The document discusses compartment syndrome, which occurs when increased pressure within a fascial compartment compromises blood flow and tissue function. It defines compartment syndrome, reviews its history, discusses causes, signs and symptoms, diagnosis, treatment with fasciotomy to release pressure on all compartments, and post-operative wound management. Compartment syndrome is a true orthopaedic emergency requiring urgent fasciotomy to prevent permanent muscle and nerve damage.
1. 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
2. Compartment Syndrome
A condition in which increased pressure
within a limited space compromises the
circulation and function of the tissues
within that space.
3. Compartment Syndrome
Definition
• Elevated tissue pressure within a closed
fascial space
• Reduces tissue perfusion - ischemia
• Results in cell death - necrosis
• True Orthopaedic Emergency
4. 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
5. 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.
6. 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
7. 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
8. History
• Ellis 1958
• Reported a 2% incidence of compartment
syndrome with tibia fractures, and increased
attention was paid to contractures involving
the lower extremities
9. 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
12. 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 1986Blick et al JBJS 1986
13. Blunt Trauma
• 2nd
most common cause
• About 23% of CS
• 25% due to direct blow
McQueen et al; JBJS Br 2000
14. 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
15. Incidence
Type of Fx % of
ACS
Incidence
all ages
Incidence
<35
Tibial
diaphysis
36% 4.3% 5.9%(3 fold)
Distal
radius
9.8% 0.25% 1.4%(30 fold)
Forearm
diaphysis
7.9% 3.1% 3.2%
McQueen et al; JBJS Br 2000
17. 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
18. Compartment Syndrome
Pathophysiology
• 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
20. Compartment Syndrome
Diagnosis
• Pain out of proportion
• Palpably tense compartment
• Pain with passive stretch
• Paresthesia/hypoesthesia
• Paralysis
• Pulselessness/pallor
21. 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 1996Whitesides AAOS 1996
22. 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 1990Willis &Rorabeck OCNA 1990
28. Compartment Syndrome
Pressure 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 1993Moed et al JBJS 1993
29. • 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, WhitesidesHeckman, Whitesides JBJS 1994JBJS 1994
Compartment Syndrome
Pressure Measurements
30.
31. 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
McQueen JBJSB 1996
32. 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
33. 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.
34. 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
35. Compartment Syndrome
Emergent Treatment
• Remove cast or dressing
• Place at level of heart
(DO NOT ELEVATE to optimize perfusion)
• Alert OR and Anesthesia
• Bedside procedure
• Medical treatment
37. Compartment Syndrome
Surgical Treatment
• Fasciotomy - prophylactic release of pressure
before permanent damage occurs. Will not
reverse injury from trauma.
• Fracture care – stabilization
– Ex-fix
– IM Nail
38. Compartment Syndrome
Indications 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)
39. Fasciotomy Principles
• Make early diagnosis
• Long extensile incisions
• Release all fascial compartments
• Preserve neurovascular structures
• Debride necrotic tissues
• Coverage within 7-10 days
40. Compartment Syndrome
Lower 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
41. Single Incision
• Perifibular Fasciotomy
– Matsen et al (1980)
– Single incision just
posterior to fibula
– Common peroneal nerve
42. 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
45. 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
46. 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
47. Compartment Syndrome
Forearm
• Anatomy-3 compartments
– Mobile wad-BR,ECRL,ECRB
– Volar-Superficial and deep
flexors
– Dorsal-Extensors
– Pronator quadratus described
as a separate compartment
48. Forearm Fasciotomy
• Volar-Henry approach
– Include a carpal tunnel
release
• Release lacertus
fibrosus and fascia
• Protect median nerve,
brachial artery and
tendons after release
50. Compartment Syndrome
Foot
• 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
51. • Dorsal incision-to release the
interosseous and adductor
• Medial incision-to release the
medial, superficial lateral and
calcaneal compartments
Compartment Syndrome
Foot
52. Compartment Syndrome
Hand
• non specific aching of
the hand
• disproportionate pain
• loss of digital motion
& continued swelling
– MP extension and
PIP flexion
• difficult to measure
tissue pressure
53. • 10 separate osteofascial
compartments
– dorsal interossei (4)
– palmar interossei (3)
– thenar and hypothenar
(2)
– adductor pollicis (1)
Fasciotomy of Hand
54. Compartment Syndrome
Thigh
• Lateral to release
anterior and posterior
compartments
• May require medial
incision for adductor
compartment
Lateral septum
Vastus lateralis
55. Compartment Syndrome
Other Areas
• Can occur anywhere in the body
• Hand-dorsal incisions, thenar, hypothenar
• Arm-lateral incision
• Buttock-posterior (Kocher) approach
• Abdominal- with the Trauma surgeons
56. Delayed Fasciotomy
Is 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.
57. Delayed Fasciotomy
Is 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
58. 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
60. 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
62. 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 2000Fitzgerald, McQueen Br J Plast Surg 2000
63. Complications related to CS
• Late Sequelae
• Volckmann’s contracture
• Weak dorsiflexors
• Claw toes
• Sensory loss
• Chronic pain
• Amputation
64. 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.
65. 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
Causes range from minor trauma to major injuries and interosseous infusion of IV fluids. Open fractures can have a 9% incidence of Compartment Syndrome-(Brumback et al). The incidence of CS in electrical injuries is proportional to the amount of voltage the patient was exposed to: minimal risk with low voltage (normal household current) and can be as high as 40% in higher voltage. Most burn literature uses the loss of pulses to decide when to perform escharotomies, however, tissue perfusion may still be compromised. Temporary vascular occlusion can occur in obtunded states(drug abuse), operative positioning (hemi and full lithotomy), and prolonged tourniquet use. If compartment syndrome is suspected, tissue pressures measurement is warranted and fasciotomies performed as indicated and supported in the literature.
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 10-15 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 &lt;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
Studies have shown that nerve tissue is the most sensitive to ischemic changes. Nerve conduction is lost in 1-2 hours of total ischemia and survive up to 4 hrs with only neuropraxia changes, while axonotmesis and irreversible changes occur after 8 hrs. Muscle may survive up to 4 hours with reversible changes, variable damage occurs by 6 hrs, and irreversible changes after 8 hrs under conditions of warm ischemia.
These physical findings have been described as the clinical hallmarks of CS. They are not very sensitive and if seen in the later stages it may be too late to change the underlying pathology. CS may be present with good pulses and no pallor and loss of pulses rarely occur unless arterial damage is present. Pain out of proportion and pain with passive stretch of a muscle in the compartment in question may be the most sensitive clinical finding before the onset of ischemic dysfunction of the nerves and muscles. These findings are useful only in a conscious cooperative patient and once paresthesia begin the pain may decrease. One important point to make is of CS is a possibility then regional anesthesia, continuous epidurals and PCA intravenous opiate analgesia should be avoided since they may mask the symptoms of compartment syndrome. Otherwise monitoring of the tissue pressure is warranted. There exist reports of missed compartment syndrome in tibia fracture and other surgical patients at risk managed postoperatively with these techniques and therefore they are generally avoided.
These are in the differential but CS must be ruled out first
CS can many times be made by PE without tissue-pressure measurements. Pressure measurements can help the treating surgeon in his clinical decision making process in these situations, but in itself does not make the diagnosis of CS. If a CS is clinically evident do not waste valuable time trying to locate the equipment or set up for the pressure measurement, perform the indicated surgical decompression ASAP
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.
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.
Initial steps in treating an extremity with elevated pressures or evolving CS. Because tissue viability depends on arterial inflow, elevating the extremity will decrease the inflow and time to prevent the secondary effects of CS. Although ideally performed in the OR, fasciotomy may have to be performed at the bedside after appropriate surgical prep. Animal studies have show some efficacy of extending muscle ischemia tolerance with the use of anticoagulants, steroids and hypothermia. Clinically most pharmacological agents are ineffective unless perfusion to the muscle tissue has been reestablished. Hypothermia may be useful to extend the time period until reperfusion or fasciotomies can be performed
Surgical decompression does not reverse the damage present but can prevent secondary sequella of the CS. Fasciotomies destabilize any long bone or extremity fracture. Studies have shown ex-fix and URN in tibias may provide temporary or permanent fixation for treatment of the fracture.
These are indications for surgical decompression. A missed CS &gt; 24-48 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.
Four compartments of the leg contain these names muscles and corresponding arteries and nerves. Complete release of all four compartments is mandatory. Physical exam based on sensory loss may be useful in exercise induced CS. The nerves are the most sensitive to ischemic changes.
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!
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!
Compartment syndromes do occur in the foot and must not be overlooked in the polytrauma patient, neurologically impaired, or assumed to be swelling and edema. Authors disagree about the number of actual compartments in the multiple layers of the foot. Clinical suspicion should be heightened with crush injuries, LisFranc injuries and looked for in the polytrauma or unconscious patient.
Dorsal incisions placed over 1st and 3rd web space, can be used to decompress and reduce and fix fractures. Medial incision releases medial compartment and affords access to the base of the hallux
DeCoster, T. Miller, R. Management of Traumatic Foot Wounds. J of AAOS 12; 4 226-230 Jul/Aug 1994.
CS can occur anywhere in the body where muscle tissue is contained within fascia. These are examples of the locations and the type of incisions used to perform the surgical decompression. Abdominal CS is now becoming well recognized in the Gen Surg and Trauma literature, the Orthopaedic surgeon should know how to measure bladder pressures with the foley.
