Compartment syndrome

Compartment syndrome- causes, pathogenesis, diagnosis and treatment.

1. COMPARTMENT SYNDROME PRESENTATION BY:- DR K TARUN RAO MBBS D.ORTHO DNB PGT[CMRI]

2. A 55yr old pt came with alleged h/o RTA on 15/10/16 at 4:30pm c/o pain in the rt leg, a/w abdomen and head injury.

3. DEFINITION :- Compartment Syndrome is an elevation of Interstitial Pressure in closed Osteofascial Compartment that results in Microvascular Compromise. It is a true orthopedic emergency.

4. Compartment? Compartments are groups of muscles surrounded by in-elastic fascia .

5. AETIOLOGY:- REDUCED COMPARTMENT SIZE:- Tight dressing:- bandage or cast localised external pressure, lying on limb closure of facial defects. INCREASED COMPARTMENT SIZE:- Bleeding:- fx , vascular injury , bleeding dis -orders. Increased capillary permeability:- ischemia/trauma/burns/exercise/snake bite/drug injection.

6. Etiology : (cont…) FRACTURE being the first most common cause. The incidence is directly proportional to the degree of injury to soft tissue and bone. Most common in low energy injury(lack of compartment disruption) Most common fx leading to ACS:- Tibial diaphysial # Distal radius # Forearm # Second most common cause:- Blunt trauma

7. TYPES OF COMPARTMENT SYNDROME : Acute Compartment Syndrome : Caused by severe injury/trauma. Acute Exertional compartment Syndrome have been reported in foot in runners, Basketball players and other athelets . Chronic Exertional Compartment Syndrome : It is recurrence of increased pressure seen most often in Anterior and deep posterior Compartment of leg. Also been reported in forearm in weight lifters,rowers,welders .

8. Involved Areas:- Anterior & Posterior Compartment of leg most common Volar compartment of Forearm Compartment Syndrome can develop anywhere Skeletal muscle is surrounded by substantial fascia such as buttock, thigh, shoulder,hand,foot,arm &lumbar Paraspinous muscles .

9. Pathophysiology : Tissue Necrosis occurs in normal blood flow if intra compartmental pressure exceeds 30mm Hg for longer than 8hrs.

10. Tissue survival:- Muscle :- 3 to 4hours- reversible changes 6 hours variable damage 8 hours irreversible changes Nerve :- 2 hours –looses nerve conduction 4 hours – neuropraxia 8 hours – irreversible changes Delayed diagnosis : permanent sensory and motor deficit. contractures Infections Amputations

11. Normal tissue pressure:- .0-4mmhg .8-10mmhg with exertion.

12. CLINICAL FEATURES :- HOW DO WE DIAGNOSE? CLINICALLY:- 5 P’s Swelling and tightness(TENSE) compartment involved. Severe pain on passive stretching Pain out of proportion to injury Pallor/Cyanosis Hyperaesthesia / Paraesthesia Paralysis pulselessness

13. Pulse oximeter :- pulse oximeter is helpful in identifying limb hypo-perfusion. But is not sensitive enough to exclude compartment pressure. NOTE:- Pain and aggrevation of pain by passive stretching of the muscles in the compartment in question are the most sensitive(and generally only) clinical finding before the onset of ischemic dysfunction in the nerve and muscle. Others:- Compartment pressure monitoring, lab investigations like CPK, Urine myoglobulin estimation.

14. Compartment pressure monitoring:- In case of suspected compartment syndrome. Pt on ventilator. Obtunded pt with tight compartments. Regional anesthesia. Vascular injury. Alcoholics,drug addicts.

15. Devices used for measurement of compartment pressure:- 1.Synthes hand-held monitor(most commonly used) 2.Whitesides threeway stopcock apparatus 3.Wick Catheter 4.Styker STIC catheter (solid-state tranducer intercompartmental catheter) for continous pressure monitoring. Newer Non Invasive methods : 1.Ultrasonography(sensitivity-77%,specificity-93%) 2.Infrared Imaging

16. Hand held monitoring device or arterial line monitering system connected to either a straight needle,aside port needle or slit catheter is preffered . BOODY found that arterial line manometer with slit catheter is more accurate technique. Use of side port needles and slit catheters were more accurate. Where as straight needles tend to over-estimate the pressure.

17. Whitesides threeway stopcock (in 1975)

18. Synthes handheld device:-

19. Acute compartment syndrome of thigh:- Less frequent than lower leg and forearm. But associated with high level of morbidity. Most commomn causes: .Blunt trauma(with or with out fracture) .Vascular injury . T orniquet (lower leg surgery) .Quadriceps tendon rupture .Heterotopic ossification

20. Thigh is divided into 3 distinct compartments by intermuscular fascial extensions:- .Anterior compartment .Medial compartment .posterior compartment Most common compartment syndrome of thigh is ANTERIOR compartment because it is surrounded by stiffest walls laterally and medially (fascia lata and illiotibial tract).

21. MEDIAL ANTERIOR POSTERIOR Adductor brevis , Adductor Magnus, Adductor Longus Quadriceps femoris , Sartorius Biceps Femoris Semi Membranosus Pectineus,obturator externus,gracilis muscles. Semi Tendinosus Obturator Nerve Femoral Nerve Saphaneous N. Sciatic nerve Profunda Femoris Artery Obturator A. Femoral Artery Femoral Vein Arterial Br. Of Profunda Femoris

22. Diagnostic criteria for Acute compartment syndrome of thigh Anterior posterior Medial pain with passive strech Passive knee flexion with hip in extension Passive knee ext. with hip in flexion Passive hip abduction with knee in ext. Motor deficit Knee extension Knee flexion,plantar flexion(sciatic tibial branch),dorsiflexion, great toe ext ( peroneal branch). Hip abduction Sensory deficit Passive hip abduction with knee in ext. Hip abduction Proximal medial thigh( obturator nerve cutaneous branch)

23. Treatment of compartment syndrome of thigh: In Isolated limb injury, splitting of cast and underlying padding can decrease compartment pressure by 50-85%. Removal of circular constrictive bandages. Positioning of the limb at heart level produces the highest arterio - venous gradient. If symptoms wont resolve with in 30 to 60min after appropriate treatment, pressure measurement should be repeated. If results are equivocal FASCIOTOMY is indicated.

24. Fasciotomy :- Good prognosis: Fasciotomy done in 25 to 30hrs Bad prognosis: delayed diagnosis, 3 rd or 4 th day. I ndications of Fasciotomy : .compartment pressure >30mmhg .Arterial disruption for more than 4hrs . C ompartment syndrome associated with fracture should be treated at the time of reduction.

25. Fasciotomy for Acute comparment syndrome of thigh: Tarlow ET AL. technique : .incision from intertrochanteric line to lateral epicondyle .anterior compartment is opened by incising fascia lata and vastus lateralis is retracted medially to expose lateral intermuscular septum, which is then incised to decompress posterior compartment.

26. Comparitive study of compartment syndrome of thigh I n one study 23 pt with acute compartment syndrome. 4 pt (17%) required amputation. In another study of 18 pt more than half did not recover full thigh muscle strength and had long term functional deficits.

27. Comparitive study of fasciotomy Need for fasciotomy varied widely according to Mechanism of injury .<1% after motor vehicle accidents to almost 9% after gunshot wounds Type of injury .2% with closed fracture to 42% with combined vascular injury. A review of out comes of fasciotomy found that 68% of pt treated with in 12 hrs of symptom onset had normal function. Compared with only 8% in those treated more than 12hrs after symptom onset.

28. Acute compartment syndrome of leg:- Associated with . tibial fractures(36%)- first most common .soft tissue injury due to blunt trauma-Second most common

29. Compartments in Leg:-

30. Diagnosis and treatment of Acute compartment syndrome of leg :-

31. Two Techniques for release of compartment of lower leg:- Single incision perifibular fasciotomy (useful if soft tissue of the limb is not extensively distorted) Double incision fasciotomy ( safer,more effective)

32. Single incision fasciotomy :- DAVEY,RORABECK AND FOWLER TECHNIQUE :- A. lateral skin incision from fibular neck to 3 to 4cm proximal to lateral malleolus. B. Skin is undermined anteriorly and fasciotomy of anterior and lateral compartments performed. C. Skin is undermined posteriorly and fasciotomy of superficial posterior compartment is performed. D.Interval between superficial posterior a nd lateral compartment is developed.

33. Double incision fasciotomy :- Decompression of anterior and lateral compartments of leg. A. Anterio lateral incision(20 – 25cm) between fibular head and tibial crest. B. Posteriomedial incision 2cm posterior margin of tibia. C. Decompression of all four compartments of leg. Mubarak and H argens

34. Delayed primary closure after fasciotomy with vessel loop shoelace tecnique :-

35. Chronic E xertional Compartment Syndrome:- Defined as reversible ischemia secondary to a non compliant osteofascial compartment that is unresponsive to expansion of muscle volume that occurs with exercise. Muscle volume can increase upto 20% of its resting size during exercise.

36. Etiology:- Rear foot landing,over pronation Muscle hypertrophy Anabolic steroid and creatine use also increase muscle volume Recreational runners Elite athletes Military recruits Anterior and posterior compartments are most commonly effected,and symptoms are bilateral in 75% of patients.

37. Clinical evaluation:- 20-30yrs old pt describes exercise induced pain and a feeling of tightness that begins after 20 to 30 minutes of running. Pain usually resolves within 15 to 30minutes of cessation of exercise. Paresthesias of nerves.

38. Differential diagnosis chronic exertional compartment syndrome: Medial tibial stress syndrome (shin splints) Stress fracture Tenosynovitis Periostitis Dvt Nerve entrapment syndrome Lumbosacral radiculopathy Neurogenic claudication Poplitela artery entrapment syndrome Vascular claudication Infection Myopathy tumors

39. Diagnostic criteria of chronic exertional compartment syndrome:- Pre- excercise resting pressure of 15mmhg or more. Pressure of 30mmhg or more 1 minute after exercise. Pressure of 20mmhg or more 5 minutes after exercise. Post exercise MRI Near Infrared spectroscopy Triple phase bone scan Methoxyisobutyl isonitrile (MIBI) perfusion imaging Tallous chloride scintigraphy

40. Treatment for chronic exertional compartment syndrome:- Non operative Operative

41. Non operative:- Rest Anti inflamatory medications Manual therapy Streching and strengthening of involved muscles Orthotics If symtoms persists,pressures extremely elevated,or athlete desired to continue activity at same level fasciotomy of involved compartment indicated

42. operative procedures:- Anterior compartent fasciotomy (80-90% success rate). Deep posterior compartment fasciotomy (50-70%). Types: 1.Double-Mini Incision Fasciotomy for chronic anterior compartment syndrome. 2.Single-Incision F asciotomy for chronic anterior and lateral compartment syndrome. 3.Double-Incision Fasciotomy for chronic posterior compartment syndrome

43. Double mini incision fasciotomy for anterior compartment syndrome: Moushine ET AL technique : .make two verticle 2cm skin incision 15cm apart. .identify subcutaneous flap by blunt dissection. .with the help of retractors retract skin anteriorly and posteriorly to allow anterior and lateral fasciotomy under direct vision.

44. Single incision fasciotomy for chronic anterior and lateral compartment synd : Fronek ET AL technique : A.make 5cm longitudinal incision between fibula and tibial crest over anterolateral intermuscular septum,when no fascial hernia exists. B.In presence of fascial hernia incision is directly over fascial defect. C.Defect is enlarged across intermuscular septum.(1) D & E.complete longitudnal release of ant. Compartment(2 & 3) and lateral compartment (4 & 5)

45. Double incision fasciotomy for chronic posterior compartment syndrome: RORABECK technique : A.Two vertical incisions;saphenous vein Is identified and retracted anteriorly. B.Superficial compartment is entered and released. c.Deep fascia is incised and deep posterior compartment is released.

46. Dorsal – extensor hallucis brevis extensor digitorum brevis Plantar – 1 st layer Abductor hallucis Flexor digitorum brevis A bductor digiti minimi 2 nd layer Quadratus plantae Lumbricles muscle 3 rd layer Flexor hallucis brevis Adductor hallucis Flexor digiti minimi brevis 4 th layer – dorsal interossei plantar interossei

47. Compartment Syndrome of forearm:- Anatomy :- 4 compartments of foream 1.The Superficial volar compartment. 2.The Deep volar compartment. 3.The Dorsal compartment. 4.The compartment containing mobile wad of Henry( brachioradialis , extensor carpi radialis longus and brevis )

48. In hand each interosseous muscle is surrounded by a tough investing fascial layer Each making an individual compartment as shown by injection dissections of H alpern and Mochizuki. The adductor pollicis muscle and thenar and hypothenar muscles form 3 separate compartments.

49. B and C:-dorsal and volar interosseous compartments and adductor compartments to thumb A and D :- thenar and hypothenar compartments

50. Thenar compartment: Abductor pollicis brevis Flexor pollicis brevis Oppenens pollicis Adductor pollicis Hypothenar compartment: Abductor digiti minimi Flexor digiti minimi brevis Opponens digiti minimi

51. Neurovascular bundles of each digit are comparmentalised by fascial layers making them vulnarable to swelling.

52. Etiology Fractures (18%) Soft tissue injuries (23%) Distal radial fractures (0.3%) Ipsilateral Elbow injuries (15%) In children;supracondylar fractures most frequent After intramedullary fixation of forearm in children Chronic exertional compartment synd. Of 1 st dorsal interisseous muscle and volar muscles seen in motorcyclists.

53. Traumatic ischemia cycle by Eaton and Green:

54. Any situation that causes a decrease in compartment size or increase in compartment pressure can initiate compartment syndrome. Muscle necrosis occur with a rise in pressure to within 20mm below diastolic pressure.

55. Diagnosis: Volar and dorsal forearm is tender and tense with swelling. Sensibility of finger tips is diminished. Two-point discrimination and 256cycles/vibratory testing can be helful in determining Nerve Ischemia. Compartment syndrome in a neonate may manifest as sentinel bullous or ulcerative skin lesion over dorsum of the forearm,wrist,hand . Compartment pressure over 30mmhg or with in 20mmhg of the diastolic pressure are indicative of compartment syndrome.

56. Management : Fasciotomy should be performed in 1.normotensive patient with positive clinical findings and compartment pressure >30mmhg 2.duration >8hrs 3.uncooperative or unconscious patients with pressure >30mmhg 4.patients with low blood pressure and compartment pressure >20mmhg.

57. Foream fasciotomy and Arterial exploration Dorsal fore arm fascia is released through the interval between the extensor carpi radialis brevis and extensor digitorum communis . Volar curvilinear incision is used that allows release of lacetrus fibrosus proximally and carpel tunnel distally. Interval between the flexor carpi ulnaris and flexor digitorum sublimis is used for release of deep and superficial compartments.

58. Vessel loop shoelace technique Arm elevated for 24 to 48 hours. Closure not possible within 5 days,a split thickness skin graft should be applied. Closure of fasciotomy by vessel loops are tightened progressively during dressing changes. Wound closure can be accomplished in 2 weeks. Vaccum assisted wound closure dressing is used in management.

59. HAND FASCIOTOMY A.longitudinal incision over second and fourth metacarpals and extending just distal to wrist. Passively flex the metacarpophalyngeal joints and extend the proximal interphalyngeal joints to strech the muscles,ensuring that all are adequately released. Release the thenar and hypothenar muscles by making palmar radial and ulnar incisions. B.Midaxial incision of finger

60. Complications of comparment syndrome: Volkman n ischemic contracture Rhabdomyolysis Acute renal failure