COMPARTMENT SYNDROME

By:
Abdullah Alshabanat
Ibrahim Alshrani
Eyas Alsuhaibany
Mohammed Alshardan

Supervisor Dr. Ibrahim Assiri

Objectives
 Definition
 Pathophysiology
 Clinical evaluation
 Diagnosis
 Management
 Complications
 References
Defination

 Clinical manif. due to sudden and severe

microvascular compromise caused by raised
interstitial pressure in a closed osteofascial
compartment
>> neuromuscular malfunction
>> irreversible tissue damage.
History
 1872- R.V. Volkmann described contracted state
believed due to ischemic muscle
 1906-Hildebrand :“Volkmann’s ischemic
contracture”
 1914 - Murphy recommended fasciotomy to
prevent contracture
 1940-Griffiths ‘4 Ps’

 1968: wick catheter introduced

Incidence
 A study done by McQueen et al; JBJS Br at 2000
shows:
 annual incidence was 7.3 per 100 000 for men and
0.7 per 100 000 for women
 164 pts were diagnosed with CS
 Male : female ratio were 10:1
 The mean age were 35 years old
 69% with associated fx. (50% tibial shaft)
 23% soft tissue injury without fx

J Bone Joint Surg [Br] 2000;82-B:200-3. Received 12 January 1999; Accepted after revision 15 June
1999
Sites of CS
 Can develop anywhere a skeletal muscle is
surrounded by a fascia.

 CS may occur in foot, leg, thigh, buttocks, lumbar

paraspinous muscles, hand, forearm, arm and
shoulder.
Forearm

 Bone :
-Ulna
-Radius
Forearm muscle

 There are two compartment :

 Anterior compartment

 Latral compartment

 Posterior compartment
Cont’

 ANTERIOR COMPARTMENT OF THE FOREARM three layers:

 1- superficial,
 2-intermediate,
 3-deep.
Generally , these muscles are associated with: movements of the wrist joint;flexion of
the fingers including the thumb;pronation.
Superficial layer : All four muscles in the superficial layer-flexor carpi ulnaris,
palmaris longus, flexor carpi radialis, and pronator teres-have a common origin
from the medial epicondyle of the humerus, and, except for pronator teres
Intermediate layer : Flexor digitorum superficialis
Deep layer : There are three deep muscles in the anterior compartment of the forearm:
flexor digitorum profundus, flexor pollicis longus, and pronator quadratus
The radial artery originates from the brachial artery at approximately the neck of the radius and
passes along the lateral aspect of the forearm
The ulnar artery is larger than the radial artery and passes down the medial side of the forearm
Veins Deep veins of the anterior compartment generally accompany the arteries and ultimately
drain into brachial veins associated with the brachial artery in the cubital fossa.
Nerves :innervated by median and ulnar nerves, and the superficial branch
of the radial nerve
Cont’

 Latral compartemnt :

 1-brachioradialis,


 2-extensor carpi radialis longus,



 3-extensor carpi radialis brevis

Cont’

 POSTERIOR COMPARTMENT OF THE FOREARM Muscles

in the posterior compartment of the forearm occur in two layers:
 1-superficial
 2-deep layer.
 The muscles are associated with: movement of the wrist joint;
 extension of the fingers and thumb;supination.
Cont’

 Superficial layer :
 1-extensor digitorum,
 2-extensor digiti minimi,
 3- extensor carpi ulnaris,
 4- anconeus
Deep layer :The deep layer of the posterior compartment of the forearm consists of
five muscles: supinator, abductor pollicis longus, extensor pollicis brevis, extensor
pollicis longus, and extensor indicis
Cont’

 All muscles of the deep layer are innervated by

the posterior interosseous nerve, the
continuation of the deep branch of the radial
nerve .
 Arteries and veins :Blood supply through
branches of the radial, posterior interosseous, and
anterior interosseous arteries
LEG

 Bones :
 Tibia

 fibula or calf bone

Muscle

 There are three compartment :

 Anterior compartment
 Lateral compartment
 posterior compartment
Anterior compartment of leg : There are four muscles tibialis anterior, extensor
hallucis longus, extensor digitorum longus, and fibularis tertius
Supply by Anterior tibial artery
Veins Deep veins follow the arteries and have similar names
Innervated by Deep fibular nerve
Lateral compartment of leg :There are two muscles -fibularis longus and
fibularis brevis
 Arteries : . It is supplied by branches (mainly from the
fibular artery in the posterior compartment of leg) that
penetrate into the lateral compartment .
 Veins :Deep veins generally follow the arteries.
 Nerves: Superficial fibular nerve
 Posterior compartment of leg :
 Muscles in the posterior (flexor) compartment of leg
are organized into two groups, superficial and deep,
separated by a layer of deep fascia. All are
innervated by the tibial nerve.
Superficial group : three muscles-gastrocnemius, plantaris, and
soleus
Deep group :There are four muscles popliteus, flexor hallucis longus, flexor
digitorum longus, and tibialis posterior
Arteries : The popliteal artery is the major blood supply to the leg
and foot and enters the posterior compartment of leg
 Pathophysiology of C.S:
 Increased intracompartmental pressure  capillary blood flow
is compromised

 Edema further increases I.C pressure  compromise

lymphatic and venous drainage

 Further increases in I.C pressure  compromise arteriole

perfusion  further muscle and nerve ischemia
 Signs and symptoms:
 5 P’s:
1) Pain

2) Paresthesia

3) Pallor

4) Paralysis

5) Pulselessness
 Pain:
 Severe, deep, constant, and poorly localized pain

 Sometimes described as out of proportion with the

injury

 Not relieved by analgesics

 Increased with passive stretch of compartment

muscles (most specific)
 Paresthesia.
 Also early sign:
 Peripheral nerve tissue is more sensitive than muscle to
ischemia
 Permanent damage may occur within 75 minutes

 Difficult to interpret

 Will progress to anesthesia if pressure not relieved

 Paralysis:
 Very late finding:
 Irreversible nerve and muscle damage present

 Paresis may be present early:

 Difficult to evaluate because of pain
 Pallor & Pulselessness:
 Rarely present

 Indicates direct damage to vessels rather than

compartment syndrome

 Vascular injury may be more of contributing factor

to syndrome rather than result
 History
 Pain out of proportion

 Determine the mechanism of injury

 Ask for anticoagulation therapy

 Physical examination:
 Pain with active contraction of compartment

 Pain with passive stretch

 Swollen, tense compartment

Investigations
 Dx is clinically in conscious patients
 If not, clinical diagnoses is enough
compartment pressure
measurement
 Taken at the site of the fracture, distal, and
proximal to it
 compared to the diastolic BP
 Whitesides found that fasciotomy was required when
the intracompartmental pressure approaches 20 mm
Hg below the diastolic pressure, whereas McQueen et
al recommend using a differential pressure (diastolic
minus the compartment pressure) of <30 mm Hg as a
criterion for fasciotomy.
Management
Acute C.S

 Medical management
 Surgical management
Medical management

 Remove cast or bandages

 Elevate the leg to the heart’s level
Surgical management

 Leg compartment syndrome:

 The aim of the surgical intervention is to
decompress the compartments and that
could be approach by either :

1-Fasciotomy:
 Double-incision approach or Single-incision approach
2- Fabiluctomy
Fasciotomy in the leg
 It is the treatment of choice
 Aimed to decompress the ICP for the four
compartments
 Could be single incision “ perifibular” or
double-incisions “ anterolateral and
postereomedial”
 Double-incisions
1. Anterolateral:

To decompress anterior and lateral compartments

15 cm longitudinal and halfway between fibula and tibial shin

Open skin and subcutaneous

Horizontal cut 2cm to visualize the intramuscular septum
“superficial peroneal nerve”

Decompress the anterior compartment first

To decompress the lateral compartment the incision is directed to
the fibular shaft. Distally scissors directed toward lateral
mallulous and proximally toward fibular head
 Double-incisions
2. Posterolateral

To decompress superfecial and deep posterior compartments

15 cm longitudinal and 2cm posterior to the medial tibial edge

Slightly distal to the anterolateral incision

Open skin and subcutaneous

Horizontal cut to visualize the septum between deep and
superficial compartments

Decompress the superficial compartment first

To decompress the deep compartment initiate distally
 Double-incisions
Things to take care :

In anterolateral incision take care about superficial peroneal
nerve

In posteriomedial incision take care about saphenous nerve and
vein which are located in the posterior media aspect of the tibia

Be generous in the incision and make sure you release the fascia
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

 Protect median nerve,

brachial artery and
tendons after release
 Consider dorsal
release
Skin closure
 One of the incision could be closed immediately
 The other one is closed gradually using shoe-lace
technique over 7-10 days
 You might need a skin graft
What about the fracture?
 Fix the fracture
 IM nail reamed or not ? no deference
 plate
 External fixating if necessary
Fibulectomy or Fasciotomy?
Prognosis

 Excellent to poor, depending on how quickly it is

diagnosed and treated

 20% of patients may have persistent sensory or motor

deficits at 1-year follow-up
Acute complications

 Rhabdomyolysis - Acidosis
 Hyperkalemia - DIC and sepsis
 Myoglobinuric renal failure
 ARDS
 Loss of limb
 Death (sepsis-MOF)
Complications related to CS

 Late Sequelae
 Volckmann’s contracture
 Weak dorsiflexors
 Claw toes
 Sensory loss
 Chronic pain
 Amputation
Volckmann’s contracture

 Volkmann’s contracture is a limb deformity that

represents one of the final stages of muscle and
nerve fibrosis following an untreated acute
compartment syndrome
(A) The hammer toe deformity is due to contracture of the intrinsic
muscles of the foot.
(B) The claw toe deformity is due to a mixed contracture of the intrinsic
and extrinsic ßexors.
(C) The mallet toe is due to isolated contraction of the extrinsic muscles
of the foot
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
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
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

Summary
 High index of suspicion remains the cornerstone
of diagnosing ACS
 ACS is a clinical Dg
 ICP measurement gives additional info.
 In doubt, cut!
 Avoid delays in management
 Promptly recognize vascular compromise
 Vacuum sealing
Thank You