compartment syndrome

detailed review of compartmental syndrome ...!! mainly i covered acute condition only ...!!!

1. DR ASHWANI PANCHAL
P.G IN ORTHOPAEDICS
JSS HOSPITAL
MYSORE

2. What is a compartment?
Closed area of muscles
group, nerves & blood
vessels surrounded by
fascia
Pressure: 5-15 mmhg

3. Definition:
An increased pressure within enclosed
osteofascial space that reduces capillary
perfusion below level necessary for
tissue viability;
the underlying mechanism is:
- increased volume within space
- decreased space for contents
- combination of both

4. What is a compartment
syndrome?
 intra comp. pressure
(35-40 mmhg)
 capillaries collapse
 Blood flow to muscles
and nerves
 Bl.Vs collapse

6. Pathophysiology:
Increased compartment pressure
leads to increased venous pressure
which decreases A-V gradient
resulting in muscle and nerve
ischemia.

8. Consequences –vicious cycle

9. Why is it dangerous?
Nerves:
neuropraxia: will
regenerate
Ischemia: cell death
Muscles: contracture
(Volkmann's ischemic
contracture)
Gangrene

10. Compartment Syndrome- CAUSES
Causes
Fractures
Contusions
Surgery
Post Ischemic swelling after arterial occlusion
Major vascular trauma
Crush injuries
Burns
Prolonged limb compression

11. Causes
Fracture of a long bone
(Supracondylar humerus,
forearm, hand,tibia and
foot)

13. CAUSES

14. Drilling &
reaming
Dissection
Tourniquet

15. CAUSES
Tight cast
swelling
Bluish
discolorationnumbness

16. CAUSES
Severe bruised muscle
(even if there is no fracture)
Don’t take contusion lightly

17. COMPARTMENT SYNDROME

18. Signs and Symptoms
Increased Pressure and Tightness
Progressive pain out of proportion to initial
injury
Markedly swollen area
Progressive neurologic deficit
Seven P’s
Pain
Pressure
Pain with passive stretch
Parethesia
Paresis/ Paralysis
Pulses
Pallor

19. SYMPTOMS
Severe pain
inappropriate to the
injury(not relieved even
with morphia)

20. SYMPTOMS
Burning of the affected limb
Tight muscle(rigid)tightness feeling
Numbness: bad sign

21. SIGNS & DIAGNOSIS
Passive stretching of fingers or toes (muscle
stretch)will lead to severe pain (diagnostic sign)
Never wait for signs of ischemia (5 Ps):irreversible
damage

22. STRECH TEST
It is possible to strech
the affected muscles by
passively moving the
joints in direction
opposite to that of the
damaged muscles,s
action (( e.g. ::: passive
extension of fingers
produces pain in flexor
compartment of forearm

23. Technique
STRYKER TECHNIQUE
MERCURY
MANOMETER
Wick hand held
instrument

24. Whiteside maneuver Wick hand held instrument
syringe
3 way stopcock
mmhg
mano.
electrode
Direct
reading

25. Stryker Stic System
Easy to use
Can check multiple compartments
Different areas in one compartment

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

27. COMPARTMENT SYNDROME

28. Management
Non surgical management:
 Remove any tight bandage, tubigrip or soaked
dressing
 Cast should be removed completely
 Elevation

29. •management
Surgical management:
(FASCIOTOMY)
Open skin and fascia
down to a compartment
It is a surgical procedure
where the fascia is cut to
relieve tension or
pressure commonly to
treat the resulting loss of
circulation to the tissue

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

31. Compartment Syndrome
Indications for Fasciotomy
Unequivocal clinical findings
Pressure within 15-20 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)

32. Forearm Fasciotomy
Volar-Henry
approach
Include a carpal
tunnel release
Release lacertus
fibrosus and fascia
Protect median
nerve, brachial artery
and tendons after
release

33. Flexor digitorum
longus
Gastroc-soleus

34. Superficial peroneal nerve
Intermuscular septum

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

37. Close skin by 2ry sutures
after oedema subsides

38. It may need skin graft

39. Wound Management
Wound is not closed at initial surgery
Second look debridement with consideration for
coverage after 48-72 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

40. 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

41. 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 2000Fitzgerald, McQueen Br J Plast Surg 2000

42. Compartment syndrome is a serious syndrome, Which needs
to be diagnosed early.
Palpable pulse doesn’t exclude compartment syndrome
If diagnosis and fasciotomy were done within 24 hrs, the
prognosis is good.
If delayed, complications will develop.
The earlier you diagnose, the safer you are