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

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

3. 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

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

5. 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

6. 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

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

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

9. Clinical Picture - Feel
Feels tense
Parasthesia
Pulse ? 9

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

11. 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

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

13. 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

14. Treatment
Medical
Surgical 14

15. 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

16. 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

17. Surgical Management Should not be delayed Fasciotomy
Skin and All compartments

18. 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 > 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.

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

20. 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)

21. Fasciotomy Principles

22. 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

23. Fasciotomy Principles

24. 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

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

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

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

28. 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

29. Complications of untreated C.S.
Volckmann’s contracture
Muscle weakness
Sensory loss
Chronic pain
Amputation

30. 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