25th September 2017

COMPARTMENT SYNDROME

Team VII : MH/ZP/QM/AB

Moderator : TM
Supervisor : Dr. dr. Muhammad Sakti, Sp.OT (K)
Introduction

 Compartment syndrome is defined as raised interstitial

tissue pressure within a confined space in the body (an
osseofascial compartment) results in microvascular
compromise leading to inadequate tissue perfusion and
eventually leading to tissue necrosis within the
compartment

Ashish K. Compartment syndrome. Mercer’s textbook of orthopaedic.

 Introduction
 Pathophysiology
 local trauma and soft tissue destruction > bleeding and
edema > increased interstitial pressure > reduced
microvascular perfusion > macrovascular arterial occlusion
> myoneural ischemia

 Swelling and ultimate loss of viability of a muscle group, is

caused by compromised circulation within a confined
anatomic space
 anterior tibial compartment of the leg, the volar compartment
of the forearm, or the interosseous compartments of the hand

Moore D. Compartement Syndrome. In: Orthobullets.com.

Bullough PG. The Effects of Injury and the Inflammatory Response. In Orthopaedic Pathology 5th ed. 2010.
 The tolerance of tissue to prolonged ischemia varies
according to the type of tissue.

 Functional impairment in muscles has been

demonstrated after 2 to 4 hours of ischemia, and
irreversible functional loss occurs after 4 to 12 hours.

 Nerve tissue shows abnormal function after 30 minutes

of ischemia, with irreversible functional loss after 12 to 24
hours.

Ashish K. Compartment syndrome. Mercer’s textbook of orthopaedic.

Introduction
 Special considerations
 vascular injuries treated with revascularization
 revascularization of a previously ischemic limb leads to swelling and
intracomparmental hypertension
 consider prophylactic fasciotomies following all repairs of traumatic
vascular injuries
 pediatrics
 children are unable to verbalize feelings
 if suspicious then perform compartment pressure measurement under
sedation
 increasing pain medication requirement and pain out of proportion to
injury is the most sensitive clinical sign

Moore D. Compartement Syndrome. In: Orthobullets.com.

Etiology of Compartement Syndrome
 The cause may be
 Endogenous pressure due to an increase in volume within
the compartment.
 Exogenous pressure (eg, restrictive plaster casts)

AO Principles of Fracture Management

Thompson JC. Basic Science. In: Netter’s Concise Orthopaedic Anatomy 3rd ed. 2010
Ashish K. Compartment syndrome. Mercer’s textbook of orthopaedic.
PATHOGENESIS

Ashish K. Compartment syndrome. Mercer’s textbook of orthopaedic.

PATHOGENESIS
 Effect on muscle
 Centre of the muscle belly undergoes more severe necrotic
damage than the periphery

 Type 1 aerobic fibres (red/slow-twitch fibres), which depend on

oxidative metabolism of triglycerides, are more vulnerable to
ischaemia than type 2 anaerobic fibres (white/fast-twitch fibres) 
That explains why some muscle groups are more vulnerable to
ischaemic damage than others.

Ashish K. Compartment syndrome. Mercer’s textbook of orthopaedic.

PATHOGENESIS
 Effect on nerve
 Peripheral nerve conduction block by high muscle
compartment pressure occurs from an as yet unclear complex
interplay of ischaemia, compression, toxic free radicals and
acidosis.
 Both the duration and magnitude of compartmental pressure
elevation are important in producing neuromuscular deficits

 Effect on bone
 Compartment syndrome reduces the healing capacity of
long bones, by possibly reducing the extra-osseous blood
supply and non-union can be a possible complication.

Ashish K. Compartment syndrome. Mercer’s textbook of orthopaedic.

CLINICAL SYMPTOMS
The Five “P”s remain the cornerstone of diagnosis :
 Pain out of proportion to the injury or with passive
stretching
 Pallor
 Pulselessness
 Paresthesia
 Paralysis

Ashish K. Compartment syndrome. Mercer’s textbook of orthopaedic.

CLINICAL SYMPTOMS
 Palpable tenseness of the swollen affected compartment is
often the earliest sign  palpation will reproduce the pain

 Pain on passively stretching the muscles of the affected

compartment is a recognized symptom, but this is also an
unreliable sign.

 Paresthesia and hypoesthesia are usually the first signs of

nerve ischemia, although sensory abnormality may be the
result of concomitant nerve injury

 Motoric weakness is a late change.

AO Principles of Fracture Management
Ashish K. Compartment syndrome. Mercer’s textbook of orthopaedic.
CLINICAL SYMPTOMS
 Pulses are almost always palpable in a compartment
syndrome, because in a normotensive patient the muscle
pressure rarely exceeds the systolic level.
 Eventhough in shock patient or in overlying swelling, it is
difficult to palpate pulses.

 Persistent, unexplained tachycardia should also be

regarded as a possible sign of compartment syndrome in
the unconscious patient once other causes (eg,
hypovolemia) have been excluded.

AO Principles of Fracture Management

CLINICAL SYMPTOMS
Hargens and Mubarak’s six Ps characteristic of acute
compartment syndrome are:
 high pressure
 pain (especially with passive stretch)
 paraesthesias
 paresis
 pink skin colour
 pulse (distal pulse present).

Ashish K. Compartment syndrome. Mercer’s textbook of orthopaedic.

Tissue Pressure Measurements
 Originally, it was believed that the threshold for compartment
syndrome was a constant intramuscular pressure > 30 mm Hg.
 However, it is now recognized that the key factor is the
difference between the diastolic blood pressure (dBP) and
the intramuscular pressure (IMP).

 If the muscle perfusion pressure is less than 30 mm Hg, there

will be hypoxia and anaerobic cell metabolism.
 Thus, multiply injured patients with hypotension and hypoxia
are predisposed to compartment syndrome

AO Principles of Fracture Management

 What about the threshold for children?

Children have a low diastolic pressure and are therefore

more likely to have a ΔP less than 30 mm Hg

Mars and Hadley recommend the use of the mean arterial

pressure rather than the diastolic pressure to obviate this
problem.
Measurement techniques
 Should be performed within 5 cm of the fracture site when
evaluating fracture patients.
 Highest pressures were obtained within 5 cm of the fracture and
dissipated as pressures were recorded further away from the
fracture site

 At the time of measurement, the position of the foot (in the

case of leg ACS) should be maintained in a neutral position
without extreme dorsiflexion or plantar flexion.
 Dorsiflexion will increase posterior compartment pressures,
whereas plantar flexion will increase the anterior and lateral
compartments.
 The ideal position is between neutral and the resting position or
between 0 and 37 degrees of plantar flexion

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG [eds.]. Skeletal
Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
Measurement techniques
 The injured extremity should not be elevated to decrease
edema  as this maneuver will increase the
intracompartmental pressure in, and decrease perfusion
to the extremity

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG [eds.]. Skeletal
Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
Intracompartmental pressure
measurement
 Several methods are available to measure the ICP:

1. Needle manometer method

2. Wick or slit catheter technique
3. Continuous monitoring infusion technique
4. Hand-held transducers (Stryker Intra-compartmental
Pressure System).

Ashish K. Compartment syndrome. Mercer’s textbook of orthopaedic.

 Measurement Techniques
 Needle Manometer

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG
[eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
 Measurement Techniques
 Continuous Infusion Technique
 Low accuracy: tissue compliance << when pressure greater
than 30 mmHg  artifically high reading

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG
[eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
 Measurement Techniques
 Wick Catheter
 Polyglycolic acid suture
pulled into tip of piece of
PE60 polyethylene tubing
 Catheter placement
sleeve + wick catheter
connected to pressure
transducer & recorder
introduced through a
large trocar. Needle is
withdrawn & catheter is
taped to the skin

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG
[eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
 Measurement Techniques

 Slit Catheter
 PE60 Polyethylene tubing with five 3-
mm slits in the end of tube
 Slit Catheter System
 Microcappilary Infusion
 Arterial Transducer Measurement
 Noninvasive Techniques (Chronic
CS)
 Tc 99m-MIBI Scintigraphy
 Laser Doppler Flow
 Near-Infrared Spectroscopy

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG
[eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
TREATMENT
 The initial treatment should include release of all
circumferential dressings and elevation of the limb to the level
of the heart (to maximize tissue perfusion pressure).

 Compartment syndrome is a surgical emergency and the

treatment of choice is immediate dermatofasciotomy

Mark T. Compartment syndromes and volkmann contracture. Campbell.

Timing

 If the ICP is rising, the ΔP is dropping and less than 30

mm Hg, and this trend has been consistent for a period of
2 hours, then fasciotomy SHOULD BE performed.

 Fasciotomy SHOULD NOT BE performed based on a

single pressure reading except in extreme cases.
Fasciotomy

 Basic principle?
Full and adequate decompression

- Skin incisions must be made along the full length of the

affected compartment

- It is essential to visualize all contained muscles

Amendola A and Twaddle BC. Compartement
Syndromes. In: Browner BD, Jupiter JB , Levine
AM and Trafton PG [eds.]. Skeletal Trauma: Basic
Science, Managmenet and Recosntruction 3rd
ed. 2003.
ARM
ARM
FOREARM
 FOREARM
 Compartment release incision :
– volar flexor  volar ulnar approach / volar
(henry’s) approach
– Dorsal
– A straight incision from the lateral epicondyle to the midline of the
wrist is used
– Interval ECRB and EDC

Volar Ulnar approach Dorsal approach

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG [eds.]. Skeletal Trauma:
Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
HAND
Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG [eds.]. Skeletal Trauma: Basic
Science, Managmenet and Recosntruction 3rd ed. 2003.
Thompson JC. Hand In: Netter’s Concise Orthopaedic Anatomy 3rd ed. 2010
THIGH
THIGH

Mark T. Compartment syndrome and volkman contracture. Campbell’s operative orthopaedic,

LEG
Leg Compartment Syndrome
 Two techniques for release of the compartments of the
lower leg are commonly used:
 Single-incision perifibular fasciotomy and
 Double-incision fasciotomy.

 The single incision may be useful if the soft tissue of the

limb is not extensively distorted.

 Because this is rarely true, the double-incision technique

is safer and more effective and generally should be used.

Mark T. Compartment syndrome and volkman contracture. Campbell’s operative orthopaedic,

• Single lateral incision
Head of fibula  distally to ankle
Retract intermuscular septum (anterior / lateral)
protect superficial peroneal nerve
Fasciotomy: 1 cm in front of intermuscular septum (ant compartment) and 1 cm posterior (lateral
compartement)
 • Bridge of skin at least 8 cm
• 1st: knee to ankle (between
anterior / lateral compartment)
o Care of superficial peroneal
nerve
• 2nd: 1-2cm behind posteromedial
border of the tibia
o Care of saphenous vein and
nerve

Mark T. Compartment syndrome and volkman contracture. Campbell’s operative orthopaedic,

FOOT
Foot Compartment Syndrome

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG [eds.]. Skeletal Trauma: Basic
Science, Managmenet and Recosntruction 3rd ed. 2003.
 Foot Compartment Syndrome
 surgical technique
 dual dorsal incisons (gold standard)
 dorsal medial incision
 allows decompressin of 1st and 2nd interosseous (lateral), medial, and deep
central compartments
 dorsal lateral incison
 allows decompression of 3rd and 4th interosseous (lateral), superfical central,
middle and central)
 some add an additional medial incision
 single medial incision
 has been described but is technically more difficult

Moore D. Compartement Syndrome. In: Orthobullets.com.

 Foot Compartment Syndrome

Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine AM and Trafton PG
[eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction 3rd ed. 2003.
Management of Fasciotomy Wounds
 The wounds should be left open and dressed, and
approximately 48 hours after fasciotomy a “second look”
procedure should be undertaken to ensure viability of all
muscle groups.

 There is no indication to prolong closure beyond 48

hours unless there is residual muscle necrosis.
Complications
 Delay to fasciotomy of more than 6 hours is likely to
cause significant sequelae
 muscle contractures
 muscle weakness
 sensory loss
 Infection
 nonunion of fractures
 In severe cases amputation may be necessary because of
infection or lack of function

McQueen MM. Acute Compartement Syndrome. In: Bucholz et al. Rockwood & Green’s fractures in Adults 7th ed.
Questions
Q1
 A 35-year-old female presents to the emergency
room after a motor vehicle collision where her
leg was pinned under the car for over 30
minutes. A clinical photo and radiographs are
shown. Which of the following is the most
accurate way to diagnose compartment
syndrome?

1. surgeon's palpation of the leg compartments

2. parathesias in her foot
3. diastolic blood pressure minus intra-
compartmental pressure is less than 30 mmHg
4. diastolic blood pressure minus intra-
compartmental pressure is greater than 30
mmHg
5. intra-compartmental pressure measurement
of 25 mmHg
 PREFERRED RESPONSE ▼ 3

 DISCUSSION: The clinical picture is consistent with

compartment syndrome. The most accurate way to make
the diagnosis is to measure the difference between the
diastolic blood pressure and intracompartmental pressure
(delta p).
Q2
 A 32-year-old male sustains the injury
seen in Figure A. His blood pressure
preoperatively was 132/84. After closed
reduction and placement of an
intramedullary nail, his intraoperative leg
compartment pressures are measured,
with the highest being 28 mmHg. His
blood pressure at this time is 84/57. What
is the next appropriate step?
1. Immediate four compartment
fasciotomy
2. Fasciotomy of the highest
compartment(s)
3. Acute shortening of the tibia with
exchange of nail as needed
4. Repeat evaluation and compartment
pressure evaluation in recovery room
5. Addition of pressors to anesthesia
 PREFERRED RESPONSE ▼ 4

 DISCUSSION: Figure A shows a mildly comminuted tibia fracture, which is

a fracture highly associated with compartment syndrome. However, in this
scenario, the delta p (difference between compartmental pressures and
diastolic pressure) is greater than 30 preoperatively, with a decrease to less
than 30 intraoperatively, due to the hypotension associated with anesthesia.

 The referenced article by Kakar et al notes that the delta p may be

spuriously low intraoperatively, and with tibial nailing, it is safe to assume
the delta p will return to a higher level postoperatively.

 They recommended continued monitoring in the postoperative period with

clinical examination and measurements as needed. The McQueen
referenced article showed that the delta p is more important than absolute
pressures, as an absolute threshold of 30mmHg would have led to
unnecessary fasciotomies in 43% of their cohort.
Q3
 A 10-year-old girl is treated for a tibia/fibula fracture with a
long leg cast. The on-call resident is called to evaluate the
patient for increasing pain medicine requirements and tingling
in her foot. Examination of the cast reveals that the ankle has
been immobilized in 10 degrees of dorsifelxion. What ankle
position results in the lowest deep posterior calf compartment
pressures in a casted leg?

1. 40-50 degrees of plantar flexion

2. 10-20 degrees of ankle dorsiflexion
3. Neutral to 30 degrees of plantar flexion
4. Neutral to 10 degrees of dorsiflexion
5. Ankle position has no effect on calf compartment pressure
 PREFERRED RESPONSE ▼ 3


 DISCUSSION: Agitation, anxiety, and increasing analgesic requirments are the "3 A's"
of pediatric compartment syndrome.

 Weiner et al measured intramuscular compartment pressure in the anterior and

deep posterior compartments of the leg in seven healthy adults who had long leg
casts placed. They found that in a casted leg the intramuscular pressure in the
anterior compartment was lowest with the ankle in neutral, and the deep posterior
compartments was lowest when the ankle joint was in the resting position,
approximately 37 degrees of plantar flexion.

 Based on this, they concluded that the safest ankle casting position regarding
compartment pressure is between 0 and 37 degrees of plantar flexion. After the
cast was bivalved, they noted a significant decrease in intramuscular pressure of 47
per cent in the anterior compartment and of 33 per cent in the deep posterior
compartment. Constrictive casts and abberant ankle positioning can exacerbate
pain/symptoms. Loosening of the cast by bivalving, spreading, and cutting underlying
stockinette/softroll should always be the first step in management of possible
compartment syndrome.
THANK YOU