Compartment Syndromes

Leslie Gullahorn, MD
Director of Orthopaedic Trauma
Yuma Regional Medical Center
,
Contributing Authors: Robert M. Harris, MD, Toni McLaurin, MD, T. Toan Le, MD
and Sameh Arebi, MD, Michael Sirkin

Today

What is it
Pathophysiology
Diagnosis
Treatment

What is Compartment Syndrome?

Increase in hydrostatic pressure in closed
osteofascial space resulting in decreased
perfusion of muscle and nerves within
compartment
Increased pressure in closed fascial space
Exceeds capillary perfusion pressure

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

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.

Today

What is it
Pathophysiology
Diagnosis
Treatment

Pathophysiology

Local Blood Flow is reduced as a

consequence:
LBF=Pa-Pv / R (A-V Gradient)

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

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

Cell death initiates a vicious cycle

increase capillary permeability
increased muscle swelling

Pathophysiology
Increased compartment pressure

Increased venous pressure

Decreased blood flow
Decreases perfusion

Increased muscle swelling

Increased permeability
Increased compartment pressure

Increased pressure
Increased venous pressure
Decreased blood flow
Decreases perfusion

Repetitive Cycle

Increased muscle swelling

Increased permeability
Increased
compartment pressure

Muscle Ischemia

4 hours - reversible damage

8 hours - irreversible changes
4-8 hours - variable

Hargens JBJS 1981

Muscle Ischemia
Myoglobinuria after 4 hours
Renal failure -Check CK levels
Maintain a high urinary output
Alkalinize the urine

Nerve Ischemia

1 hour - normal conduction

1- 4 hours - neuropraxic damage
reversible
8 hours - axonotmesis and
irreversible change
Hargens et al. JBJS 1979

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

Etiology
Fractures
Arterial Injury
Post-ischemic swelling
Reperfusion injury

Soft Tissue Injury (Crush)

Patient Obtunded-(limb compression)
Burns

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

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

Today

What is it
Pathophysiology
Diagnosis
Treatment

Thehiddencomponentofanyfractureisthe
softtissueinjury,itsseverityandvariability.
AOManual

Signs & Symptoms

Tense compartment on palpation
Elevated compartment pressure

Difficult Diagnosis
Classic signs of the 5 Ps - 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.

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

Diagnosis
The most important
symptom of an impending
compartment syndrome is
PAIN
DISPROPORTIONATE
TO THAT EXPECTED
FOR THE INJURY and
PAIN WITH PASSIVE
STRETCH
Clinical diagnosis
High index of suspicion

Signs & Symptoms

Pain
May be worse with elevation
Patient will not initiate motion on
own

Be careful with coexisting nerve

injury

Signs & Symptoms

Parasthesia
Secondary to nerve ischemia

Must be differentiated from nerve

injury
Paralysis (Weakness)
Ischemic muscles lose function

Tissue Pressure
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
< 30 mm Hg of diastolic pressure McQueen, et al

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

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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

Who is at high risk?-Beware of

polytrauma patient
Increased risk for compartment syndrome
Inability to accurately obtain history and physical
exam
Head trauma
Drug/ETOH intake

May have decreased diastolic pressure

Compartment syndrome can occur at lower absolute
pressure

High energy fractures

Severe
comminution
Joint extension
Segmental
injuries

Widely
displaced
Bilateral
Floating knee
Open fractures

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Impaired Sensorium

Alcohol
Drug
Decreased
GCS
Unconscious

Chemically
unconscious
Neurologic
deficit
Cognitively
challenged

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

Criteria-Compartment Pressure
Accurately examine
Difference < 30mm Hg

Impaired
Absolute > than 30mm Hg

12

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

Pressure Measurement
Arterial line

Infusion
manometer
saline
3-way stopcock
(Whitesides, CORR 1975)

Catheter

16 - 18 ga. Needle
(5-19 mm Hg higher)
transducer
monitor

Stryker device

wick
slit catheter

Side port needle

Pressure Measurement
Needle
18 gauge
Side ported

Catheter
wick
slit

Performed within 5 cm
of the injury if
possible-Whitesides,
Heckman

Side port

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Most Common Locations

Leg: deep posterior and the
anterior compartments
Forearm: volar compartment,
especially in the deep flexor area

Pressure
Deeper muscles are initially involved
Distance from fracture affects pressure

Heckmen et al. JBJS 1994

Compartments

Anterior
Lateral
Posterior
Deep
Superficial

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Compartments
Where to Measure
KEEP CALF OFF THE BED
TA

Anterior
Lateral
Posterior

EDL
EHL
Peroneus
TP

FDL

FHL

Deep
Superficial

Soleus

Gastroc

Today

What is it
Pathophysiology
Diagnosis
Treatment

Treatment
Remove restricting bandages
Serial exams
When diagnosis made
Immediate FASCIOTOMY
All compartment fasciotomy

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

Treatment
Fasciotomy
One incision
With or without
Fibulectomy

Two incisions

All 4 compartments
must be released
Not selective

One Incision

Direct lateral incision

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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

Lateral compartment

Avoid superficial peroneal nerve

Anterior compartment

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 Superficial posterior compartment

Deep posterior compartment

Alternative

Through
intermuscular
septum to reach
superficial
posterior
compartment

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Two incisions

Lateral

Medial

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

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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

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

Thigh
Quadriceps
Lateral

Hamstrings
Posterior

Adductor
Medial

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Treatment

Based upon involvement

Usually Quadriceps and
Hamstrings
Usually, a single lateral incision
will suffice

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

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.

21

Henry Approach

Fascia over superficial

muscles is incised
Care of NV structures

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

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

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Post Fasciotomy
Must get bone stability
IMN/palte
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

Aftercare

Xeroform
VAC dressings
Elevation of limb
Serial tighten jacobs
ladder
Delayed wound closure
Split thickness skin graft

Remember

If can only close one

side-close lateral

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 !!!

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

Chronic Compartment
Syndrome
Stress Test
Serial
Compartment
Pressure
Resting >15mm Hg
5 min post-ex. >25mm
Hg

Volumetrics
Nerve
conduction
Velocities
Pedowitz et al. JHS
1988

Rydholm et al CORR 1983

Chronic Compartment
Syndrome
Treatment
Modification of activity
Splinting
Elective Fasciotomy

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Conclusion

Very important to make diagnosis

Missed compartment is devastating
Physical exam
Re-examine patient!
Remember Pain with passive stretch
If in doubtdo the fasciotomy

THANK YOU

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