Compartement Syndrome

Compartement Syndrome
RC/WL/WO/FH/ZP/JA
McQueen MM. Acute Compartement Syndrome. In: Bucholz et al. Rockwood & Greens fractures in
Adults 7th ed.
Etiology
Conditions Associated with
Less Common Causes of Acute
Injury Causing Acute
Compartment Syndrome
Presenting to an Orthopaedic
Conditions Increasing the Volume of Compartment
Contents
Trauma Unit
Fracture
Underlying Condition
% of Cases
Soft tissue injury
Tibial diaphyseal fracture36
Crush syndrome (including use of the lithotomy
position)90
Soft tissue injury
23.2
Revascularization
Distal radius fracture
9.8
Exercise79
Crush syndrome
7.9
Fluid infusion (including arthroscopy)10,129
Diaphyseal fracture
Arterial puncture130
Ruptured ganglia/cysts29
forearm
7.9
Osteotomy43
Femoral diaphyseal
Snake bite145
fracture
3.0
Nephrotic syndrome139
Leukemic infiltration144
Tibial plateau fracture
3.0
Viral myositis76
Hand fracture(s)
2.5
Acute hematogenous osteomyelitis137
Tibial pilon fractures
2.5
Conditions Reducing Compartment Volume
Burns
Foot fracture(s)
1.8
Repair of muscle hernia4
Ankle fracture
0.6
Medical Comorbidity
Elbow fracture
Diabetes20
Hypothyroidism65
dislocation
0.6
Bleeding diathesis/anticoagulants63
Pelvic
fracture
0.6
Adults
7th ed. diaphyseal
Humeral
Adults 7th ed.
Introduction
Pathophysiology
local trauma and soft tissue destruction>bleeding
and edema>increased interstitial pressure>
reduced microvascular perfusion >macrovascular
arterial occlusion >myoneural ischemia
Swelling and ultimate loss of viability of a

muscle group, is caused by compromised
circulation within a confined anatomic space
anterior tibial compartment of the leg, the volar
compartment of the forearm, or the interosseous
compartments of the hand
Moore D. Compartement Syndrome. In: Orthobullets.com.
Bullough PG. The Effects of Injury and the Inflammatory Response. In Orthopaedic Pathology
Introduction
Vascular occlusion from either direct injury or
increased pressure within the anatomic
compartment > diminished tissue viability and
function.
Pain and swelling are prominent symptoms.
Muscle necrosis > original tissue is replaced by
dense, fibrous connective tissue, with subsequent
deformity and loss of function.
Microscopic findings depend on the stage at which
the tissue is obtained.
Muscle necrosis, granulation, scar tissue, and
calcification may be present
Bullough PG. The Effects of Injury and the Inflammatory Response. In Orthopaedic Pathology 5th ed.
Etiology of Compartement
Syndrome
Thompson JC. Basic Science. In: Netters Concise Orthopaedic Anatomy 3rd ed. 2010
Introduction
Special considerations
vascular injuries treated withrevascularization
revascularization of a previously ischemic limb leads to swelling and
intracomparmental hypertension
consider prophylactic fasciotomies following all repairs of traumatic vascular
injuries
pedriatrics
children are unable to verbalize feelings
if suspicious thenperform compartment pressure measurementunder sedation
increasing pain medication requirement and pain out of proportion to injuryis
the most sensitive clinical sign
functional outcome is inversely related to the duration of elevated tissue
pressures before surgical decompression
hemophiliacs
giveFactor VIII replacementbefore measuring compartment
pressures
Tissue Pressure
Measurements
Indications:
Polytrauma Patient
Ass. HI, intoxication, ETT interfere HT and
PE
Low Diastolic Pressure
Px with chemical overdose/ HI and

Isolated Long Bone Fracture
Difficult assess HT & PE
Inconclusive Clinical Diagnosis
Amendola
A
and
Twaddle
BC.
Compartement
Syndromes.
In:
Browner BD, Jupiter JB , Levine AM and
Trafton PG [eds.]. Skeletal Trauma:
Basic Science, Managmenet and
Recosntruction 3rd ed. 2003.
Measurement Techniques
Needle Manometer
Amendola A and Twaddle BC. Compartement Syndromes. In: Browner BD, Jupiter JB , Levine
AM and Trafton PG [eds.]. Skeletal Trauma: Basic Science, Managmenet and Recosntruction
Continuous Infusion Technique
Low accuracy: tissue compliance <<
when pressure greater than 30 mmHg
artifically high reading
Wick Catheter
Polyglycolic acid suture
pulled into tip of piece
of PE60 polyethylene
tubing
Catheter placement
sleeve + wick catheter
connected to pressure
transducer & recorder
introduced through a
large trocar. Needle is
withdrawn & catheter
is taped to the skin
Slit Catheter
PE60 Polyethylene tubing with
five 3-mm slits in the end of tube
Slit Catheter System

Microcappilary Infusion
Arterial Transducer
Measurement
Noninvasive Techniques
(Chronic CS)
Tc 99m-MIBI Scintigraphy
Laser Doppler Flow
Near-Infrared Spectroscopy
Arm Compartement
Syndrome
2 Compartment:
Anterior
Compartment
Anterior: Brachial
fascia
Medial / lateral:
intermusc Septa
Post: humerus
Posterior
Compartment
Same as anterior but
lies posterior to
Adults 7th ed.
Compartments of the Arm, Their

Contents, and Clinical Signs of
Acute Compartment Syndrome
Compartment
Contents
Anterior
Biceps
Brachialis
Coracobrachialis
Median nerve
Ulnar nerve
Musculocutaneous nerve
Lateral cutaneous nerve
Antebrachial nerve
Posterior
Triceps
Radial nerve
Ulnar nerve (distally)
Signs
Radial nerve (distal third)
Pain on passive elbow
extension
Numbnessmedian/ulnar
distribution
Numbnessvolar/lateral
distal forearm
Weaknesselbow flexion
Weaknessmedian/ulnar
motor function
Pain on passive elbow
flexion
Numbnessulnar/radial
distribution
Weaknesselbow
extension
Weaknessradial/ulnar
motor function
Adults 7th ed.
Forearm Compartment
Syndrome
Relatively rare
Associated with direct blow or crushing
component
Forearm: 3 osseofacial compartment
Henrys
deep flexor, extensor)
approach
(superficial
volar flexor flexor,
volar ulnar
approach / volar (henrys)
approach
Dorsal thompson
exposure
A straight incision from the lateral
epicondyle to the midline of the
wrist is used
Interval ECRB and EDC
3rd ed. 2003.
Compartments of The Forearm,

Their Contents, and Signs of Acute
Compartment
Contents
Signs
Volar
Flexor carpi radialis longus Pain on passive

and brevis
wrist/finger extension
Flexor digitorum
Numbnessmedian/ulnar
superficialis and profundusdistribution
Pronator teres
Weaknesswrist/finger
Pronator quadratus
flexion
Median nerve
Weaknessmedian/ulnar
Ulnar nerve
motor function in hand
Dorsal
Extensor digitorum
Extensor pollicis longus
Abductor pollicis longus
Extensor carpi ulnaris
Painpassive wrist/finger
flexion
Weaknesswrist/finger
flexion
Mobile wad
Brachioradialis
Extensor carpi radialis
Pain on passive wrist

flexion/elbow extension
Weaknesswrist
extension/elbow flexion
Adults 7th ed.
Forearm Compartment
Syndrome
Henrys
approach
Volar Ulnar
approach
Dorsal approach
midforear
m
3rd ed. 2003.
Hand Compartment
IntroductionSyndrome
Volkman's ischemic contracture is a posttraumatic
contracture of the wrist, hand, and forearm
FDPandFPLare most commonly affected
Interossei
Physical exam
diagnosis based primarily on physical exam in patient
withintact mental status
pain with passive stretchof fingers (intrinsic muscle) and
Instrinsic paralysis
Compartment pressure measurement

indicated in patients withaltered mental status
absolute value of30 mm Hgis indicator of fasciotomy
use threshold of20 mm Hgin hypotensive patient
Thompson
JC. Hand In: Netters Concise Orthopaedic Anatomy 3rd ed. 2010
3rd ed. 2003.
Thigh Compartment
Syndrome
Three muscle compartments: quadriceps,
hamstrings and adductors
Can be due to IM Nailing
Quadriceps compartment
Anterolateral incision (Q)

Splitting iliotibial band
fascia overlying vastus lateralis is divided along its
length
Intermuscular septum (H)

Separate longitudinal incision along its
length (A)
3rd ed. 2003.
Compartments of the Thigh, Their

Contents, and Signs of Acute
Compartmen
t
Contents
Signs
Anterior
Quadriceps muscles
Sartorius
Femoral nerve
Pain on passive knee flexion

Numbnessmedial leg/foot
Weaknessknee extension
Posterior
Hamstring muscles
Sciatic Nerve
Adductor
Adductor muscles
Obturator nerve
Pain on passive knee

extension
Sensory changes rare
Weaknessknee flexion
Pain on passive hip
abduction
Sensory changes rare
Weaknesship adduction
Adults 7th ed.
Thigh Compartment
Syndrome
3rd ed. 2003.
Thigh Compartment
Syndrome
Medial
compartment
3rd ed. 2003.
Leg Compartment
Syndrome
Introduction
occur in 1-10% of
tibial shaft fractures
crush injuries
Physical exam
diagnosis based primarily onphysical examin patient
pain out of proportionto injury

pain with passive stretchof ankle or toes (most reliable test)
tense lower extremity
pulses (presence of pulses is not a reliable factor for excluding the
diagnosis)
sensory or motor nerve deficits
isolated lateral compartment compartment syndrome would only affect
superficial peroneal nerve
Leg Compartment
Syndrome
Compartment pressure
measurement
indicated in patients withaltered mental
status
absolute value of 30 to 45 mm Hg or
within 30 mm Hg of diastolic BP (delta p)
if delta p is less than 30 mmHg intraoperatively,
check preoperative diastolic pressure and follow
postoperatively as intraoperative pressures may
be low and misleading
Compartments of the Leg with Their

Contents and Clinical Signs of Acute
Compartment Syndrome in Each
Compartment
Anterior
Lateral
Contents
Signs
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Peroneus tertius
Deep peroneal (anterior
tibial) nerve and vessels
Peroneus longus
Peroneus brevis
Superficial peroneal nerve
Pain on passive flexion

ankle/toes
Numbness1st web space
Weaknessankle/toe
flexion
Pain on passive foot

inversion
Numbnessdorsum of
foot
Weakness of eversion
Superficial posterior
Gastrocnemius
Pain on passive ankle
Soleus
extension
Plantaris
Numbnessdorsolateral
Sural nerve
foot
Weaknessplantar flexion
Deep posterior
Tibialis posterior
Pain on passive ankle/toe
Flexor digitorum longus
extension/ foot eversion
Flexor hallucis longus
Numbnesssole of foot
tibial
nerve et al. Rockwood
Weaknesstoe/ankle
McQueen MM. Acute CompartementPosterior
Syndrome.
In: Bucholz
& Greens fractures in
flexion, foot inversion
Adults 7th ed.
Leg Compartment
Syndrome
Treatment
initial treatment for swelling or pain that is NOT
compartment syndrome involves bi-valving the
cast and loosening circumferential dressings
emergent fasciotomy of all four
compartments
if untreated for8 hoursirreversible myoneural
necrosis and fibrosis will occur
15-18 cm incision required for adequate
decompression
Leg Compartment
Syndrome
two methods
dual medial-lateral incisions
elevation of the soleus must be done via
medial approach to access deep posterior
compartment
single lateral incision
common peroneal nerve at risk with
proximal dissection
superficial peroneal nerve at risk with
distal dissection
postoperative dressing changes followed by

delayed primary closure or skin grafting at
3-7 days post decompression
hyperbaric oxygen therapy

works by increasing the oxygen diffusion
Leg Compartment
Syndrome
Three Techniques:
Fibulectomy
Unnecessary & too radical
Perifibular fasciotomy
Single lateral incision
Head of fibula distally to ankle
Retract intermuscular septum (anterior / lateral)
protect superficial peroneal nerve
Fasciotomy: 1 cm in front of intermuscular septum (ant
compartment) and 1 cm posterior (lateral compartement)
Double-incision Technique
3rd ed. 2003.
Amendola A and Twaddle BC.

Compartement Syndromes. In:
Browner BD, Jupiter JB , Levine
AM and Trafton PG [eds.].
Skeletal Trauma: Basic Science,
Managmenet and Recosntruction
3rd ed. 2003.
Leg Compartment
Syndrome
Three Techniques:
Fibulectomy
Perifibular fasciotomy
Double-incision Technique
Bridge of skin at least 8 cm
1st: knee to ankle (between anterior / lateral
compartment)
Care of superficial peroneal nerve
2nd: 1-2cm behind posteromedial border of the

tibia
Care of saphenous vein and nerve
3rd ed. 2003.
Leg Compartment
Syndrome
3rd ed. 2003.
Leg Compartment
Syndrome
3rd ed. 2003.
Leg Compartment
Syndrome
3rd ed. 2003.
Foot Compartment
Syndrome
Introduction
higher incidence with
calcaneal fxs
Lisfranc complex injuries
crush injuries
open injuries have a higher incidence than closed fractures
Physical exam
diagnosis based primarily on physical exam in patient
pain out of proportion to injury

pain with dorsiflexion of toes(places intrinsic muscles on stretch)
tense swollen foot
pulses (presence of pulses is not a reliable factor for excluding the
diagnosis)
3rd
ed.D.
2003.
Moore
Compartement Syndrome. In: Orthobullets.com.
Foot Compartment
Syndrome
Compartment pressure
measurement
indicated in patients withaltered mental
status
absolute value of 30 to 45 mm Hg or
within 30 mm Hg of diastolic BP (delta p)
if delta p is less than 30 mmHg intraoperatively,
check preoperative diastolic pressure and follow
postoperatively as intraoperative pressures may
be low and misleading
Foot Compartment
Syndrome
Treatment
emergent foot fasciotomy
9 major compartments of foot have been
described
medial (Intrinsic muscles of the great toe)
Lateral (Flexor digiti minimi & Abductor digiti minimi)
interosseous(x4) - Interosseous muscles & Digital
nerves
central(x3: superfical - Flexor digitorum brevis, middle
- Adductor hallucis, and deep/Calcaneal - Quadratus
plantae)
posterior tibial neurovascular bundle and quadratus
plantae are in the deep central compartment
Moore D.
Syndrome. In: Orthobullets.com.
Adults
7thCompartement
ed.
Foot Compartment
Syndrome
3rd ed. 2003.
Foot Compartment
Syndrome
surgical technique
dual dorsal incisons (gold standard)
dorsal medial incision
allows decompressin of 1st and 2nd
interosseous (lateral), medial, and deep
central compartments
dorsal lateral incison
allows decompression of 3rd and 4th
interosseous (lateral), superfical central,
middle and central)
some add an additional medial incision
single medial incision

has been described but is technically more
difficult
Foot Compartment
Syndrome
3rd ed. 2003.
Complications
Delay to fasciotomy of more than 6 hours
is likely to cause significant sequelae
muscle contractures
muscle weakness
sensory loss
Infection
nonunion of fractures
In severe cases amputation may be necessary
because of infection or lack of function
Adults 7th ed.
Pathology
Pathology
QUESTIONS
Q1
A 28-year-old male sustains a midshaft fibula fracture after
being kicked during a karate tournament and develops
compartment syndrome isolated to the lateral compartment
of his leg. If left untreated, which of the following sensory or
motor deficits would be expected?
1. Decreased sensation on the dorsum of his foot involving
the hallux, 3rd, and 4th toes
2. Inability to plantar flex the ankle
3. Decreased sensation on the dorsum of his foot involving
the first webspace
4. Inability to dorsiflex the ankle
5. Inability to abduct his toes
PREFERRED RESPONSE 1
DISCUSSION: The clinical vignette describes a scenario of isolated
compartment syndrome in the lateral compartment of the leg. The
only nervous structure residing in the lateral compartment is the
superficial peroneal nerve. In compartment syndrome of the lateral
leg compartment, failure of prompt surgical fasciotomy would
present as a sensory deficit of the superficial peroneal nerve
presenting as numbness on the dorsum of his foot involving the
hallux, 3rd, and 4th toes, as seen in Illustration A.
Matsen et al discuss the poor results which can be a cause of late
diagnosis and surgical decompression. They recommended
compartment monitoring in equivocal cases as well as release of all
four leg compartments when facing leg compartment syndrome. A
diagram of a two-incision fasciotomy is shown in Illustration B.
Olson et al provide a review of compartment syndrome for the lower
extremity. They discuss a variety of injuries and medical conditions
may initiate acute compartment syndrome, including fractures,
bleeding disorders, and other trauma. Although the diagnosis is
primarily a clinical one, they also recommend supplementation with
compartment pressure measurements in equivocal cases.
Q2
During a dual incision fasciotomy of the leg, the
soleus is elevated from the tibia to allow access to
which of the following compartments?
1.
2.
3.
4.
5.
Superficial posterior
Deep posterior
Lateral
Anterior
Mobile wad
DISCUSSION: The soleus is elevated/released
from the posterior tibia during the medial
approach to allow access to the deep
posterior compartment. Release of this
compartment cannot be done without proper
elevation of the soleus. The superficial
posterior compartment mass is primarily
located in the proximal half of the leg, while
the deep posterior musculature is located in
the distal 2/3 of the leg.
Q3
A 35-year-old female presents to the emergency
room after a motor vehicle collision where her leg
was pinned under the car for over 30 minutes. A
clinical photo and radiographs are shown. Which
of the following is the most accurate way to
diagnose compartment syndrome?
1. surgeon's palpation of the leg compartments
2. parathesias in her foot
3. diastolic blood pressure minus intracompartmental pressure is less than 30 mmHg
4. diastolic blood pressure minus intracompartmental pressure is greater than 30
mmHg
5. intra-compartmental pressure measurement of
25 mmHg
DISCUSSION: The clinical picture is consistent with compartment
syndrome. The most accurate way to make the diagnosis is to
measure the difference between the diastolic blood pressure and
intracompartmental pressure (delta p). In a prospective study of
116 patients with tibial diaphyseal fractures, McQueen et al found
that the use of a differential pressure of 30 mmHg as a threshold
for fasciotomy led to no missed cases of acute compartment
syndrome. They recommended that a fasciotomy should be
performed if the differential pressure level drops to under 30
mmHg. The cited study by Kakar et al found the intraoperative
DBP is significantly lower than the preoperative DBP in patient
undergoing IM nailing for tibia shaft fractures. Therefore, they
emphasize that the surgeon should recognize that intraoperative
DeltaP may be lower than DeltaP once the patient is awakened in
deciding whether to perform a fasciotomy versus awaken the
patient and perform serial examinations and or compartment
pressure measurements. An absolute intra-compartmental value
greater than 30 to 45mmHg can also be used to make the
diagnosis of compartment syndrome, but is more controversial
than the delta p according to Kakar and Amendola.
Q4
A 32-year-old male sustains the injury
seen in Figure A. His blood pressure
preoperatively was 132/84. After closed
reduction and placement of an
intramedullary nail, his intraoperative
leg compartment pressures are
measured, with the highest being 28
mmHg. His blood pressure at this time
is 84/57. What is the next appropriate
step?
1. Immediate four compartment
fasciotomy
2. Fasciotomy of the highest
compartment(s)
3. Acute shortening of the tibia with
exchange of nail as needed
4. Repeat evaluation and compartment
pressure evaluation in recovery room
5. Addition of pressors to anesthesia
DISCUSSION: Figure A shows a mildly comminuted tibia fracture,
which is a fracture highly associated with compartment syndrome.
However, in this scenario, the delta p (difference between
compartmental pressures and diastolic pressure) is greater than 30
preoperatively, with a decrease to less than 30 intraoperatively,
due to the hypotension associated with anesthesia. The referenced
article by Kakar et al notes that the delta p may be spuriously low
intraoperatively, and with tibial nailing, it is safe to assume the
delta p will return to a higher level postoperatively. They
recommended continued monitoring in the postoperative period
with clinical examination and measurements as needed. The
McQueen referenced article showed that the delta p is more
important than absolute pressures, as an absolute threshold of
30mmHg would have led to unnecessary fasciotomies in 43% of
their cohort.
Q5
A 10-year-old girl is treated for a tibia/fibula fracture with a
long leg cast. The on-call resident is called to evaluate the
patient for increasing pain medicine requirements and
tingling in her foot. Examination of the cast reveals that the
ankle has been immobilized in 10 degrees of dorsifelxion.
What ankle position results in the lowest deep posterior calf
compartment pressures in a casted leg?
1.
2.
3.
4.
5.
40-50 degrees of plantar flexion

10-20 degrees of ankle dorsiflexion
Neutral to 30 degrees of plantar flexion
Neutral to 10 degrees of dorsiflexion
Ankle position has no effect on calf compartment pressure
DISCUSSION: Agitation, anxiety, and increasing analgesic
requirments are the "3 A's" of pediatric compartment syndrome.
Weiner et al measured intramuscular compartment pressure in the
anterior and deep posterior compartments of the leg in seven
healthy adults who had long leg casts placed. They found that in a
casted leg the intramuscular pressure in the anterior compartment
was lowest with the ankle in neutral, and the deep posterior
compartments was lowest when the ankle joint was in the resting
position, approximately 37 degrees of plantar flexion. Based on this,
they concluded that the safest ankle casting position regarding
compartment pressure is between 0 and 37 degrees of plantar
flexion. After the cast was bivalved, they noted a significant
decrease in intramuscular pressure of 47 per cent in the anterior
compartment and of 33 per cent in the deep posterior
compartment. Constrictive casts and abberant ankle positioning
can exacerbate pain/symptoms. Loosening of the cast by bivalving,
spreading, and cutting underlying stockinette/softroll should always
be the first step in management of possible compartment
syndrome.
THANK YOU

Compartement Syndrome

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Compartement Syndrome

Uploaded by

Copyright:

Available Formats

Compartement Syndrome

Swelling and ultimate loss of viability of a

Px with chemical overdose/ HI and

Inconclusive Clinical Diagnosis

Slit Catheter System

Compartments of the Arm, Their

Compartments of The Forearm,

Flexor carpi radialis longus Pain on passive

Pain on passive wrist

Compartment pressure measurement

Anterolateral incision (Q)

Intermuscular septum (H)

Compartments of the Thigh, Their

Pain on passive knee flexion

Pain on passive knee

pain out of proportionto injury

Moore D. Compartement Syndrome. In: Orthobullets.com.

Moore D. Compartement Syndrome. In: Orthobullets.com.

Compartments of the Leg with Their

Pain on passive flexion

Pain on passive foot

Moore D. Compartement Syndrome. In: Orthobullets.com.

postoperative dressing changes followed by

hyperbaric oxygen therapy

Moore D. Compartement Syndrome. In: Orthobullets.com.

Amendola A and Twaddle BC.

2nd: 1-2cm behind posteromedial border of the

pain out of proportion to injury

Moore D. Compartement Syndrome. In: Orthobullets.com.

single medial incision

40-50 degrees of plantar flexion

You might also like