1. Compartment Syndrome T. Toan Le, MD and Sameh Arebi, MD
Original Author: Robert M. Harris, MD; Created March 2004
New Authors: T. Toan Le, MD and Sameh Arebi, MD; Revised December 2005

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

3. Compartment Syndrome Definition
Elevated tissue pressure within a closed fascial space
Reduces tissue perfusion - ischemia
Results in cell death - necrosis
True Orthopaedic Emergency

4. 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

5. 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.

6. 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

7. 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

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

9. 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

10. Compartment Syndrome Etiology
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

11. Compartment Syndrome Etiology
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
Causes range from minor trauma to major injuries and interosseous infusion of IV fluids. Open fractures can have a 9% incidence of Compartment Syndrome-(Brumback et al). The incidence of CS in electrical injuries is proportional to the amount of voltage the patient was exposed to: minimal risk with low voltage (normal household current) and can be as high as 40% in higher voltage. Most burn literature uses the loss of pulses to decide when to perform escharotomies, however, tissue perfusion may still be compromised. Temporary vascular occlusion can occur in obtunded states(drug abuse), operative positioning (hemi and full lithotomy), and prolonged tourniquet use. If compartment syndrome is suspected, tissue pressures measurement is warranted and fasciotomies performed as indicated and supported in the literature.

12. 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

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

14. 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

15. Incidence Type of Fx % of ACS Incidence all ages Incidence <35
Tibial diaphysis
36%
4.3%
5.9%(3 fold)
Distal radius
9.8%
0.25%
1.4%(30 fold)
Forearm diaphysis
7.9%
3.1%
3.2%
McQueen et al; JBJS Br 2000

16. Patient positioning
Meyer, Mubarak JBJS 2002

17. 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

18. Compartment Syndrome Pathophysiology
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
Normal resting muscle tissue pressure is up to 4 mm Hg and 8-10 with exertion. Exercise induced CS may have a resting based line of mmHg. Many studies utilizing clinical evaluations and animal models by Whitesides, Mubarak, Matsen, Heckman, Heppenstall and Matava have help to establish a better understanding of the pathophysiology and thresholds of ischemia. Two schools of though prevail: 1. The Absolute Pressure Theory of Murbarak and Matsen who suggest surgical decompression in CS with pressures that reach or exceed these thresholds. 2. The Perfusion Theory of Whitesides who demonstrated in animal models and human subjects the relationship of tissue perfusion and diastolic blood pressure. His group recommends surgical decompression when the tissue pressure is within 20mm Hg of the DBP. McQueen suggested a differential <30mmHg of the diastolic pressure and the intramuscular pressure as a threshold for release as being more reliable. Mean arterial pressure can also serve as a benchmark with a release suggested when intramuscular pressure is within 45 mm Hg. Caution must be exercised in traumatized tissue and especially in hypotensive patients

19. Compartment Syndrome Tissue Survival
Muscle
3-4 hours - reversible changes
6 hours - variable damage
8 hours - irreversible changes
Nerve
2 hours - looses nerve conduction
4 hours - neuropraxia
Studies have shown that nerve tissue is the most sensitive to ischemic changes. Nerve conduction is lost in 1-2 hours of total ischemia and survive up to 4 hrs with only neuropraxia changes, while axonotmesis and irreversible changes occur after 8 hrs. Muscle may survive up to 4 hours with reversible changes, variable damage occurs by 6 hrs, and irreversible changes after 8 hrs under conditions of warm ischemia.

20. Compartment Syndrome Diagnosis
Pain out of proportion
Palpably tense compartment
Pain with passive stretch
Paresthesia/hypoesthesia
Paralysis
Pulselessness/pallor
These physical findings have been described as the clinical hallmarks of CS. They are not very sensitive and if seen in the later stages it may be too late to change the underlying pathology. CS may be present with good pulses and no pallor and loss of pulses rarely occur unless arterial damage is present. Pain out of proportion and pain with passive stretch of a muscle in the compartment in question may be the most sensitive clinical finding before the onset of ischemic dysfunction of the nerves and muscles. These findings are useful only in a conscious cooperative patient and once paresthesia begin the pain may decrease. One important point to make is of CS is a possibility then regional anesthesia, continuous epidurals and PCA intravenous opiate analgesia should be avoided since they may mask the symptoms of compartment syndrome. Otherwise monitoring of the tissue pressure is warranted. There exist reports of missed compartment syndrome in tibia fracture and other surgical patients at risk managed postoperatively with these techniques and therefore they are generally avoided.

21. 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

22. 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 pallor, pulselessness, paralysis, paraesthesia etc. appear very late and we should not wait for these things.
Willis &Rorabeck OCNA 1990

23. 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

24. Compartment Syndrome Differential Diagnosis
Arterial occlusion
Peripheral nerve injury
Muscle rupture
These are in the differential but CS must be ruled out first

25. Compartment Syndrome Pressure Measurements
Suspected compartment syndrome
Equivocal or unreliable exam
Clinical adjunct
Contraindication
Clinically evident compartment syndrome
CS can many times be made by PE without tissue-pressure measurements. Pressure measurements can help the treating surgeon in his clinical decision making process in these situations, but in itself does not make the diagnosis of CS. If a CS is clinically evident do not waste valuable time trying to locate the equipment or set up for the pressure measurement, perform the indicated surgical decompression ASAP

26. Compartment Syndrome Pressure Measurements
Arterial line
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 wick
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.

27. Compartment Syndrome Pressure Measurements
Arterial line
Zero at the level of the affected limb

28. Compartment Syndrome Pressure 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
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.
Moed et al JBJS 1993

29. Compartment Syndrome Pressure 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

31. 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

32. 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

33. 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.

34. 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

35. Compartment Syndrome Emergent Treatment
Remove cast or dressing
Place at level of heart
(DO NOT ELEVATE to optimize perfusion)
Alert OR and Anesthesia
Bedside procedure
Medical treatment
Initial steps in treating an extremity with elevated pressures or evolving CS. Because tissue viability depends on arterial inflow, elevating the extremity will decrease the inflow and time to prevent the secondary effects of CS. Although ideally performed in the OR, fasciotomy may have to be performed at the bedside after appropriate surgical prep. Animal studies have show some efficacy of extending muscle ischemia tolerance with the use of anticoagulants, steroids and hypothermia. Clinically most pharmacological agents are ineffective unless perfusion to the muscle tissue has been reestablished. Hypothermia may be useful to extend the time period until reperfusion or fasciotomies can be performed

36. Fasciotomy, Fasciotomy, Fasciotomy,
Surgical Treatment
Fasciotomy, Fasciotomy, Fasciotomy,
All compartments !!!

37. Compartment Syndrome Surgical Treatment
Fasciotomy - prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma.
Fracture care – stabilization
Ex-fix
IM Nail
Surgical decompression does not reverse the damage present but can prevent secondary sequella of the CS. Fasciotomies destabilize any long bone or extremity fracture. Studies have shown ex-fix and URN in tibias may provide temporary or permanent fixation for treatment of the fracture.

38. Compartment Syndrome Indications for Fasciotomy
Unequivocal clinical findings
Pressure within 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)
These are indications for surgical decompression. A missed CS > hours should not be opened. (see Rockwood and Green 5th edition and Campbell’s 10 th edition) The damage cannot be reversed and there is a significant infection rate when the dead tissue is exposed to the hospital environment. The surgeon must deal with the residual contractures of the ischemic muscle and not risk the chance of infection. Some have suggested that the scarred ant tib muscle can serve as a check rein and limit foot drop sequelae.

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

40. Compartment Syndrome Lower Leg
Lateral: Peroneus longus and brevis
Anterior: EHL, EDC, Tibialis anterior, Peroneus tertius
Supeficial posterior-Gastrocnemius, Soleus
Deep posterior-Tibialis posterior, FHL, FDL .
Four compartments of the leg contain these names muscles and corresponding arteries and nerves. Complete release of all four compartments is mandatory. Physical exam based on sensory loss may be useful in exercise induced CS. The nerves are the most sensitive to ischemic changes.

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

42. 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

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

44. Fasciotomy: Lateral Leg
Intermuscular septum
Superficial peroneal nerve

45. Look for Superficial Peroneal Nerve
superficial peroneal nerve exits from lateral compartment about 10 cm above lateral malleolus and courses into the anterior compartment
Risk of injury

46. 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

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

48. Forearm Fasciotomy Volar-Henry approach
Include a carpal tunnel release
Release lacertus fibrosus and fascia
Protect median nerve, brachial artery and tendons after release
Volar approach use Henry Approach to release superficial and deep flexors flexors followed by the pronators and supinator. The dorsal approach is centered over the proximal forearm and can be used to release the Mobile Wad (BR, ECRL,ECRB). It is important to remember when treating and electrical injury with a compartment syndrome, the most damage is deep along the bone (i.e. the Pro and Sup muscles) and may require debridement at the initial surgery…Do not miss this!

49. Forearm Fasciotomy
Protect median nerve, brachial artery and tendons after release
Consider dorsal release
Volar approach use Henry Approach to release superficial and deep flexors flexors followed by the pronators and supinator. The dorsal approach is centered over the proximal forearm and can be used to release the Mobile Wad (BR, ECRL,ECRB). It is important to remember when treating and electrical injury with a compartment syndrome, the most damage is deep along the bone (i.e. the Pro and Sup muscles) and may require debridement at the initial surgery…Do not miss this!

50. Compartment Syndrome Foot
Medial, Superficial, Lateral, Calcaneal
Interossei(4), Adductor
Careful exam with any swelling
Clinical suspicion with certain mechanisms of injury
Lisfranc fracture dislocation
Calcaneus fracture
Compartment syndromes do occur in the foot and must not be overlooked in the polytrauma patient, neurologically impaired, or assumed to be swelling and edema. Authors disagree about the number of actual compartments in the multiple layers of the foot. Clinical suspicion should be heightened with crush injuries, LisFranc injuries and looked for in the polytrauma or unconscious patient.

51. Compartment Syndrome Foot
Dorsal incision-to release the interosseous and adductor
Medial incision-to release the medial, superficial lateral and calcaneal compartments
Dorsal incisions placed over 1st and 3rd web space, can be used to decompress and reduce and fix fractures. Medial incision releases medial compartment and affords access to the base of the hallux
DeCoster, T. Miller, R. Management of Traumatic Foot Wounds. J of AAOS 12; Jul/Aug 1994.

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

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

54. Compartment Syndrome Thigh
Lateral to release anterior and posterior compartments
May require medial incision for adductor compartment
Vastus lateralis
Lateral septum

55. Compartment Syndrome Other Areas
Can occur anywhere in the body
Hand-dorsal incisions, thenar, hypothenar
Arm-lateral incision
Buttock-posterior (Kocher) approach
Abdominal- with the Trauma surgeons
CS can occur anywhere in the body where muscle tissue is contained within fascia. These are examples of the locations and the type of incisions used to perform the surgical decompression. Abdominal CS is now becoming well recognized in the Gen Surg and Trauma literature, the Orthopaedic surgeon should know how to measure bladder pressures with the foley.

56. Delayed Fasciotomy Is 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.

57. Delayed Fasciotomy Is 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

58. 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

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

60. Wound Management Wound is not closed at initial surgery
Second look debridement with consideration for coverage after 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

61. Wound Closure
STSG
Delayed primary closure with relaxing incisions

62. 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

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

64. 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.

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

66. Questions
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