Compartment Syndrome T. Toan Le, MD and Sameh Arebi, MD Original Author: Robert M. Harris, MD; Created March 2004 New Authors: T. Toan Le, MD and Sameh Arebi, MD; Revised December 2005

Compartment Syndrome A condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space.

Compartment Syndrome Definition Elevated tissue pressure within a closed fascial space Reduces tissue perfusion - ischemia Results in cell death - necrosis True Orthopaedic Emergency

History Volkmann 1881 Richard von Volkmann published an article in which he attempted to describe the condition of irreversible contractures of the flexor muscles of the hand to ischemic processes occurring in the forearm Application of restrictive dressing to an injured limb

History Hildebrand 1906 First used the term Volkmann ischemic contracture to describe the final result of any untreated compartment syndrome, and was the first to suggest that elevated tissue pressure may be related to ischemic contracture.

History Thomas 1909 Reviewed the 112 published cases of Volkmann ischemic contracture and found fractures to be the predominant cause. Also, noted that tight bandages, an arterial embolus, or arterial insufficiency could also lead to the problem

History Murphy 1914 First to suggest that fasciotomy might prevent the contracture. Also, suggested that tissue pressure and fasciotomy were related to the development of contracture

History Ellis 1958 Reported a 2% incidence of compartment syndrome with tibia fractures, and increased attention was paid to contractures involving the lower extremities

History Seddon, Kelly, and Whitesides 1967 Demonstrated the existence of 4 compartments in the leg and to the need to decompress more than just the anterior compartment. Since then, compartment syndrome has been shown to affect many areas of the body, including the hand, foot, thigh, and buttocks

Compartment Syndrome Etiology Compartment Size tight dressing; Bandage/Cast localised external pressure; lying on limb Closure of fascial defects Compartment Content Bleeding; Fx, vas inj, bleeding disorders Capillary Permeability; Ischemia / Trauma / Burns / Exercise / Snake Bite / Drug Injection / IVF

Compartment Syndrome Etiology Fractures-closed and open Blunt trauma Temp vascular occlusion Cast/dressing Closure of fascial defects Burns/electrical Exertional states GSW IV/A-lines Hemophiliac/coag Intraosseous IV(infant) Snake bite Arterial injury Causes range from minor trauma to major injuries and interosseous infusion of IV fluids. Open fractures can have a 9% incidence of Compartment Syndrome-(Brumback et al). The incidence of CS in electrical injuries is proportional to the amount of voltage the patient was exposed to: minimal risk with low voltage (normal household current) and can be as high as 40% in higher voltage. Most burn literature uses the loss of pulses to decide when to perform escharotomies, however, tissue perfusion may still be compromised. Temporary vascular occlusion can occur in obtunded states(drug abuse), operative positioning (hemi and full lithotomy), and prolonged tourniquet use. If compartment syndrome is suspected, tissue pressures measurement is warranted and fasciotomies performed as indicated and supported in the literature.

Fracture The most common cause incidence of accompanying compartment syndrome of 9.1% The incidence is directly proportional to the degree of injury to soft tissue and bone occurred most often in association with a comminuted, grade-III open injury to a pedestrian Blick et al JBJS 1986

Blunt Trauma 2nd most common cause About 23% of CS 25% due to direct blow McQueen et al; JBJS Br 2000

Incidence McQueen et al; JBJS Br 2000 164 pts with CS, 149 male, 15 female Most pts were usually under 35 69% with associated fx, about half were tibial shaft 23% soft tissue injury without fx Ranges of 2-12% have been published

Incidence Type of Fx % of ACS Incidence all ages Incidence <35 Tibial diaphysis 36% 4.3% 5.9%(3 fold) Distal radius 9.8% 0.25% 1.4%(30 fold) Forearm diaphysis 7.9% 3.1% 3.2% McQueen et al; JBJS Br 2000

Patient positioning Meyer, Mubarak JBJS 2002

Patient Positioning Leaving the calf free when the leg is placed in the hemilithotomy position instead of using a standard well-leg holder Increases the difference between the diastolic blood pressure and the intramuscular pressure May decrease the risk of compartment syndrome Meyer, Mubarak JBJS 2002

Compartment Syndrome Pathophysiology Normal tissue pressure 0-4 mm Hg 8-10 with exertion Absolute pressure theory 30 mm Hg - Mubarak 45 mm Hg - Matsen Pressure gradient theory < 20 mm Hg of diastolic pressure – Whitesides McQueen, et al Normal resting muscle tissue pressure is up to 4 mm Hg and 8-10 with exertion. Exercise induced CS may have a resting based line of 10-15 mmHg. Many studies utilizing clinical evaluations and animal models by Whitesides, Mubarak, Matsen, Heckman, Heppenstall and Matava have help to establish a better understanding of the pathophysiology and thresholds of ischemia. Two schools of though prevail: 1. The Absolute Pressure Theory of Murbarak and Matsen who suggest surgical decompression in CS with pressures that reach or exceed these thresholds. 2. The Perfusion Theory of Whitesides who demonstrated in animal models and human subjects the relationship of tissue perfusion and diastolic blood pressure. His group recommends surgical decompression when the tissue pressure is within 20mm Hg of the DBP. McQueen suggested a differential <30mmHg of the diastolic pressure and the intramuscular pressure as a threshold for release as being more reliable. Mean arterial pressure can also serve as a benchmark with a release suggested when intramuscular pressure is within 45 mm Hg. Caution must be exercised in traumatized tissue and especially in hypotensive patients

Compartment Syndrome Tissue Survival Muscle 3-4 hours - reversible changes 6 hours - variable damage 8 hours - irreversible changes Nerve 2 hours - looses nerve conduction 4 hours - neuropraxia Studies have shown that nerve tissue is the most sensitive to ischemic changes. Nerve conduction is lost in 1-2 hours of total ischemia and survive up to 4 hrs with only neuropraxia changes, while axonotmesis and irreversible changes occur after 8 hrs. Muscle may survive up to 4 hours with reversible changes, variable damage occurs by 6 hrs, and irreversible changes after 8 hrs under conditions of warm ischemia.

Compartment Syndrome Diagnosis Pain out of proportion Palpably tense compartment Pain with passive stretch Paresthesia/hypoesthesia Paralysis Pulselessness/pallor These physical findings have been described as the clinical hallmarks of CS. They are not very sensitive and if seen in the later stages it may be too late to change the underlying pathology. CS may be present with good pulses and no pallor and loss of pulses rarely occur unless arterial damage is present. Pain out of proportion and pain with passive stretch of a muscle in the compartment in question may be the most sensitive clinical finding before the onset of ischemic dysfunction of the nerves and muscles. These findings are useful only in a conscious cooperative patient and once paresthesia begin the pain may decrease. One important point to make is of CS is a possibility then regional anesthesia, continuous epidurals and PCA intravenous opiate analgesia should be avoided since they may mask the symptoms of compartment syndrome. Otherwise monitoring of the tissue pressure is warranted. There exist reports of missed compartment syndrome in tibia fracture and other surgical patients at risk managed postoperatively with these techniques and therefore they are generally avoided.

Clinical Evaluation “Pain and the aggravation of pain by passive stretching of the muscles in the compartment in question are the most sensitive (and generally the only) clinical finding before the onset of ischemic dysfunction in the nerves and muscles.” Whitesides AAOS 1996

Clinical Evaluation Pain – most important. Especially pain out of proportion to the injury (child becoming more and more restless /needing more analgesia) Most reliable signs are pain on passive stretching and pain on palpation of the involved compartment Other features like pallor, pulselessness, paralysis, paraesthesia etc. appear very late and we should not wait for these things. Willis &Rorabeck OCNA 1990

Clinical Evaluation Beware of epidural analgesia Strecker JBJS 1986 Morrow J. Trauma 1994 Beware long acting nerve blocks Hyder JBJS Br 1995 Beware controlled intravenous opiate analgesia

Compartment Syndrome Differential Diagnosis Arterial occlusion Peripheral nerve injury Muscle rupture These are in the differential but CS must be ruled out first

Compartment Syndrome Pressure Measurements Suspected compartment syndrome Equivocal or unreliable exam Clinical adjunct Contraindication Clinically evident compartment syndrome CS can many times be made by PE without tissue-pressure measurements. Pressure measurements can help the treating surgeon in his clinical decision making process in these situations, but in itself does not make the diagnosis of CS. If a CS is clinically evident do not waste valuable time trying to locate the equipment or set up for the pressure measurement, perform the indicated surgical decompression ASAP

Compartment Syndrome Pressure Measurements Arterial line 16 - 18 ga. Needle (5-19 mm Hg higher) transducer monitor Stryker device Side port needle Infusion manometer saline 3-way stopcock (Whitesides, CORR 1975) Catheter wick slit wick Whitesides described the use of a 3-way stop cock connected to a mercury manometer(now against JCAH rules-biohazard) An arterial line using a large bore needle hooked up to a transducer and monitor in any ICU, OR or the recovery room will work. Remember that a standard needle will give higher results than a side port (Srtyker) or wick catheter. (Moed and Thorderson, JBJS(A), 1993) The stryker device is one of the more commonly used portable hand-held devices used for the tissue pressure measurements and since the redesign of the side port needle is very accurate. All devices must have the transducer at the level of the needle to be zeroed for an accurate reading.

Compartment Syndrome Pressure Measurements Arterial line Zero at the level of the affected limb

Compartment Syndrome Pressure Measurements Simple Needle 18 gauge Least accurate Usually gives falsely higher reading Slit Catheter and Side ported needle No significant difference More accurate Side port Whitesides et al have demonstrated that the pressure measurements should be done within 5 cm of the fracture (tibia) to obtain a true pressure reading within the suspected compartment. Moed et al JBJS 1993

Compartment Syndrome Pressure Measurements Measurements must be made in all compartments Anterior and deep posterior are usually highest Measurement made within 5 cm of fx Marginal readings must be followed with repeat physical exam and repeat compartment pressure measurement Heckman, Whitesides JBJS 1994

SUSPECTED COMPARTMENT SYNDROME Unequivocal + Findings FASCIOTOMY Pt. not alert/polytrauma/inconc. Comp. pressure measurement w/i 30 mm Hg >30 mm Hg of DBP Serial exams FASCIOTOMY McQueen JBJSB 1996

Threshold for fasciotomy McQueen, Court-Brown JBJS Br 1996 116 pts with tibial diaphyseal fx had continuous monitoring of anterior compartment pressure for 24 hours 53 pts had ICP over 30 mmHg 30 pts had ICP over 40 mmHg 4 pts had ICP over 50 mmHg Only 3 had delta pr(DBP-ICP) of < 30, they had fasciotomy None of the patients had any sequelae of the compartment syndrome Decompression should be performed if the differential pressure level drops to under 30 mmHg

Medical Management Ensure patient is normotensive ,as hypotension reduces prefusion pressure and facilitates further tissue injury. Remove cicumferential bandages and cast Maintain the limb at level of the heart as elevation reduces the arterial inflow and the arterio-venous pressure gradient on which perfusion depends. Perfusion pressure = A pr(30-35mmHg) – V pr(10-15mmHg) Supplemental oxygen administration.

Medical Management Compartmental pressure falls by 30% when cast is split on one side Falls by 65% when the cast is spread after splitting. Splitting the padding reduces it by a further 10% and complete removal of cast by another 15% Total of 85-90% reduction by just taking off the plaster! Garfin, Mubarak JBJS 1981

Compartment Syndrome Emergent Treatment Remove cast or dressing Place at level of heart (DO NOT ELEVATE to optimize perfusion) Alert OR and Anesthesia Bedside procedure Medical treatment Initial steps in treating an extremity with elevated pressures or evolving CS. Because tissue viability depends on arterial inflow, elevating the extremity will decrease the inflow and time to prevent the secondary effects of CS. Although ideally performed in the OR, fasciotomy may have to be performed at the bedside after appropriate surgical prep. Animal studies have show some efficacy of extending muscle ischemia tolerance with the use of anticoagulants, steroids and hypothermia. Clinically most pharmacological agents are ineffective unless perfusion to the muscle tissue has been reestablished. Hypothermia may be useful to extend the time period until reperfusion or fasciotomies can be performed

Fasciotomy, Fasciotomy, Fasciotomy, Surgical Treatment Fasciotomy, Fasciotomy, Fasciotomy, All compartments !!!

Compartment Syndrome Surgical Treatment Fasciotomy - prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma. Fracture care – stabilization Ex-fix IM Nail Surgical decompression does not reverse the damage present but can prevent secondary sequella of the CS. Fasciotomies destabilize any long bone or extremity fracture. Studies have shown ex-fix and URN in tibias may provide temporary or permanent fixation for treatment of the fracture.

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) 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.

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

Compartment Syndrome Lower Leg Lateral: Peroneus longus and brevis Anterior: EHL, EDC, Tibialis anterior, Peroneus tertius Supeficial posterior-Gastrocnemius, Soleus Deep posterior-Tibialis posterior, FHL, FDL .   Four compartments of the leg contain these names muscles and corresponding arteries and nerves. Complete release of all four compartments is mandatory. Physical exam based on sensory loss may be useful in exercise induced CS. The nerves are the most sensitive to ischemic changes.

Single Incision Perifibular Fasciotomy Matsen et al (1980) Single incision just posterior to fibula Common peroneal nerve

Double Incision In most instances it affords better exposure of the four compartments 2 vertical incisions separated by minimum 8 cm One incision over anterior and lateral compartments Superficial peroneal nerve One incision located 1-2 cm behind postero -medial aspect of tibia Saphenous nerve and vein Mubarak et al JBJS 1977

Fasciotomy: Medial Leg Gastroc-soleus Flexor digitorum longus

Fasciotomy: Lateral Leg Intermuscular septum Superficial peroneal nerve

Look for Superficial Peroneal Nerve superficial peroneal nerve exits from lateral compartment about 10 cm above lateral malleolus and courses into the anterior compartment Risk of injury

Use a Generous Incision Lengthening the skin incisions to an average of 16 cm decreases intracompartmental pressures significantly. The skin envelope is a contributing factor in acute compartment syndromes of the leg and The use of generous skin incisions is supported Cohen, Mubarak JBJS Br 1991

Compartment Syndrome Forearm Anatomy-3 compartments Mobile wad-BR,ECRL,ECRB Volar-Superficial and deep flexors Dorsal-Extensors Pronator quadratus described as a separate compartment  

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

Forearm Fasciotomy Protect median nerve, brachial artery and tendons after release Consider dorsal release 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!

Compartment Syndrome Foot Medial, Superficial, Lateral, Calcaneal Interossei(4), Adductor Careful exam with any swelling Clinical suspicion with certain mechanisms of injury Lisfranc fracture dislocation Calcaneus fracture Compartment syndromes do occur in the foot and must not be overlooked in the polytrauma patient, neurologically impaired, or assumed to be swelling and edema. Authors disagree about the number of actual compartments in the multiple layers of the foot. Clinical suspicion should be heightened with crush injuries, LisFranc injuries and looked for in the polytrauma or unconscious patient.

Compartment Syndrome Foot Dorsal incision-to release the interosseous and adductor Medial incision-to release the medial, superficial lateral and calcaneal compartments Dorsal incisions placed over 1st and 3rd web space, can be used to decompress and reduce and fix fractures. Medial incision releases medial compartment and affords access to the base of the hallux DeCoster, T. Miller, R. Management of Traumatic Foot Wounds. J of AAOS 12; 4 226-230 Jul/Aug 1994.

Compartment Syndrome Hand non specific aching of the hand disproportionate pain loss of digital motion & continued swelling MP extension and PIP flexion difficult to measure tissue pressure

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

Compartment Syndrome Thigh Lateral to release anterior and posterior compartments May require medial incision for adductor compartment Vastus lateralis Lateral septum

Compartment Syndrome Other Areas Can occur anywhere in the body Hand-dorsal incisions, thenar, hypothenar Arm-lateral incision Buttock-posterior (Kocher) approach Abdominal- with the Trauma surgeons CS can occur anywhere in the body where muscle tissue is contained within fascia. These are examples of the locations and the type of incisions used to perform the surgical decompression. Abdominal CS is now becoming well recognized in the Gen Surg and Trauma literature, the Orthopaedic surgeon should know how to measure bladder pressures with the foley.

Delayed Fasciotomy Is it Safe? Sheridan, Matsen.JBJS 1976 infection rate of 46% and amputation rate of 21% after a delay of 12 hours 4.5 % complications for early fasciotomies and 54% for delayed ones Recommendations If the CS has existed for more than 8-10 hrs, supportive treatment of acute renal failure should be considered. Skin is left intact and late reconstructions maybe planned.

Delayed Fasciotomy Is it Safe? Finkelstein et al. J Trauma 1996 5 pts, nine fasciotomies in lower limbs Avg delay 56 h. (35-96 hrs). 1 pt died of septicaemia and multi organ failure, the others required amputations Recommendations: In delayed cases, routine fasciotomy may not be successful

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

Interim Coverage Techniques Simple absorbent dressing Semipermeable skin-like membrane Vessel loop “bootlace” “VAC” (Vacuum Assisted Closure)

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

Wound Closure STSG Delayed primary closure with relaxing incisions

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 2000

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

Medical/Legal Pitfalls Most frequent cause of litigation In 1993, Templeman reported an average litigation award of $280,000 for 8 cases of missed CS. In all 8 cases, compartment pressures were never measured. Failure to consider potential errors in compartment pressure measurements Equipment errors occur, and needles are misplaced into tendons, fascia, or a wrong compartment. Interpret all pressure readings within the context of the clinical presentation.

Summary Keep a high index of suspicion Treat as soon as you suspect CS If clinically evident, do not measure Fasciotomy Reliable, safe, and effective The only treatment for compartment syndrome, when performed in time

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