DR REMYA R KRISHNAN RESIDENT INTERN AZEEZIA MEDICAL COLLEGE

DefinitionAn elevation of the intercompartment

pressure to a level & duration without decompression will results in tissue ischemia and necrosis.

Occurs in closed osteofascial compartment Causes microvascular compromise

Types of compartment syndromeAcute compartment syndrome (ACS)

medical emergencycaused by a severe injurycan lead to permanent muscle damage.

Chronic compartment syndrome (CCS) known as exertional compartment syndrome not a medical emergencymost often caused by athletic exertion.

Pathophysiology

Pathophysiology The vicious cycle of Volkmann's

ischemia Increased intracompartmental Pressure increases local venous Pressure narrowed AV perfusion gradient compartment tamponadedecrease capillary blood flow O2 deprivation local tissue necrosis nerve injury and muscle ischemia

TheoriesCritical closing pressure theoryArteriovenous gradient theoryMacrovascular occlusion thoery

Etiology of ACSDECREASED COMPARTMENT SIZEINCREASED COMPARTMENT PRESSURE

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Etiology of ACS Decrease compartment size Tight dressings/closure of fascial

defect External pressures : casts, splints ,

burn eschar, lying on limb for long period, lithotomy position

Etiology Increased compartment contentsSNAKE BITEIATROGENIC CAUSESFractures : the most common are

Tibial diaphysealDistal radial and forearm diaphyseal

Etiology Increased compartment contents• Hemorrhage -- vascular injury, coagulopathy• Muscle edema -- severe exercise , crush injury• Increase capillary permeability–

burn,orthopaedic surgeries• Soft tissue injury• Metabolic diseases– diabetes, hypertension

Increased compartment contents

Clinical features

Swelling/ Tightness of compartmentInappropiate and uncontrolled painStretch pain & rest painPallorPulselessnessParesthesiaParalysis (full recovery is rare)

In children :3 AANXIETYAGITATIONINCREASED REQUIREMENT OF

ANALGESICS

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Whiteside' Theory:The development of a compartment syndrome also depends on

MPP = DBP(Diastolic BP) – CP(Intracompartment P)

Muscle perfusion pressure(MPP) < 30 mmHg

Tissue hypoxia

Measurement of Compartment pressures

Devices

Stryker hand-held system Stryker slit catheter

Newer devices

ManagementRemove cast/bandagePositioning of the limb at the level of the

heart - Do not elevate the affected limb decreases arterial pressure IV hydrationOxygen supplement

TreatmentOperative

Emergency fasciotomyPositive clinical presentation pressure = 30-45 mm Hg

Contraindications : Missed compartment syndrome (Various stage of muscle

infarction)

TypesForearm Syndromes

Deep forearm SyndromeCompresion ischemia

Anterior tibial SyndromeDeep posterior tibial SyndromePeroneal Compartment SyndromeSuperficial posttibial compartment Syndrome

Types by location2 compartments of arm4compatments of forearm10 compartments of hand3 compartments of thigh4 compartments of leg9compartments of foot

2 Compartments of arm1.Anterior

1. Biceps,Bracialis

2.Musculocutaneous n.

3.Brachial a.2.Posterior

1. Triceps2. Radial n.

4 Compartments of forearm1. Mobile wad : Brachioradialis, Radial n

2,3. Dorsal superficial&deep :Posterior intero-seous n & a

4. Volar superficial&deep :Median and Ulnar n. Radial a., Ulnar a., ant. interosseous a.

-most commonly affect volar

Dorsal incision

10 Compartments of hand

3 Compartments of thighAnterior

femoral nquadriceps sartorious 

Posterior sciatic nhamstrings

Medialobturator nadductors

4 Compartments of leg1. Anterior : Tibialis anterior, EDL,EHLPeroneus2. Posterior-Superficial : Gastrocnemius, soleus, plantaris3. Posterior-Deep: FDL, FHL,Popliteus,Tibialis posterior, Tibial a,v,n.4. Lateral: Peroneus longus and brevis,peroneal n

9 Compartments of foot

Dorsal dual incision

Medial incision

ComplicationsMyonecrosis : after an ischemic insult of > 8 hrs.Treatment

fasciotomy + debridement of the muscles + neurolysis Volkmann ischemic contracture : myonecrosis

replaced with fibrous tissue myotendinous adhesion formation.

TreatmentNon-surgical (physiotherapy & bracing involve the

joints)Surgical

contracture release, nerve compression release,

Reperfusion syndrome : group of complications following reestablished blood flow to ischemic tissues

Occur after fasciotomy & restoration of blood flow

Evaluation : Fluid loss, Shock Acidosis Hyperkalemia Myoglobinuria, Renal failure

Management : Preoperative hydration Mannitol Bicarbonate

Complications

Complications Neurovascular injuryInfection

Chronic Compartment Syndrome

Known as exertional CS, recurrent CS or subacute CS

Typical patient is young (20-30s) athlete (long distance runner)or military recruits

Occur mainly in the lower limb

Pathophysiology

Not yet fully understoodProbably from increased muscle relaxation

pressure during exercise decreased muscle blood flow ischemic pain and impaired muscle

function

Recurrent pain Temporary paraesthesia & numbnessLimitation of movementsTenderness over the compartmentMuscle hernias seenBilateral involvement is common

Clinical features

PeriostitisEntrapment of the superficial peroneal

nerveTendinitis of the posterior tibial tendonStress fracture of tibiaIntermittent claudication

Differential diagnosis

Plain x-rays : show stress fractureTinel test : may be positive in superficial

peroneal nerve entrapmentNerve Conduction StudyMRI

Investigations

Treatment

Non-operative : NSAIDs Muscle relaxantsCessation or significant reduction of athletic

activities

Treatment Operative treatment

Single incision fasciotomy Double incision fasciotomy

After surgery :Physiotherapy is a must

Compartment syndrome is a serious syndrome, Which needs to be diagnosed early.Palpable pulse doesn’t exclude compartment syndromeIf diagnosis and fasciotomy were done within 24 hrs, the prognosis is good.If delayed, complications will develop.

The earlier you diagnose, the safer you are

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