COMPARTMENT SYNDROME

Ppt on Compartment syndrome by Kmct ORTHOPAEDICS

1. COMPARTMENT SYNDROME DR. GOKUL DEV C JR, DEPT. OF ORTHOPAEDICS KMCT MEDICAL COLLEGE

2. COMPARTMENT SYNDROME DEFINITION TYPES ANATOMY PATHOPHYSIOLOGY ETIOLOGY CLINICAL EVALUATION DIAGNOSIS MANAGEMENT COMPLICATION

3. DEFINITION The muscle groups of the human limbs are divided into sections, or compartments, formed by strong, unyielding fascial membranes. "Elevation of the interstitial pressure in these closed osteofascial compartment that result in microvascular compromise" Most commonly involved - Compartments with relatively noncompliant fascial or osseous structures (eg : anterior and deep posterior compartments of leg, volar compartment of forearm)

4. TYPES • Depending on the cause of the increased pressure and the duration of symptoms • A) ACUTE COMPARTMENT SYNDROME (surgical emergency) • B) CHRONIC EXERTIONAL COMPARTMENT SYNDROME

5. ANATOMY OF COMPARTMENTS Closed area of muscles, blood vessels and nerves surrounded by fascia • ARM - 2 compartments • FOREARM - 4 compartments • HAND - 10 compartments • THIGH - 3 compartments • LEG - 4 compartments • FOOT- 9 compartments

6. ARM

7. FOREARM

8. HAND

9. THIGH

10. LEG

11. FOOT

12. PATHOPHYSIOLOGY - Insult to normal local tissue homeostasis results in - Increased tissue pressure - decreased capillary blood flow - local tissue necrosis caused by oxygen deprivation

13. EATON AND GREEN VICIOUS CYCLE

14. ETIOLOGY OF ACS 1. Decreased compartment size Tight dressing / bandage/ cast Thermal injuries, burn eschar Localised external pressure ( eg: lying on limb, Military anti-shock garments, Tourniquet Lying on limb) Entrapment under collapsed weights Tight closure of facial defects Excessive traction to fractured limbs Limb lengthening Intramedullary nailing for long neglected fractures or deformity correction stretching individual muscles

15. ETIOLOGY OF ACS 2. Increased compartment content Fracture - most common (both open and closed) Crush and direct blow to compartment ( blunt trauma - 2nd most common ) Vigorous exercise Animal bites and stings Hemorrhage ( large vessel injury) / anticoagulants Ruptured cysts (eg: baker’s cyst) Revascularization / Reperfusion after ischemia IV fluid extravasation High-pressure injections, Intraosseous fluid transfusion in children Reaming in intramedullary nailing Use of fluid pumps in arthroscopy

16. CLINICAL EVALUATION • SIX ‘ P ’ characteristics of ACS Pain out of proportion Paresthesia/ hypoasthesia Pallor Poikilothermia Pulselessness Paralysis

17. PAIN Earliest symptom Classically out of proportion to injury Burning and deep aching in nature ( symptom) Exaggerated with passive stretch of muscles (sign) Bony injury may cause pain(false positive) pain may be absent if nerves injured or patient has received efficient analgesia/ anesthesia (postoperative) Can’t evaluate- head injury, drug abuse, intubated or sedated etc

18. PARESTHESIA • Unreliable early complaint • In acute anterior lower leg CS, the first sign to develop may be numbness between the first 2 toes (superficial peroneal nerve) , • Test: pinprick, light touch , 2 point discrimination • Decreased light touch is the best and first indicator • Decreased 2-point discrimination is also a reliable early test

19. PARALYSIS • Very late finding (being a function of thicker motor nerves) • Irreversible nerve and muscle damage present • Paresis may be present early but difficult to evaluate because of pain • If objective evidence of a major sensory deficit, a motor deficit, or loss of peripheral pulse is found, the syndrome is far advanced

20. PALLOR & PULSELESSNESS • Rarely present • Distal pulses are almost always present • Indicates direct damage to vessels rather than compartment syndrome • Vascular injury may be more of contributing factor to syndrome rather than result

21. DIAGNOSIS Based on The history Clinical Examination findings The measurement of compartment pressures (not needed always) Intramuscular pH monitoring ( rarely done)

22. MEASUREMENT OF COMPARTMENT PRESSURE CRITICAL PRESSURE ? • no consensus exists regarding the exact pressure at which fasciotomy should be performed • Currently, many surgeons use a measured compartment pressure of 30 mm Hg as a cutoff for fasciotomy • A single normal compartment pressure reading, does not rule out ACS. • Serial or continuous measurements are important when patient risk is moderate to high or clinical suspicion persists

23. ACS DELTA PRESSURE = Diastolic Blood Pressure ‒ Measured Compartment Pressure ● ACS delta pressure < 20 to 30 mmHg indicates need for fasciotomy Intra muscular pH monitoring - pH < 6.38 (80% specific and 95% sensitive for diagnosing early and accurately

24. INTERPRETATION OF MEASUREMENTS The normal pressure of a tissue compartment falls between 0 and 8 mmHg . Compartment pressure > 30 mm of hg Delta pressure < 20-30 mm of hg

25. MEASUREMENT OF COMPARTMENT PRESSURE INDICATIONS High clinical suspicion Significant tissue injury If clinical findings are equivocal or difficult to interpret (unresponsive patients, uncooperative patients, Children, with multiple or distracting injuries) Signs and symptoms not resolved after 60 min of appropriate precaution Prophylactic with major corrective osteotomy of the leg and forearm

26. CONTRAINDICATIONS: Absolute – none Relative – coagulation disorders, overlying infection, cellulitis or burns

27. • TECHNIQUE - performed in each compartment as close to the fracture site as possible (< 5 cm both proximally and distally) or maximal swelling area • Highest pressure is noted - is compared to diastolic blood pressure • If Marginal readings - repeat physical examination and pressure measurement

28. NON INVASIVE METHODS • Ultrasonography: measures submicrometric displacement of fascia by volume expansion • Laser Doppler Flowmetry • Infrared spectroscopy (NIRS) : determine temperature difference between proximal and distal skin surface and tracking variations in the oxygenation of muscle tissue BECOMING POPULAR AND STANDARDISED

29. INVASIVE METHODS Direct methods SOLID STATE TRANSDUCER TIPPED CATHETER SYSTEM Indirect methods STRYKER HANDHELD SYSTEM ARTERIAL LINE MANOMETER WHITESIDES THREE WAY STOPCOCK APPARATUS WICK MONITOR STIC TECHNIQUE

30. STRYKER HANDHELD SYSTEM The transducer is connected to a needle that has several side ports. These side ports help eliminate muscle occlusion of the needle

31. WHITESIDES THREE WAY STOPCOCK APPARATUS SANGWAN TECHNIQUE - saline manometer, cheap and easy to assemble A simple arterial line setup (16–18 gauge needle) and a mercury manometer -least accurate -values consistently higher, by an average of 5–19 mm Hg

32. WICK MONITOR Dexon fibers that are fixed at the tip of a fluid filled polyethylene catheter (in the form of a “wick”)

33. STIC TECHNIQUE

34. MANAGEMENT EARLY MANAGEMENT- older concept , debatable reserved only for patients presenting too late or missed (> 24–48 hours ) remove cast or bandage positioning of the limb at the level of heart (do not elevate the affected limb which decreases arterial pressure- further tissue injury) correct hypoperfusion- hydration with IV fluids, blood products (if acute anemia) ensure patient is normotensive oxygen supplementation Role of mannitol - doubtful

35. MANAGEMENT • NON-OPERATIVE -if the stage is of impending compartment syndrome (serial clinical evaluation and compartment pressure monitoring) • OPERATIVE - Emergency Fasciotomy + fracture stabilisation

36. FASCIOTOMY - prophylactic release of compartment pressure before permanent damage occurs. - Emergency procedure Will not reverse injury from trauma first suggested by Bardenheuer in 1906 and Murphy in 1914 FRACTURE CARE - stabilization ( Ex fix, IM nail )

37. INDICATIONS OF FASCIOTOMY Normotensive with positive clinical findings Compartment pressure > 30 mmHg Delta pressure < 25 mm hg If duration of increased pressure unknown or > 8 hours Worsening of clinical conditions Those who are uncooperative or unconscious, with pressure > 30 mm Hg Hypotensive and a compartment pressure > 20 mm Hg In hand > 15-20 mm Hg is a relative indication for release. Unequivocal clinical findings

38. CONTRAINDICATION OF FASCIOTOMY Missed compartment syndrome - > 24-48 hours - damage cannot be reversed - significant infection rate when dead tissue exposed

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. ALGORITHM

41. FOREARM DECOMPRESSION Volar curvilinear approach of Henry Dorsal approach

42. Volar curvilinear approach of Henry Skin incision proximal to the antecubital fossa on ulnar aspect of the arm crossing the antecubital fossa horizontally in the flexion crease Extend incision - S-shape to the wrist flexion crease and then cross the crease into the palm to allow release of the carpal tunnel.

43. Release the superficial fascia, and identify median nerve proximally and release the lacertus fibrosus. Release the proximal edge of flexor pronator mass from humerus. Follow the median nerve between the FDS and FDP and decompress it all the way to the carpal tunnel. Identify and preserve the palmar cutaneous branch. Release the carpal tunnel. Inspect the deep volar muscles (FDP, FPL, PQ) and release fascial coverings as needed.

44. Dorsal Approach Incision is similar to that used in the Thompson approach can extend from the lateral epicondyle to the mid-portion of the wrist Full incision may not be needed fascia of dorsal and mobile wad compartments is easily released.

45. DECOMPRESSION OF LEG The two-incision techniques of Mubarak et al. a) Anterolateral incision b) Posteromedial incision Single-incision technique of Davey et al.

46. Anterolateral incision To approach the anterior and lateral compartments extensive longitudinal skin incision, halfway b etween the fibular shaft and tibial crest. Undermine the skin edges to widen exposure of the fascia. Identify anterior intermuscular septum Identify superficial peroneal nerve, which lies in the lateral compartment next to the septum. Open the anterior compartment fascia and ensure complete fascial release.

47. Make the lateral compartment fasciotomy in line with the fibular shaft. Direct the scissors proximally toward the fibular head and distally toward the lateral malleolus. The fascial incision is posterior to the superficial peroneal nerve.

48. Posteromedial incision longitudinal incision 2–3 cm posterior to the posterior tibial margin, to approach the superficial and deep posterior compartments Retract saphenous vein and nerve anteriorly. Identify septum between the deep and superficial posterior compartments Identify the tendon of the FDL in the deep post compartment and the Achilles tendon in the superficial post compartment.

49. Decompress the superficial post compartment first by releasing fascia proximally as far as possible and then distally behind the medial malleolus. Release the deep post compartment distally and then proximally under the soleus bridge. Release the soleus if it attaches to tibia distally more than halfway. If both compartments are anchored to the posteromedial edge of tibia, the deep compartment is released from within the superficial compartment by retracting soleus.

50. Single-incision technique of Matsen et al. Incision from the head of fibula to lateral malleolus. Visualize the posterior edge of the anterior, lateral, and the anterior edge of the superficial posterior compartment. Make a transverse incision in the middle portion of leg through the deep fascia, beginning in the anterior compartments , crossing the lateral compartment, and extending into the posterior compartment Identify the anterior intermuscular septum and the posterior intermuscular septum

51. Release the deep fascia of the anterior, lateral and superficial posterior compartments for the full length of each compartment and decompress all muscle proximally Identify the deep posterior compartment. Dissect the soleus free from its origin on the posterior intermuscular septum in the middle or proximal third of the wound. Release the deep fascia of this compartment throughout its full length, taking care to avoid injury to the neurovascular structures (common peroneal nerve)

52. SINGLE-INCISION PERIFIBULAR FASCIOTOMY DAVEY ET AL Make a single longitudinal, lateral incision in line with the fibula, extending from just distal to the head of the fibula to 3 to 4 cm proximal to the lateral malleolus Undermine the skin anteriorly and avoid injuring the superficial peroneal nerve. Perform a longitudinal fasciotomy of the anterior and lateral compartments Undermine the skin posteriorly and perform a fasciotomy of the superficial posterior compartment

53. Identify the interval between the superficial and lateral compartments distally and develop this interval proximally by detaching the soleus from the fibula. Subperiosteally dissect the flexor hallucis longus from the fibula. Retract the muscle and the peroneal vessels posteriorly. Identify the fascial attachment of the posterior tibial muscle to the fibula and incise this fascia longitudinally Close only the skin over a suction drain or a negative pressure wound device .

54. DOUBLE-INCISION FASCIOTOMY SAFER AND MORE EFFECTIVE (MUBARAK AND HARGENS) ■ Make a 20- to 25-cm incision in the anterior compartment, centered halfway between the fibular shaft and the crest of the tibia .Use subcutaneous dissection for wide exposure of the fascial compartments. ■ Make a transverse incision to expose the lateral intermuscular septum and identify the superficial peroneal nerve just posterior to the septum. ■ Using Metzenbaum scissors, release the anterior compartment proximally and distally in line with the anterior tibial muscle. ■ Perform a fasciotomy of the lateral compartment proximally and distally in line with the fibular shaft.

55. ■ Make a second longitudinal incision 2 cm posterior to the posterior margin of the tibia . Use wide subcutaneous dissection to allow identification of the fascial planes. ■ Retract the saphenous vein and nerve anteriorly ■ Make a transverse incision to identify the septum between the deep and superficial posterior compartments. Release the fascia over the gastrocnemius-soleus complex for the length of the compartment.. ■ Make another fascial incision over the flexor digitorum longus muscle and release the entire deep posterior compartment. As dissection is carried proximally, if the soleus bridge extends more than halfway down the tibia, release this extended origin.

56. ■ After release of the posterior compartment, identify the deep posterior muscle compartment. If increased tension is evident in this compartment, release it over the extent of the muscle belly ■ Pack the wound open and apply a posterior plaster splint with the foot plantigrade.

57. FOOT DECOMPRESSION DORSAL —two incisions overlying the second and fourth metatarsals is the gold standard. Maintain the widest skin bridge and bluntly approach the metatarsals. Continue blunt dissection into the web spaces, and decompress the hematoma. MEDIAL —one incision along the inferior border of first metatarsal, but superior to abductor muscle. Enter the central compartment from superior aspect of abductor muscle.

58. CALCANEAL —one incision uncommonly used beginning medially, from the inferior border of the posterior tuberosity extending toward the inferior surface of the first metatarsal. DORSAL APPROACH. MEDIAL APPROACH

59. FASCIOTOMY OF THE THIGH TARLOW ET AL. Prepare and drape the thigh exposing the limb from the iliac crest to the knee joint. Make a lateral incision beginning just distal to the intertrochanteric line and extending to the lateral epicondyle Use subcutaneous dissection to expose the iliotibial band and then make a straight incision in line with the skin incision through the iliotibial band reflect the vastus lateralis off the lateral intermuscular septum.

60. Make a 1.5-cm incision in the lateral intermuscular septum and, using Metzenbaum scissors, extend it proximally and distally the length of the incision. After the anterior and posterior compartments released, measure the pressure of the medial compartment. If the pressure is elevated, make a separate medial incision to release the adductor compartment.

61. FRACTURE CARE Stabilization of fracture is essential along with compartment decompression. For supracondylar fractures of humerus in children - K-wires are preferred. metatarsal and metacarpal fractures - K-wires are preferred. Forearm fractures - compression or locked plates. Femur or tibia fractures - nailing is not good option (can worsen an existing compartment syndrome) External fixator is better

62. POST OPERATIVE CARE AND REHABILITATION Pack the wounds loosely open (saline-dampened gauze) apply a bulky dressing + splinting in functional position Keep extremity above the level of heart to aid venous drainage. Shoe- lace technique of placing vessel loop suture and skin staple help in gradual closure of skin wound. The sutures can be pulled even at bedside.

63. Return to OT for 2nd look in 2-5 days - IV fluorescein and a Wood light - helpful in evaluating muscle viability - If no muscle necrosis- then skin is loosely closed - If closure is not accomplished - Skin closure or SSG VAC (Vaccum Assisted Closure) highly recommended immediate post -op Hyperbaric Oxygen

64. Begin active and active-assisted range-of-motion of the adjacent joints on the second day after fasciotomy. After split-thickness skin grafting, immobilize the limb for 3–5 days more.

65. Drugs that may help recovery from metabolic effects by primarily scavenging free radicals Allopurinol Superoxide dismutase Deferoxamine Pentafraction of hydroxyethyl starch.

66. COMPLICATIONS Myonecrosis Nerve damage (Sensory and motor loss, Chronic pain) Volkmann ischemic contracture Reperfusion syndrome Recurrent ulceration and muscle herniation Infection Amputation Death

67. MYONECROSIS Functional impairement - after 2- 4 hr of ischemia Irreversible functional loss - after 4 -12 hr of ischemia CRUSH SYNDROME - sequelae of muscle necrosis (creatine phosphokinase >20,000 IU) - nonoliguria renal failure, myoglobinuria, oliguria, shock, acidosis, hyperkalemia and cardiac arrhythmias.

68. NERVE DAMAGE NEUROPRAXIA - AXONOTEMESIS - NEUROTEMESIS Loose nerve conduction – 2 hours Neuropraxia - 4 hours Irreversible changes – 8 hours Irreversible functional loss - after 12 to 24 hr

69. VOLKMANN ISCHEMIC CONTRACTURE Acute ischemia leading to contracture and necrosis of muscle and nerve tissue (replaced with fibrous tissue)

70. REPERFUSION SYNDROME - Influx of myoglobulin ,phosphorus, potassium into the circulation - resulting in myoglobunuria, hyperkalemia, hypovolemic shock acidosis, renal failure

71. CHRONIC COMPARTMENT SYNDROME

72. CHRONIC COMPARTMENT SYNDROME Also known as EXERTIONAL CS, RECURRENT CS, SUBACUTE CS Typical patients are young athelet (long distance runner) and military recruits Occur mainly in lower limb

73. PATHOPHYSIOLOGY Not yet fully understood Probably muscle volume can increase up to 20% of its resting size during exercise increased muscle relaxation pressure during exercise Decreased muscle blood flow Ischemic pain and impaired muscle function Approximately 15% to 40% of patients treated for chronic exertional compartment syndrome have been found to have a fascial hernia

74. REFERENCE

75. PHYSICAL EXAM IN CCS • Exercise/ Exertion induced pain • Tenderness over the compartment • Bilateral involvement is very common • Fascial hernia common

76. DIFFERENTIAL DIAGNOSIS Medial tibial stress syndrome (shin splints) Stress fracture Tenosynovitis Periostitis DVT Nerve entrapment syndrome Lumbosacral radiculopathy Neurogenic claudication Popliteal artery entrapment syndrome Vascular claudication Infection Tumor Tendinitis

77. WORK UP OF CCS • Plain X ray- show 90% of stress fracture • Bone scan - diffuse uptake - periostitis - localized uptake - stress fracture • Tinel test - +ve in nerve entrapment • NCS - could be helpful • MRI - promising results, fatty infiltration associated with chronic ischemia • Near infrared spectroscopy

78. DIAGNOSIS OF CCS • Intracompartmental testing is the hallmark of diagnosis 1) Pre-exercise resting pressure of 15 mm hg or more 2) After 1 minute of exercise pressure of 30 mm hg 3) After 5 minute of exercise pressure of 20 mm hg or more 4) An elevated pressure > 25mm hg after 15 minutes is a more reliable cutoff

79. TREATMENT OF CCS • NONOPERATIVE - - Analgesics (eg: NSAID) - Electrostimulation - Muscle relaxant - Cessation or significant reduction of athletic activities

80. • OPERATIVE TREATMENT- 1. Single Incision Fasciotomy 2. Double Mini Incision Fasciotomy 3. Double Incision Fasciotomy

81. SINGLE INCISION FASCIOTOMY (FRONEK ET AL.) 5-cm longitudinal incision halfway btw the fibula and the tibial crest in the midportion of the leg or over the fascial defect (if a muscular hernia is present at the exit of the superficial peroneal nerve) Identify the nerve and the intermuscular septum pass a fasciotome into the anterior compartment in line with the anterior tibial muscle In the lateral compartment, run the fasciotome posterior to the superficial peroneal nerve in line with the fibular shaft Do not repair muscular hernias. Close the skin in the usual fashion and apply a sterile dressing.

82. SINGLE INCISION FASCIOTOMY

83. DOUBLE MINI-INCISION FASCIOTOMY (MOUHSINE ET AL.) Without the use of a tourniquet, make two vertical 2-cm skin incisions over the anterior compartment 15 cm apart Identify the fascia and carefully develop a subcutaneous flap with blunt dissection of the bridge of skin and subcutaneous tissue. Identify the anterior intermuscular septum and the superficial peroneal nerve through the distal incision (10 to 12 cm proximal to the lateral malleolus).

84. Retract the skin anteriorly and posteriorly to allow anterior and/or lateral fasciotomy under direct vision If needed, use a gloved finger to complete the release. Close the two incisions with 3.0 monofilament and sterile adhesive strips and apply a firm bandage from midfoot to the knee.

85. DOUBLE MINI-INCISION FASCIOTOMY

86. DOUBLE INCISION FASCIOTOMY (RORABECK) Make two incisions in the leg 1 cm behind the posteromedial border of the tibia Identify the saphenous vein in the proximal incision and retract it anteriorly along with the nerve. Enter and release the superficial compartment Incise the deep fascia Expose the deep compartment, including the flexor digitorum longus and posterior tibial muscles, by detaching the soleal bridge.

87. Identify the neurovascular bundle and posterior tibial tendon incise proximally and distally the fascia overlying the tendon. The posterior tibial tendon is the key to posterior compartment decompression, and it usually is constricted proximally between the two origins of the flexor hallucis longus; enlarge the opening between these two structures to check for constriction. Release the tourniquet and obtain meticulous hemostasis. Close the wound over a suction drain to minimize the risk of hematoma formation

88. DOUBLE INCISION FASCIOTOMY

89. POST FASCIOTOMY CARE Close the wound with an interdermal running stitch Apply light dressing Early ROM encouraged Weight bearing on crutches is allowed on POD1 After suture removal at 2-3 weeks Light jogging is allowed exercises as tolerated over the next 3–6 weeks according to the patient’s abilities and pain tolerance .

90. COMPLICATIONS Hemorrhage Skin breakdown Altered sensation over the fasciotomy site Recurrence (6–11%)—more with subcutaneous and endoscopic technique Infection Deep vein thrombosis Vascular injury Nerve damage / Nerve entrapment Lymphocele Complex regional pain syndrome.

91. REFERENCE Campbell's Operative Orthopaedics - 14th Edition Handbook of Fractures 6th Edition 2019 By Kenneth Egol, Kenneth J. Koval & Joseph Zuckerman UpToDate: Evidence-based Clinical Decision Support Essential Orthopedics Principles & Practice by Manish Kumar Varshney

92. THANK YOU