Prof. Mamoun Kremli AlMaarefa College Compartment Syndrome Prof. Mamoun Kremli AlMaarefa College

Pathophysiology Increasing volume in a closed compartment Pressure increased in compartment Decreasing arteriovenous difference Hypoxia : Muscle necrosis

Pathophysiology N=0-4 mmHg > 30 mmHg Compartment pressure Venous outflow Venous pressure Gradient A.V pressure Arterial perfusion Capillary permeability Ischemia, tissue necrosis, edema

Pathophysiology Increased compartment pressure: ICP >30mm Hg (>40mm Hg) Delta Pressure: Pdiast - Pcomp < 30 mm Hg

Causes Fractures Soft tissue trauma Surgery Bleeding in closed compartment Soft tissue trauma Bleeding and edema in closed compartment Surgery Post osteotomy (Tibia / Forearm) Circumfrential dressings Does not allow swelling of skin

Clinical Picture – 5Ps Pain: Paresthesia Paralysis Pallor Pain out of proportion of expectation Increased pressure / burst sensation Pain with passive motion / stretch Paresthesia Paralysis Pallor Pulselessness TREAT  too late, >8h 6

Clinical Picture - Look Shiny skin Pallor / or Dusky skin Swelling of compartment 7

Clinical Picture - Look Shiny skin Pallor / or Dusky skin Increased volume Blisters Clear fluid Dusky Bloody -worst 8

Clinical Picture - Feel Feels tense Parasthesia Pulse ? 9

Clinical Picture - Move Pain on passive stretch Passive dorsiflexion of ankle (leg) Passive dorsiflexion of wrist (forearm) 10

Diagnosis Diagnosis 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

Diagnosis Compartment pressure measurement: NOT a substitute for clinical diagnosis Invaluable in unconscious or anesthetized patients

Measuring compart. pressure When is pressure measurement needed? Measure pressure only if: Clinical picture equivocal Altered consciousness Multiple injuries Epidural anesthesia Concomitant nerve injury Children

Treatment Medical Surgical 14

Medical Management ABC’s. Correct hypotension Remove circumferential bandages & cast Limb at level of the heart more elevation reduces the arterial inflow Supplemental oxygen administration

Medical Management With tight cast, compartmental pressure falls: 30%  when cast is split on one side 65%  when cast is split Bilaterally 75%  with Splitting the inside padding 85 – 90%  complete removal of cast

Surgical Management Should not be delayed Fasciotomy Skin and All compartments

Fasciotomy Indications: High suspicion Unequivocal clinical findings Significant tissue injury Delta pressure (DBP - compartment P.) < 25 mm Hg. Compartment pressure > 30mm Hg. S&S not resolved after 30-60min of appropriate precautions Prophylactic with major corrective osteotomy of the leg & forearm High risk patients These are indications for surgical decompression. A missed CS > 24-48 hours should not be opened. (see Rockwood and Green 5th edition and Campbell’s 10 th edition) The damage cannot be reversed and there is a significant infection rate when the dead tissue is exposed to the hospital environment. The surgeon must deal with the residual contractures of the ischemic muscle and not risk the chance of infection. Some have suggested that the scarred ant tib muscle can serve as a check rein and limit foot drop sequelae.

High Risk Patients Clinical picture equivocal Altered consciousness Multiple injuries Epidural anesthesia Concomitant nerve injury Children

Fasciotomy Principles Long 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 Volar approach use Henry Approach to release superficial and deep flexors flexors followed by the pronators and supinator. The dorsal approach is centered over the proximal forearm and can be used to release the Mobile Wad (BR, ECRL,ECRB). It is important to remember when treating and electrical injury with a compartment syndrome, the most damage is deep along the bone (i.e. the Pro and Sup muscles) and may require debridement at the initial surgery…Do not miss this! 22

Fasciotomy Principles

Fasciotomy Principles Wound closure: Bulky dressing with a splint “Boot lace” vessel loop closure “V.A.C” dressing (Vacuum Assisted Closure) Later skin graft / flap: Usually skin graft Flap coverage needed if nerves, vessels, or bone exposed

Compartment Syndrome Evaluation of muscle viability (4Cs): Color Consistency Contractility Capacity to bleed

✓ Treatment - early Color red Consistency normal Capable of bleeding Contracts when pinched ✓ 26

✗ Treatment – late Color dark Consistency abnormal Not bleeding No contractions when pinched ✗ 27

Contraindication to fasciotomy Confirmed acute compartment syndrome diagnosis for > 48 hours damage cannot be reversed and significant 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

Summary Compartment 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