Prof. Mamoun KremliAlMaarefa College

Compartment Syndrome

PathophysiologyIncreasing volume in a closed compartment

Pressure increased in compartment

Decreasing arteriovenous difference

Hypoxia : Muscle necrosis

PathophysiologyCompartment

pressure

Venous outflow

Venous pressure

Gradient A.V pressure

Arterial perfusion

Ischemia, tissue necrosis, edema

Capillary permeability

N=0-4 mmHg > 30 mmHg

PathophysiologyIncreased compartment pressure:

ICP >30mm Hg (>40mm Hg)

Delta Pressure: Pdiast - Pcomp < 30 mm Hg

CausesFractures

Bleeding in closed compartment

Soft tissue traumaBleeding and edema in closed compartment

SurgeryPost osteotomy (Tibia / Forearm)Circumfrential dressings

Does not allow swelling of skin

Clinical Picture – 5Ps

Pain:Pain out of proportion of expectationIncreased pressure / burst sensationPain with passive motion / stretch

Paresthesia

Paralysis

Pallor

Pulselessness too late, >8h

TREAT

Clinical Picture - LookShiny skin

Pallor / or Dusky skin

Swelling of compartment

Clinical Picture - LookShiny skin

Pallor / or Dusky skin

Increased volume

BlistersClear fluidDuskyBloody -worst

Clinical Picture - FeelFeels tense

Parasthesia

Pulse ?

Clinical Picture - MovePain on passive stretch

Passive dorsiflexion of ankle (leg)Passive dorsiflexion of wrist (forearm)

DiagnosisDiagnosis is clinical:

Unrelenting, bursting pain Unrelifed by analgesia Swollen compartment Pain on passive stretching Sensory deficit? Pulses always palpable

Open fractures DO NOT necessarily decompress an elevated compartment pressure

DiagnosisCompartment pressure measurement:

NOT a substitute for clinical diagnosisInvaluable in unconscious or anesthetized patients

Measuring compart. pressureWhen is pressure measurement needed?

Measure pressure only if:Clinical picture equivocalAltered consciousnessMultiple injuriesEpidural anesthesiaConcomitant nerve injuryChildren

TreatmentMedical

Surgical

Medical ManagementABC’s.

Correct hypotension

Remove circumferential bandages & cast

Limb at level of the heartmore elevation reduces the arterial inflow

Supplemental oxygen administration

Medical ManagementWith tight cast, compartmental pressure falls:

30% when cast is split on one side65% when cast is split Bilaterally75% with Splitting the inside padding85 – 90% complete removal of cast

Surgical ManagementShould not be delayed

FasciotomySkin and All compartments

FasciotomyIndications:

High suspicionUnequivocal clinical findingsSignificant tissue injury

Delta pressure (DBP - compartment P.) < 25 mm Hg.Compartment pressure > 30mm Hg.S&S not resolved after 30-60min of appropriate

precautionsProphylactic with major corrective osteotomy of the leg &

forearmHigh risk patients

High Risk PatientsClinical picture equivocal

Altered consciousness

Multiple injuries

Epidural anesthesia

Concomitant nerve injury

Children

Fasciotomy PrinciplesLong extensile incisions

Release all compartments

Debride necrotic muscles (4C’s)

Preserve neurovascular structures

Never close fascia

Keep wound open

Repeated looks x48h, as needed

Coverage within 7-10 days (usually within 3-5 d)

Fasciotomy Principles

Fasciotomy Principles

Fasciotomy Principles

Fasciotomy PrinciplesWound closure:

Bulky dressing with a splint“Boot lace” vessel loop

closure“V.A.C” dressing (Vacuum

Assisted Closure)Later skin graft / flap:

Usually skin graftFlap coverage needed if

nerves, vessels, or bone exposed

Compartment SyndromeEvaluation of muscle viability (4Cs):

Color

Consistency

Contractility

Capacity to bleed

Treatment - earlyColor redConsistency normalCapable of bleedingContracts when pinched✓

Treatment – lateColor darkConsistency abnormalNot bleedingNo contractions when pinched✗

Contraindication to fasciotomyConfirmed acute compartment syndrome

diagnosis for > 48 hoursdamage cannot be reversed andsignificant infection rate when dead tissue exposed

Already dead muscles, as in crush injuries

Complications of untreated C.S.Volckmann’s contracture

Muscle weakness

Sensory loss

Chronic pain

Amputation

SummaryCompartment syndrome is a clinical diagnosis

Should not be missed - Disaster

Requires urgent treatment

“Time” is the most important factor to avoid irreversible complications

Do NOT apply circumferential dressings