1. Compartment Syndromes
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; Revised May 2011 – Michael Sirkin

2. Today
What is it
Pathophysiology
Diagnosis
Treatment

3. Increase in hydrostatic pressure in closed osteofascial space resulting in decreased perfusion of muscle and nerves within compartment

4. RAISED PRESSURE WITHIN A CLOSED SPACE with a potential to cause irreversible damage to the contents of the closed space

5. Richard Von Volkmann, 1881
“For many years I have noted on occasion, following the use of bandages too tightly applied, the occurrence of paralysis and contraction of the limb, NOT … due to the paralysis of the nerve by pressure, but as a quick and massive disintegration of the contractile substance and the effect of the ensuing reaction and degeneration.”

6. Symptoms resulting from increased pressure within a limited space
Definition
Symptoms resulting from increased pressure within a limited space
compromising
circulation
function

7. Local Blood Flow is reduced as a consequence:
Pathophysiology
Local Blood Flow is reduced as a consequence:
LBF=Pa-Pv / R (A-V Gradient)

8. Pathophysiology
A continuous increase in pressure within a compartment occurs until the low intramuscular arteriolar pressure is exceeded and blood cannot enter the capillaries

9. Increased venous pressure
Pathophysiology
Increased compartment pressure
Increased venous pressure
Decreased blood flow
Decreases perfusion

10. Pathophysiology Autoregulatory mechanisms may compensate:
Decrease in peripheral vascular resistance
Increased extraction of oxygen
As system becomes overwhelmed:
Critical closing pressure is reached
Oxygen perfusion of muscles and nerves decreases

11. 4 hours - reversible damage 8 hours - irreversible changes
Muscle Ischemia
4 hours - reversible damage
8 hours - irreversible changes
4-8 hours - variable
Hargens JBJS 1981

12. Muscle Ischemia Myoglobinuria after 4 hours
Renal failure
Maintain a high urinary output
Alkalinize the urine
Cell death initiates a “vicious cycle”
increase capillary permeability
increased muscle swelling

13. Increased muscle swelling
Increased permeability
Increased compartment pressure

14. Increased pressure
Increased venous pressure
Decreased blood flow
Decreases perfusion

15. Increased muscle swelling
Repetitive Cycle
Increased muscle swelling
Increased permeability
Increased compartment pressure

16. 1 hour - normal conduction 1- 4 hours - neuropraxic damage reversible
Nerve Ischemia
1 hour - normal conduction
1- 4 hours - neuropraxic damage reversible
8 hours - axonotmesis and irreversible change
Hargens et al. JBJS 1979

17. Pathophysiology: CAUSES:
Increased Volume - internal : hemmorhage, fractures, swelling from traumatized tissue, increased fluid secondary to burns, post-ischemic swelling
Decreased volume - external: tight casts, dressings
Most common cause of hemmorhage into a compartment: fractures of the tibia, elbow, forearm or femur

18. Etiology Fractures Soft Tissue Injury (Crush) Arterial Injury
Post-ischemic swelling
Reperfusion injury
Drug Overdose (limb compression)
Burns

19. Pathophysiology:
Most common cause of compartment syndrome is muscle injury that leads to edema

20. Arterial Injuries Secondary to revascularization:
Ischemia causes damage to cellular basement membrane that results in edema
With reestablishment of flow, fluid leaks into the compartment increasing the pressure

21. Diagnosis Clinical diagnosis Syndrome High index of suspicion History
Physical Exam

22. Difficult Diagnosis Classic signs of the 5 P’s - ARE NOT RELIABLE:
pain
pallor
paralysis
pulselessness
paresthesias
These are signs of an ESTABLISHED compartment syndrome where ischemic injury has already taken place
These signs may be present in the absence of compartment syndrome.

23. Diagnosis Pain Compartment pressure Confirmatory test
Don’t just measure

24. Diagnosis
Palpable pulses are usually present in acute compartment syndromes unless an arterial injury occurs
Sensory changes and paralysis do not occur until ischemia has been present for about 1 hour or more

25. Diagnosis
The most important symptom of an impending compartment syndrome is PAIN DISPROPORTIONATE TO THAT EXPECTED FOR THE INJURY

26. Pain Signs & Symptoms Passive muscle stretching Out of proportion
Progressive
Not relieved by immobilization

27. Be careful with coexisting nerve injury
Signs & Symptoms
Pain
May be worse with elevation
Patient will not initiate motion on own
Be careful with coexisting nerve injury

28. Must be differentiated from nerve injury
Signs & Symptoms
Parasthesia
Secondary to nerve ischemia
Must be differentiated from nerve injury

29. Signs & Symptoms
Paralysis (Weakness)
Ischemic muscles lose function

30. Signs & Symptoms Tense compartment on palpation
Elevated compartment pressure

31. Tissue Pressure Normal tissue pressure Absolute pressure theory
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
< 30 mm Hg of diastolic pressure 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 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

32. Tissue-Pressure: Principles
Originally, fasciotomies for tissue-pressures greater-than 30mmHg
Whitesides et al in 1975 was the first to suggest that the significance of tissue pressures was in their relation to diastolic blood pressure.
McQueen et al: absolute compartment pressure is an UNRELIABLE indication for the need for fasciotomies. BUT, pressures within 30mmHg of DP indicate compartment syndrome

33. Tissue-Pressure: Principles
Heckman et al demonstrated that pressure within a given compartment is not uniform
They found tissue pressures to be highest at the site or within 5cm of the injury
3 of their 5 patients requiring fasciotomies had sub-critical pressure values 5cm from the site of highest pressure

34. Who is at high risk?

35. High energy fractures Severe comminution Widely displaced
Joint extension
Segmental injuries
Widely displaced
Bilateral
Floating knee
Open fractures

36. Chemically unconscious Neurologic deficit Cognitively challenged
Impaired Sensorium
Alcohol
Drug
Decreased GCS
Unconscious
Chemically unconscious
Neurologic deficit
Cognitively challenged

37. Diagnosis
The presence of an open fracture does NOT rule out the presence of a compartment syndrome
6-9% of open tibial fractures are associated with compartment syndromes
McQueen et al found no significant differences in compartment pressures between open and closed tibial fractures
No significant difference in pressures between tibial fractures treated with IM Nails and those treated with Ex-Fix

38. Criteria-Compartment Pressure
Accurately examine
Difference < 30mm Hg
Impaired
Absolute > than 30mm Hg

39. Needle Infusion Technique-Historical
Needle inserted into muscle, tube with air/saline interval kept at this height, manometer indicates pressure
Air injected by syringe via 3-way stopcock
When the pressure of the injected air exceeds the compartment pressure pressure, the saline interval moves in the tube
AT this point, the second person reads the pressure from the manometer
NEED 2 PEOPLE !
saline

40. Pressure Measurement Arterial line Infusion Stryker device Catheter
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 catheter
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.

41. Pressure Measurement Needle Catheter
18 gauge
Side ported
Catheter
wick
slit
Performed within 5 cm of the injury if possible-Whitesides, Heckman
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.
Side port

42. Assemble unit and prime Hold at angle to measure Zero machine
Unit and needle set
Assemble unit and prime
Hold at angle to measure
Zero machine
Test each of 4 compartments
Keep calf off of bed

43. Most Common Locations
Leg: deep posterior and the anterior compartments
Forearm: volar compartment, especially in the deep flexor area

44. Where to Measure

45. Pressure Deeper muscles are initially involved
Distance from fracture affects pressure
Heckmen et al. JBJS 1994

46. Compartments
Anterior
Lateral
Posterior
Deep
Superficial

47. Anterior Lateral Posterior Compartments Deep Superficial TA EDL EHL
Peroneus TP
FDL
FHL
Soleus
Gastroc

48. Treatment Remove restricting bandages Serial exams When diagnosis made
Immediate surgery
4 compartment fasciotomy

49. Treatment
THE ONLY EFFECTIVE WAY TO DECOMPRESS AN ACUTE COMPARTMENT SYNDROME IS BY SURGICAL FASCIOTOMY!!! (unless missed compartment syndrome)

50. All 4 compartments must be released
Treatment
Fasciotomy
One incision
With or without Fibulectomy
Two incisions
All 4 compartments must be released
Not selective

51. One Incision
Direct lateral incision

52. Perifibular Fasciotomy
One incision
Head of fibula to proximal tip of lateral malleolus
Incise fascia between soleus and FHL distally and extended proximally to origin of soleus from fibula
Deep posterior compartment released off of the interosseous membrane, approached from the interval between the lateral and superfical posterior compartments

53. Lateral compartment

54. Anterior compartment

55. Superficial posterior compartment

56. Deep posterior compartment

57. Alternative
Through intermuscular septum to reach superficial posterior compartment

58. Two incisions
Lateral
Medial

59. Medial
Soleus bridge
Saphenous

61. Double Incision
2 vertical incisions separated by a skin bridge of at least 8 cm
Anterolateral Incision: from knee to ankle, centered over interval between anterior and lateral compartments

62. Double Incision
Posteromedial Incision: centered 1-2cm behind posteromedial border of tibia
Soleus must be detached from tibia in order to adequately decompress proximal portion of deep posterior compartment

63. Thigh Rare Crush injury with femur fracture Over distraction
relative under distraction

64. Thigh
Quadriceps
Lateral
Hamstrings
Posterior
Abductor
Medial

65. Based upon involvement Usually Quadriceps and Hamstrings
Treatment
Based upon involvement
Usually Quadriceps and Hamstrings
Usually, a single lateral incision will suffice

66. Compartments of the Forearm
Forearm can be divided into 3 compartments: Dorsal, Volar and “Mobile Wad”
Mobile Wad: Brachioradialis, ECRL, ECRB
Dorsal: EPB, EPL, ECU, EDC
Volar: FPL, FCR, FCU, FDS, FDP, PQ

67. Henry Approach
Incision begins proximal to antecubital fossa and extends across carpal tunnel
Begins lateral to biceps tendon, crosses elbow crease and extends radially, then it is extended distally along medial aspect of brachioradialis and extends across the palm along the thenar crease
Alternatively, a straight incision from lateral biceps to radial styloid can be used.

68. Henry Approach Fascia over superficial muscles is incised
Care of NV structures

69. Henry Approach
Brachioradialis and superficial radial n. are retracted radially and FCR and radial artery are retracted ulnar to expose the deep volar muscles
Fascia of each of the deep muscles is then incised

70. Dorsal Approach Usually not necessary for forearm compartment syndrome
Straight incision from the lateral epicondyle to the midline of the wrist
Interval between the ECRB and EDC is used to access deep fascia

71. Post Fasciotomy… Must get bone stability
IMN
exfix
~48hrs after procedure patient should be brought back to OR for further debridement
Delayed skin closure or skin-grafting 3-7 days after the fasciotomies

72. Aftercare Xeroform VAC dressings Elevation of limb
Delayed wound closure
Split thickness skin graft

73. Remember… Fasciotomies are not benign Complications are real >25%
Chronic swelling
Chronic pain
Muscle weakness
Iatrogenic NV injury
Cosmetic concerns
*** BUT if they are needed do not come up with
excuses to not do them !!!

74. Chronic (Exertional) Compartment Syndrome
Transient rise in compartmental pressure following activity
Symptoms
Pain
Weakness
Neurologic deficits

75. Chronic Compartment Syndrome
Volumetrics
Nerve conduction Velocities
Pedowitz et al. JHS 1988
Stress Test
Serial Compartment Pressure
Resting >15mm Hg
5 min post-ex. >25mm Hg
Rydholm et al CORR 1983

76. Chronic Compartment Syndrome
Treatment
Modification of activity
Splinting
Elective Fasciotomy

77. Conclusion Very important to make diagnosis
Missed compartment is devastating
Physical exam
Re-examine patient!

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