DR. SIDHARTH YADAVDEPT. OF ORTHOPAEDICS

NKPSIMS

ACUTE COMPARTMENT SYNDROME

Compartment SyndromeDefinition

Elevated tissue pressure within a closed osteofascial space

Reduces tissue perfusion – ischemia

Results in cell death - necrosis

HistoryVolkmann 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

HistoryHildebrand 1906

First used the term Volkmann ischemic contracture to describe the final result of any untreated compartment syndrome.

First to suggest that elevated tissue pressure may be related to ischemic contracture.

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

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

History

Ellis 1958

Reported a 2% incidence of compartment syndrome with tibia fractures, and increased attention was paid to contractures involving the lower extremities

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

Types of compartment syndrome

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Compartment syndromes can be classified as :

Acute compartment syndrome (ACS)

Chronic compartment syndrome (CCS) depending on the cause of increased intra-compartmental pressure and the duration of symptoms

Sites of Acute Compartment Syndrome

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Acute compartment syndrome can develop anywhere a skeletal muscle is surrounded by a substantial fascia.

ACS may occur in foot, leg, thigh, buttocks, lumbar paraspinous muscles, hand, forearm, arm and shoulder.

Compartments

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Foot 9

Leg 4 (anterior,lateral, sup & deep posterior )

Hand 4

Thigh 3 (anterior, posterior, medial )

Forearm 4 (sup &deep volar,dorsal, mobile wad of Henry)

QUADRICEPS

MOBILE WAD

VOLAR COMPARTMENT

DORSAL

Pathophysiology of ACS

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CS develops after prolonged elevated intra-compartmental pressure , which results from either externally applied or internally expanding pressure forces.

Increased tissue pressure will decrease capillary blood flow leading to local tissue necrosis caused by O2 deprivation .

Local blood flow (LBF) =Pa-Pv/R.

Pathophysiology of ACS

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The elevated intra-compartmental pressure increases the local venous pressure leading to narrowed arteriovenous perfusion gradient and compartment tamponade, resulting -if uncontrolled - in nerve injury and muscle ischemia

Etiology of ACS

External Restriction of Compartment Size :

- casts - tight dressings - splints - lying on limb for long period - burn eschar - closure of fascial defect - lithotomy position

Etiology of ACS

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•Factures (the most common are) :

In adults --- closed and open tibial shaft fracture , distal radial fracture

In children --- radial head or neck fracture , supracondylar fracture , forearm fractures

Etiology of ACS

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Hemorrhage (e.g. due to vascular injury )

Coagulopathy (e.g. hemophilia , thrombolytics , sickle cell disease or trait )

Muscle edema (e.g. severe exercise , crush injury, trauma with or without fx )

Etiology of ACS

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Surgically related (e.g. knee arthroscopy , tibial osteotomy without drainage , after epidural anesthesia )

Massive crystalloid infusion

Ruptured Backer’s cyst

Muscle hypertrophy ( androgens )

Etiology of ACS

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Intracompartmental fluid infusion (interosseosus infusion)

Capillary leak syndrome

Intra-arterial injections of sclerosing agents

Post –ischemic reperfusion

Compartment SyndromeTissue Survival

Muscle 3-4 hours - reversible changes6 hours - variable damage8 hours - irreversible changes

Nerve 2 hours - looses nerve conduction4 hours - neuropraxia8 hours - irreversible changes

Compartment SyndromePathophysiology

Normal tissue pressure 0-4 mm Hg 8-10 with exertion

Absolute pressure theory30 mm Hg - Mubarak45 mm Hg - Matsen

Pressure gradient theory< 20 mm Hg of diastolic pressure – Whitesides

McQueen, et al

Compartment Syndrome Diagnosis

Pain out of proportion

Palpably tense compartment

Pain with passive stretch

Paresthesia/hypoesthesia

Paralysis

Pulselessness/pallor

PainClassically out of portion to injury

Exaggerated with passive stretch of the involved muscles in compartment

Earliest symptom

ParesthesiaAlso early sign

Peripheral nerve tissue is more sensitive than muscle to ischemia

Permanent damage may occur in 75 minutes

Difficult to interpret

Will progress to anesthesia if pressure not relieved

ParalysisVery late finding

Irreversible nerve and muscle damage present

Paresis may be present earlyDifficult to evaluate because of pain

Pallor & PulselessnessRarely present

Indicates direct damage to vessels rather than compartment syndrome

Vascular injury may be more of contributing factor to syndrome rather than result

Compartment Pressure

Technique

Whiteside infusion

Stic technique: side port needle

Wick catheter

Slit catheter

Whiteside TechniqueSimple techniqueReadily available suppliesWith 18 gauge needle least accurateMore accurate if use side port needle

Stryker Stic SystemEasy to useCan check multiple compartmentsDifferent areas in one compartment

Management of ACS

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Removal of the possible cause (release of tight dressings or circular constrictive bandages, splitting of casts)

Correction of coagulopathy

Positioning of the limb at the level of the heart

Management of ACS

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If symptoms don’t resolve in 30 to 60 min after appropriate treatment ,pressure measurement should be repeated,and,if equivocal, fasciotomy is indicated

Management of ACS

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The definitive treatment of acute compartment syndrome is FASCIOTOMY

Procedure is done without a tourniquet,each potentially limiting envelope is opened over the entire length of the compartment, all muscle groups should be soft to palpation at the end of the procedure

Muscle debridement should be kept to a minimum

FACIOTOMY OF LOWER LIMBFOR THIGH Make a lateral incision distal to

intertrochantric line extending to the lateral epicondyle.

Expose the iliotibial band & make aa straight incision in line with skin incision

Reflect the vastus lateralis off the intermuscular septum

• FOR LEG

Single incision faciotomy

Double incision faciotomy

fibuloectomy

Chronic Compartment Syndrome

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Also known as exertional CS, recurrent CS and subacute CS

Exercise –induced pain

Occur mainly in the lower limb

Typical patient is young (20-30s) athlete (long distance runner)or military recruits pushed past normal limits of functional tolerance

Pathophysiology of CCS

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Not yet fully understood

Probably occurs from increased muscle relaxation pressure during exercise , which causes decreased muscle blood flow, leading to ischemic pain and impaired muscle function

COMPLICATION OF COMPARTMENT SYNDROMEReperfusion injuryVolkmann’s contractureWeak dorsiflxorsClaw toeSensory lossChronic painAmputation

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