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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.

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compartment syndrome

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 syndrome1
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
Compartment SyndromeDefinition
  • Elevated tissue pressure within a closed fascial space
  • Reduces tissue perfusion - ischemia
  • Results in cell death - necrosis
  • True Orthopaedic Emergency
history
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
history1
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.
history2
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
history3
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
history4
History
  • Ellis 1958
  • Reported a 2% incidence of compartment syndrome with tibia fractures, and increased attention was paid to contractures involving the lower extremities
history5
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 SyndromeEtiology

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 etiology1
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

Compartment SyndromeEtiology
fracture
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
Blunt Trauma
  • 2nd most common cause
  • About 23% of CS
  • 25% due to direct blow

McQueen et al; JBJS Br 2000

incidence
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
incidence1
Incidence

McQueen et al; JBJS Br 2000

patient positioning
Patient positioning

Meyer, Mubarak JBJS 2002

patient positioning1
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
Compartment SyndromePathophysiology
  • 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
compartment syndrome tissue survival
Compartment SyndromeTissue Survival
  • Muscle
    • 3-4 hours - reversible changes
    • 6 hours - variable damage
    • 8 hours - irreversible changes
  • Nerve
    • 2 hours - looses nerve conduction
    • 4 hours - neuropraxia
    • 8 hours - irreversible changes
compartment syndrome diagnosis
Compartment SyndromeDiagnosis
  • Pain out of proportion
  • Palpably tense compartment
  • Pain with passive stretch
  • Paresthesia/hypoesthesia
  • Paralysis
  • Pulselessness/pallor
clinical evaluation
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 evaluation1
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 evaluation2
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
Compartment SyndromeDifferential Diagnosis
  • Arterial occlusion
  • Peripheral nerve injury
  • Muscle rupture
compartment syndrome pressure measurements
Compartment SyndromePressure Measurements
  • Suspected compartment syndrome
  • Equivocal or unreliable exam
  • Clinical adjunct
  • Contraindication
    • Clinically evident compartment syndrome
compartment syndrome pressure measurements1
Infusion

manometer

saline

3-way stopcock

(Whitesides, CORR 1975)

Catheter

wick

slit wick

Arterial line

16 - 18 ga. Needle

(5-19 mm Hg higher)

transducer

monitor

Stryker device

Side port needle

Compartment SyndromePressure Measurements
compartment syndrome pressure measurements2
Compartment SyndromePressure Measurements
  • Arterial line
    • Zero at the level of the affected limb
compartment syndrome pressure measurements3
Compartment SyndromePressure 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

Moed et al JBJS 1993

compartment syndrome pressure measurements4
Compartment SyndromePressure 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, WhitesidesJBJS 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

SUSPECTED COMPARTMENT SYNDROME

McQueen JBJSB 1996

threshold for fasciotomy
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
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 management1
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
Compartment SyndromeEmergent Treatment
  • Remove cast or dressing
  • Place at level of heart

(DO NOT ELEVATE to optimize perfusion)

  • Alert OR and Anesthesia
  • Bedside procedure
  • Medical treatment
surgical treatment
Surgical Treatment
  • Fasciotomy, Fasciotomy, Fasciotomy,
    • All compartments !!!
compartment syndrome surgical treatment
Compartment SyndromeSurgical Treatment
  • Fasciotomy - prophylactic release of pressure before permanent damage occurs. Will not reverse injury from trauma.
  • Fracture care – stabilization
    • Ex-fix
    • IM Nail
compartment syndrome indications for fasciotomy
Compartment SyndromeIndications 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)
fasciotomy principles
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
Compartment SyndromeLower Leg
  • 4 compartments
    • Lateral: Peroneus longus and brevis
    • Anterior: EHL, EDC, Tibialis anterior, Peroneus tertius
    • Supeficial posterior-Gastrocnemius, Soleus
    • Deep posterior-Tibialis posterior, FHL, FDL
  • .
single incision
Single Incision
  • Perifibular Fasciotomy
    • Matsen et al (1980)
    • Single incision just posterior to fibula
    • Common peroneal nerve
double incision
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
Fasciotomy: Medial Leg

Gastroc-soleus

Flexor digitorum

longus

fasciotomy lateral leg
Fasciotomy: Lateral Leg

Intermuscular septum

Superficial peroneal nerve

look for 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
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
Compartment SyndromeForearm
  • Anatomy-3 compartments
    • Mobile wad-BR,ECRL,ECRB
    • Volar-Superficial and deep flexors
    • Dorsal-Extensors
    • Pronator quadratus described as a separate compartment
forearm fasciotomy
Forearm Fasciotomy
  • Volar-Henry approach
    • Include a carpal tunnel release
  • Release lacertus fibrosus and fascia
  • Protect median nerve, brachial artery and tendons after release
forearm fasciotomy1
Forearm Fasciotomy
  • Protect median nerve, brachial artery and tendons after release
  • Consider dorsal release
compartment syndrome foot
Compartment SyndromeFoot
  • 9 compartments
    • 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 syndrome foot1
Compartment SyndromeFoot
  • Dorsal incision-to release the interosseous and adductor
  • Medial incision-to release the medial, superficial lateral and calcaneal compartments
compartment syndrome hand
Compartment SyndromeHand
  • 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
Fasciotomy of Hand
  • 10 separate osteofascial compartments
    • dorsal interossei (4)
    • palmar interossei (3)
    • thenar and hypothenar (2)
    • adductor pollicis (1)
compartment syndrome thigh
Compartment SyndromeThigh
  • Lateral to release anterior and posterior compartments
  • May require medial incision for adductor compartment

Vastus lateralis

Lateral septum

compartment syndrome other areas
Compartment SyndromeOther Areas
  • Can occur anywhere in the body
  • Hand-dorsal incisions, thenar, hypothenar
  • Arm-lateral incision
  • Buttock-posterior (Kocher) approach
  • Abdominal- with the Trauma surgeons
delayed fasciotomy is it safe
Delayed FasciotomyIs 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 safe1
Delayed FasciotomyIs 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
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
Interim Coverage Techniques
  • Simple absorbent dressing
  • Semipermeable skin-like membrane
  • Vessel loop “bootlace”
  • “VAC” (Vacuum Assisted Closure)
wound management1
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
Wound Closure
  • STSG
  • Delayed primary closure with relaxing incisions
complications related to fasciotomies
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
Complications related to CS
  • Late Sequelae
      • Volckmann’s contracture
      • Weak dorsiflexors
      • Claw toes
      • Sensory loss
      • Chronic pain
      • Amputation
medical legal pitfalls
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
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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