as a consequence of compression.

5. Pathophysiology
A continuous increase in pressure within a compartment occurs until the low intramuscular arteriolar pressure is exceeded and blood cannot enter the capillaries

6. Increased venous pressure
Pathophysiology
Increased compartment pressure
Increased venous pressure
Decreased blood flow
Decreases perfusion

7. 4 hours - reversible damage 8 hours - irreversible changes
Muscle Ischemia
4 hours - reversible damage
8 hours - irreversible changes
4-8 hours - variable
Hargens JBJS 1981

8. Muscle Ischemia Myoglobinuria after 4 hours
Renal failure
Maintain a high urinary output
Alkalinize the urine
Cell death initiates a “vicious cycle”
increase capillary permeability
increased muscle swelling

9. Increased muscle swelling
Increased permeability
Increased compartment pressure

10. Increased pressure
Increased venous pressure
Decreased blood flow
Decreases perfusion

11. 1 hour - normal conduction 1- 4 hours - neuropraxic damage reversible
Nerve Ischemia
1 hour - normal conduction
1- 4 hours - neuropraxic damage reversible
8 hours - axonotmesis and irreversible change
Hargens et al. JBJS 1979

12. Pathophysiology: CAUSES:
Increased Volume - internal : hemmorhage, fractures, swelling from traumatized tissue, increased fluid secondary to burns, post- ischemic swelling
Decreased volume - external: tight casts, dressings
Most common cause of hemmorhage into a compartment: fractures of the tibia, elbow, forearm or femur

13. Etiology Fractures Soft Tissue Injury (Crush) Arterial Injury
Post-ischemic swelling
Reperfusion injury
Drug Overdose (limb compression)
Burns

14. Pathophysiology:
Most common cause of compartment syndrome is muscle injury that leads to edema

15. Diagnosis Clinical diagnosis Syndrome High index of suspicion History
Physical Exam

16. Difficult Diagnosis pain pallor paralysis pulselessness paresthesias
Classic signs of the 5 P’s –( ARE NOT RELIABLE):
pain
pallor
paralysis
pulselessness
paresthesias
These are signs of an ESTABLISHED compartment syndrome where ischemic injury has already taken place
These signs may be present in the absence of compartment syndrome.

17. Diagnosis
Palpable pulses are usually present in acute compartment syndromes unless an arterial injury occurs
Sensory changes and paralysis do not occur until ischemia has been present for about 1 hour or more

18. Diagnosis
The most important symptom of an impending compartment syndrome is PAIN OUT OF PROPORTION TO THAT EXPECTED FOR THE INJURY

19. Pain Passive muscle stretching Out of proportion Progressive
Signs & Symptoms
Pain
Passive muscle stretching
Out of proportion
Progressive
Not relieved by immobilization

20. Signs & Symptoms Tense compartment on palpation
Elevated compartment pressure

21. Who is at high risk?

22. High energy fractures Widely displaced Severe comminution Bilateral
Floating knee
Open fractures
Severe comminution
Joint extension
Segmental injuries

23. Criteria-Compartment Pressure
INTRA COMPARTMENTAL PRESSURE > THAN 30 mm of Hg.

24. Pressure Measurement Arterial line Infusion Catheter Stryker device
ga. Needle
(5-19 mm Hg higher)
transducer
monitor
Stryker device
Side port needle
Infusion
manometer
saline
3-way stopcock
(Whitesides, CORR 1975)
Catheter
wick
slit catheter
Whitesides described the use of a 3-way stop cock connected to a mercury manometer(now against JCAH rules-biohazard)
An arterial line using a large bore needle hooked up to a transducer and monitor in any ICU, OR or the recovery room will work. Remember that a standard needle will give higher results than a side port (Srtyker) or wick catheter. (Moed and Thorderson, JBJS(A), 1993) The stryker device is one of the more commonly used portable hand-held devices used for the tissue pressure measurements and since the redesign of the side port needle is very accurate. All devices must have the transducer at the level of the needle to be zeroed for an accurate reading.

25. Pressure Measurement Needle Catheter
18 gauge
Side ported
Catheter
wick
slit
Performed within 5 cm of the injury if possible-Whitesides, Heckman
Whitesides et al have demonstrated that the pressure measurements should be done within 5 cm of the fracture (tibia) to obtain a true pressure reading within the suspected compartment.
Side port

26. Most Common Locations
Leg: deep posterior and the anterior compartments
Forearm: volar compartment, especially in the deep flexor area

27. Where to Measure

28. Pressure Deeper muscles are initially involved
Distance from fracture affects pressure
Heckmen et al. JBJS 1994

29. Compartments
Anterior
Lateral
Posterior
Deep
Superficial

30. Anterior Lateral Posterior Deep Superficial Compartments TA EDL EHL
Peroneus TP
FDL
FHL
Soleus
Gastroc

31. Treatment Remove restricting bandages Serial exams When diagnosis made
Immediate surgery
4 compartment fasciotomy

32. Treatment
THE ONLY EFFECTIVE WAY TO DECOMPRESS AN ACUTE COMPARTMENT SYNDROME IS BY SURGICAL FASCIOTOMY!!! (unless missed compartment syndrome)

33. All 4 compartments must be released
Treatment
Fasciotomy
One incision
With or without Fibulectomy
Two incisions
All 4 compartments must be released
Not selective

34. One Incision
Direct lateral incision

35. Perifibular Fasciotomy
One incision
Head of fibula to proximal tip of lateral malleolus
Incise fascia between soleus and FHL distally and extended proximally to origin of soleus from fibula
Deep posterior compartment released off of the interosseous membrane, approached from the interval between the lateral and superfical posterior compartments

36. Lateral compartment

37. Anterior compartment

38. Superficial posterior compartment

39. Deep posterior compartment

40. Two incisions
Lateral
Medial

41. Medial
Soleus bridge
Saphenous

43. Double Incision
2 vertical incisions separated by a skin bridge of at least 8 cm.

44. Thigh Rare Crush injury with femur fracture Over distraction
relative under distraction

45. Thigh
Quadriceps
Lateral
Hamstrings
Posterior
Abductor
Medial

46. Based upon involvement Usually Quadriceps and Hamstrings
Treatment
Based upon involvement
Usually Quadriceps and Hamstrings
Usually, a single lateral incision will suffice

47. Compartments of the Forearm
Forearm can be divided into 3 compartments: Dorsal, Volar and “Mobile Wad”
Mobile Wad: Brachioradialis, ECRL, ECRB
Dorsal: EPB, EPL, ECU, EDC
Volar: FPL, FCR, FCU, FDS, FDP, PQ

48. Henry Approach

49. Henry Approach Fascia over superficial muscles is incised
Care of NV structures

50. Dorsal Approach Usually not necessary for forearm compartment syndrome
Straight incision from the lateral epicondyle to the midline of the wrist
Interval between the ECRB and EDC is used to access deep fascia

51. Aftercare VAC dressings Elevation of limb Delayed wound closure
Split thickness skin graft

52. Remember… Fasciotomies are not benign Complications are real >25%
Chronic swelling
Chronic pain
Muscle weakness
Iatrogenic NV injury
Cosmetic concerns
*** BUT if they are needed do not come up with
excuses to not do them !!!