compartment syndrome, acute, chronic, anatomy and operation

Ext.Sawanya SaowapapHadyai hospital

Compartment SyndromesDefinitionTypesPathophysiologyEtiologyClinical evaluationDiagnosisManagementComplications

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DefinitionAn elevation of the interstitial pressure in a

closed osteofascial compartment that results in micrvascular compromise.

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S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11 th edition. Philadelphia, Pensylvania. Mosby Elsevier, 2003.

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.

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The vicious cycle of Volkmann's ischemia

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Increased intracompartmental P

increases local venous P narrowed AV perfusion

gradient compartment tamponadedecrease capillary blood flow O2 deprivation local tissue necrosis nerve injury and muscle

ischemia

Pathophysiology of ACS

S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition.

Philadelphia, Pensylvania. Mosby Elsevier, 2003.

Pathophysiology of ACS

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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


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

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Etiology of ACS Increase compartment contents Fractures : the most common are

•In adults --- closed and open tibial shaft fx ,

distal radial fx •In children --- radial head or neck fx , supracondylar fx , forearm fx

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Etiology of ACS Increase compartment contents• Hemorrhage -- vascular injury, coagulopathy• Muscle edema -- severe exercise , crush injury• Burn -- increase capillary permeability

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Increase compartment contents

10S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11 th edition.

Philadelphia, Pensylvania. Mosby Elsevier, 2003.

Clinical Evaluation of ACSClinical presentations :

Swelling/ Tightness of compartmentInappropiated and uncontrolled painSevere pain at rest or passive stretchingPallor/CyanosisHyperesthesia/ParesthesiaParalysis : full recovery is rare

11Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com ,

Duke Orthopaedics : North Calorina, 2013.

http://www.wheelessonline.com/

Clinical Evaluation of ACSPhysical examination :

Pain at compartment on passive stretching :

test each compartment separately Thigh : - anterior compartment - passive knee flexion

- posterior compartment - passive knee extension

- medial compartment - passive hip abductionHyperesthesia/Paresthesia Peripheral pulses absent - amputation usually

inevitable




Measurement of Compartment pressures

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Indications : High risk injuries inpolytrauma patientspatient not alert/unreliableinconclusive physical exam findings

Technique : performed each compartments at close to the fracture

site as possible (highest pressure) or maximal swelling area

Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com ,Duke Orthopaedics : North Calorina, 2013.


Measurement of Compartment pressuresDevices

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Stryker hand-held system Stryker slit catheter



Early management of ACSRemove cast/bandagePositioning of the limb at the level of the

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

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Early management &reevaluation

S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. Philadelphia ,

Pensylvania. Mosby Elsevier, 2003.

TreatmentNonoperative

observationdelta p > 30 mmHg, no clinical presentation of compartment

syndrome

Operative emergent fasciotomy

Positive clinical presentationCP = 30-45 mm Hgdelta p < 30 mmHg

Contraindications : Missed compartment syndrome (Various stage of muscle infarction)

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Anatomy of CompartmentsArm 2 compartmentsForearm 4 compartments Hand 4 compartmentsThigh 3 compartmentsLeg 4 compartmentsFoot 9 compartments

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2 Compartments of arm1.Anterior

1. Biceps,Bracialis

2.Musculocutaneous n.

3.Brachial a.2.Posterior

1. Triceps2. Radial n.

20Mark Karafsheh.MD, “Compartment Syndrome”on www.Orthobullets.com, Havard university, 2013.

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.

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-most commonly affect volar

Dorsal incision

Mark Karafsheh.MD, “Compartment Syndrome”on www.Orthobullets.com, Havard university, 2013.

10 Compartments of hand


3 Compartments of thighAnterior

femoral nquadriceps sartorious

Posterior sciatic nhamstrings

Medialobturator nadductors


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4 Compartments of leg

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1. 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

29Karafsheh.MD, “Compartment Syndrome”Mark on www.Orthobullets.com, Havard university, 2013.

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Dorsal dual incision

Medial incision Mark Karafsheh.MD, “Compartment Syndrome”on www.Orthobullets.com, Havard university, 2013.

Fasciotomy - post op careSkeletal fixation can all be applied at time of initial

surgical decompression

After decompression care : sterile dressing (saline soaks ), splinting in functional position

Return to OR for 2nd look in 2-5 days - If no muscle necrosis the skin is loosely closed. - If closure is not accomplished Debridement after another 72- h interval Skin closure or skin grafting

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Complications of ACSMyonecrosis : after an ischemic insult of > 8 hrs.

Treatmentfasciotomy + debridement of the muscles +

neurolysis may lead to myoglobinuria and eventually renal

failure. Diuresis ( by mannitol,diuretics or IV fluids ) should be prompted to increase the tubular flushing and eliminate the proteinaceous material



Complications of ACSVolkmann ischemic contracture : myonecrosis

replaced with fibrous tissue myotendinous adhesion formation.

TreatmentNon-surgical (physiotherapy & bracing involve the joints)Surgical

contracture release, nerve compression release, amputation reconstruction with tissue transfers



Reperfusion syndrome : influx of myoglobin, potassium, and phosphorus into the circulation

characterized by hypovolemic shock and hyperkalemia

Evaluation : Fluid loss, Shock Acidosis Hyperkalemia Myoglobinuria, Renal failure : need fluid 12 Lt over 48-hour

Management : Prioperative hydration Mannitol Bicarbonate

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Complications of ACS


Complications of ACSNeurovascular injuryInfection Amputation Death



Chronic Compartment Syndrome

Known as exertional CS, recurrent CS and subacute CS

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

Occur mainly in the lower limb

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Pathophysiology of CCS

Not yet fully understoodProbably from increased muscle relaxation

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

function

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Physical Exam in CCS

Exercise –induced pain Tenderness over the compartmentBilateral involvement is common ( up to

82% )Fascial hernias ( 39% in one of the

studies )

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DDx of CCS

PeriostitisEntrapment of the superficial peroneal

nerveTendinitis of the posterior tibial tendonStress fracture of tibiaIntermittent claudication

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Work up of CCS

Plain x-rays : will show 90% of stress fxBone scan : diffuse uptake ……..periostitis localized uptake……stress fxTinel test : may be positive in superficial

peroneal nerve entrapmentNCS : could be helpfulMRI : promising results reported

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Robert J. Duggan. “ How To Diagnose And Treat Chronic Exertional Compartment Syndrome” Podiatry Today Volume 22 ,2009

Diagnosis of CCS

Intracompartmental testing is the hallmark of diagnosis (as reported by Pedwotiz et al ) :

1) Pre-exercise resting pressure of 15 mm Hg or more.

2) Pressure of 30 mm Hg 1 minute after the exercise.

3) Pressure of 20 mm Hg or more 5 minutes after the exercise.

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Treatment of CCS

Non-operative : NSAIDsElectrostimulation Muscle relaxantsUltrasoundCessation or significant reduction of athletic

activities

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Treatment of CCSOperative treatment

Single incision fasciotomy Double incision fasciotomy

After surgery :Early ROM exercises are encouraged. Weight bearing on crutches is allowed on

POD1.Light jogging is allowed at 2-3 weeks if no

swelling or tenderness

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References

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S. Terry Canele. Campeell’s Operative Orthopedics Volume 3. 11th edition. Philadelphia, Pensylvania. Mosby Elsevier, 2003.

Clifford R. Wheeles, Wheeless' Textbook of Orthopaedics at site : www.wheelessonline.com, Duke Orthopaedics : North Calorina, 2013.

Mark R. Brinker. Fundamental of orthopedics. Bathesta, Maryland : University of Texan Health Sciences Center, 1992.


Mark Karafsheh.MD, “Compartment Syndrome” on www.Orthobullets.com, Havard university, 2013.

compartment syndrome, acute, chronic, anatomy and operation

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